Neurological Sciences

, Volume 40, Issue 4, pp 745–752 | Cite as

Predicting cerebral edema in ischemic stroke patients

  • Antonio MuscariEmail author
  • Luca Faccioli
  • Maria Vittoria Lega
  • Andrea Lorusso
  • Marco Pastore Trossello
  • Giovanni M. Puddu
  • Luca Spinardi
  • Marco Zoli
Original Article



To produce a scoring system for predicting the development of edema in ischemic stroke patients without edema on admission.


This retrospective study included 572 ischemic stroke patients (73.3 ± 13.0 years, 300 male) without signs of cerebral edema on the first CT scan, which was performed on admission. Another scan was normally performed 3 days later, and subsequently whenever needed. Edema was defined as cerebral hypodensity with compression of lateral ventricles. The main clinical, laboratory, and instrumental variables obtained during the first 24 h were related to the appearance of edema on the CT scans performed after the first one.


Cerebral edema occurred in 158 patients (27.6%) after a median time of 4 days. The variables independently associated with edema development were (odds ratio, 95% CI) the following: (1) total anterior circulation syndrome (4.20, 2.55–6.93; P < 0.0001), (2) hyperdense appearance of middle cerebral artery (4.12, 2.03–8.36; P = 0.0001), (3) closed eyes (2.53, 1.39–4.60; P = 0.002), (4) vomiting (3.53, 1.45–8.60; P = 0.006), (5) lacunar cerebral syndrome (0.36, 0.17–0.77; P = 0.008); and (6) white matter lesions (0.53, 0.33–0.86; P = 0.01). Counting one positive point for the first four variables and one negative point for the last two variables, a scoring system (E-score) was built. Cerebral edema could be predicted when the score was ≥ 1 (positive predictive value 61.6%, specificity 85.3%, sensitivity 62.0%). The area under the receiver operating characteristic curve was 0.78.


In ischemic stroke patients, six variables obtained during the first 24 h of hospitalization were predictive of subsequent cerebral edema development.


Brain CT scan Cerebral edema Determinants Ischemic stroke Predictors 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.


