Prognosis of Patients With Middle Cerebral Artery Occlusion - Stroke

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1 482 STROKE VOL. 7, No. 5, SEPTEMBER-OCTOBER 1976 Summarizing our findings we noted that after the follow-up 3. Bruun B, Richter RW: The epidemiology of stroke in central Harlem. Stroke 4: 406-408, 1973 period (median 53 months) half of the patients were fully in- 4. Shafer SQ, Bruun B, Richter RW: The outcome of stroke at hospital dis- dependent in ADL. One-fifth of all patients could return to charge in New York City blacks. Stroke 4: 782-786, 1973 work, one-fifth required assistance, one-fifth had died, and 5. Aho K: Incidence, profile and early prognosis of stroke. Epidemiological and clinical study of 286 persons with onset of stroke in 1972 and 1973 in one-tenth was disabled. a South-Finnish urban area. Thesis, Espoo, Meder-Offset, 1975 The patients' condition at the acute stage was of prime 6. Robinson RW, Cohen WD, Higano N, et al: Life-table analysis of sur- vival after cerebral thrombosis ten-year experience. JAMA 169: importance in the early prognosis and the functional 1149-1152, 1959 recovery in our series as in previous studies.2-6'18 In our series 7. David NJ, Heyman A: Factors influencing the prognosis of cerebral the survival was independent of the patients' age, which thrombosis and infarction due to atherosclerosis. J Chron Dis 11: 394-404, 1960 agreed with previous reports.17-18 On the other hand, func- 8. McDowell F, Louis S: Improvement in motor performance in paretic and tional recovery was much better in the younger age groups. paralyzed extremities following nonembolic cerebral infarction. Stroke 2: The same was found in most previous series dealing with this 395-399, 1971 9. Stallones RA, Dyken ML, Fang HCH, et al: Epidemiology for stroke question.21317 facilities planning. Stroke 3: 360-371, 1972 It is well known that cigarette smoking is a risk factor of 10. Marshall J, Shaw DA: The natural history of cerebrovascular disease. Br Med J 1: 1614-1616, 1959 cerebrovascular disease.19 In the present series it could also 11. Sindermann F, Bechinger D, Dichgans J: Occlusions of the internal be shown that prognosis and functional