  1. 1.
    Brogan ME, Manno EM (2015) Treatment of malignant brain edema and increased intracranial pressure after stroke. Curr Treat Options Neurol 17:327CrossRefGoogle Scholar
  2. 2.
    Grände PO, Romner B (2012) Osmotherapy in brain edema: a questionable therapy. J Neurosurg Anesthesiol 24:407–412CrossRefGoogle Scholar
  3. 3.
    Bereczki D, Fekete I, Prado GF, Liu M (2007) Mannitol for acute stroke. Cochrane Database Syst Rev:CD001153.
  4. 4.
    Righetti E, Celani MG, Cantisani T, Sterzi R, Boysen G, Ricci S (2004) Glycerol for acute stroke. Cochrane Database Syst Rev:CD000096.
  5. 5.
    Diringer MN, Scalfani MT, Zazulia AR, Videen TO, Dhar R (2011) Cerebral hemodynamic and metabolic effects of equi-osmolar doses mannitol and 23.4% saline in patients with edema following large ischemic stroke. Neurocrit Care 14:11–17CrossRefGoogle Scholar
  6. 6.
    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL, American Heart Association Stroke Council. 2018 (2018) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110CrossRefGoogle Scholar
  7. 7.
    Hofmeijer J, Algra A, Kappelle LJ, van der Worp HB (2008) Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis 25:176–184CrossRefGoogle Scholar
  8. 8.
    Thomalla G, Hartmann F, Juettler E, Singer OC, Lehnhardt FG, Köhrmann M, Kersten JF, Krützelmann A, Humpich MC, Sobesky J, Gerloff C, Villringer A, Fiehler J, Neumann-Haefelin T, Schellinger PD, Röther J, for the Clinical Trial Net of the German Competence Network Stroke (2010) Clinical trial net of the German competence network stroke. Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: a prospective multicenter observational study. Ann Neurol 68:435–445CrossRefGoogle Scholar
  9. 9.
    Shimoyama T, Kimura K, Uemura J, Yamashita S, Saji N, Shibazaki K, Iguchi Y (2014) The DASH score: a simple score to assess risk for development of malignant middle cerebral artery infarction. J Neurol Sci 338:102–106CrossRefGoogle Scholar
  10. 10.
    Kim H, Jin ST, Kim YW, Kim SR, Park IS, Jo KW (2015) Predictors of malignant brain edema in middle cerebral artery infarction observed on CT angiography. J Clin Neurosci 22:554–560CrossRefGoogle Scholar
  11. 11.
    Ong CJ, Gluckstein J, Laurido-Soto O, Yan Y, Dhar R, Lee JM (2017) Enhanced detection of edema in malignant anterior circulation stroke (EDEMA) score: a risk prediction tool. Stroke 48:1969–1972CrossRefGoogle Scholar
  12. 12.
    Strbian D, Meretoja A, Putaala J, Kaste M, Tatlisumak T, Helsinki Stroke Thrombolysis Registry Group (2013) Cerebral edema in acute ischemic stroke patients treated with intravenous thrombolysis. Int J Stroke 8:529–534CrossRefGoogle Scholar
  13. 13.
    Thorén M, Azevedo E, Dawson J, Egido JA, Falcou A, Ford GA, Holmin S, Mikulik R, Ollikainen J, Wahlgren N, Ahmed N (2017) Predictors for cerebral edema in acute ischemic stroke treated with intravenous thrombolysis. Stroke 48:2464–2471CrossRefGoogle Scholar
  14. 14.
    Lyden P, Lu M, Jackson C, Marler J, Kothari R, Brott T, Zivin J (1999) Underlying structure of the National Institutes of Health Stroke Scale: results of a factor analysis. NINDS tPA Stroke Trial Investigators. Stroke 30:2347–2354CrossRefGoogle Scholar
  15. 15.
    Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:1521–1526CrossRefGoogle Scholar
  16. 16.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84CrossRefGoogle Scholar
  17. 17.
    van Swieten JC, Hijdra A, Koudstaal PJ, van Gijn J (1990) Grading white matter lesions on CT and MRI: a simple scale. J Neurol Neurosurg Psychiatry 53:1080–1083CrossRefGoogle Scholar
  18. 18.
    Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, and the Interdisciplinary Council on Peripheral Vascular Disease et al (2009) Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke 40:3646–3678CrossRefGoogle Scholar
  19. 19.
    Osborn AG, Salzman L, Barkovich AJ (2009) Acute cerebral ischemic infarction. In: Diagnostic imaging: brain, 2nd edn. Lippincott, Philadelphia, pp 108–111Google Scholar
  20. 20.
    Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 355:1670–1674CrossRefGoogle Scholar
  21. 21.
    Luo S, Yang L, Luo Y (2018) Susceptibility-weighted imaging predicts infarct size and early-stage clinical prognosis in acute ischemic stroke. Neurol Sci 39:1049–1055CrossRefGoogle Scholar
  22. 22.
    Naylor J, Churilov L, Chen Z, Koome M, Rane N, Campbell BCV (2017) Reliability, reproducibility and prognostic accuracy of the Alberta Stroke Program Early CT Score on CT perfusion and non-contrast CT in Hyperacute stroke. Cerebrovasc Dis 44:195–202CrossRefGoogle Scholar
  23. 23.
    Demeestere J, Scheldeman L, Cornelissen SA, Heye S, Wouters A, Dupont P et al (2018) Alberta Stroke Program Early CT Score versus computed tomographic perfusion to predict functional outcome after successful reperfusion in acute ischemic stroke. Stroke 49:2361–2367CrossRefGoogle Scholar
  24. 24.
    Kong WY, Tan BYQ, Ngiam NJH, Tan DYC, Yuan CH, Holmin S, Andersson T, Lundström E, Teoh HL, Chan BPL, Rathakrishnan R, Ting EYS, Sharma VK, Yeo LLL (2017) Validation of Serial Alberta Stroke Program Early CT Score as an outcome predictor in thrombolyzed stroke patients. J Stroke Cerebrovasc Dis 26:2264–2271CrossRefGoogle Scholar
  25. 25.
    Muscari A, Puddu GM, Conte C, Falcone R, Kolce B, Lega MV, Zoli M (2015) Clinical predictors of fever in stroke patients: relevance of nasogastric tube. Acta Neurol Scand 132:196–202CrossRefGoogle Scholar
  26. 26.
    Muscari A, Collini A, Fabbri E, Giovagnoli M, Napoli C, Rossi V, Vizioli L, Bonfiglioli A, Magalotti D, Puddu GM, Zoli M (2014) Changes of liver enzymes and bilirubin during ischemic stroke: mechanisms and possible significance. BMC Neurol 14:122CrossRefGoogle Scholar
  27. 27.
    Kasner SE, Demchuk AM, Berrouschot J et al (2001) Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke 32:2117–2123CrossRefGoogle Scholar
  28. 28.
    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41CrossRefGoogle Scholar
  29. 29.
    Muscari A, Faccioli L, Ghinelli M, Napoli C, Pirazzoli E, Puddu GM, Spinardi L, Trossello MP, Zoli M (2016) Hypertension and other determinants of white matter lesions in stroke patients. J Clin Hypertens (Greenwich) 18:907–912CrossRefGoogle Scholar

Copyright information

© Fondazione Società Italiana di Neurologia 2019

Authors and Affiliations

  1. 1.Stroke Unit – Medical Department of Continuity of Care and DisabilityS.Orsola-Malpighi HospitalBolognaItaly
  2. 2.Department of Medical and Surgical Sciences, Stroke Unit, S.Orsola-Malpighi HospitalUniversity of BolognaBolognaItaly
  3. 3.Diagnostic and Interventional Neuroradiology UnitS.Orsola-Malpighi HospitalBolognaItaly

Personalised recommendations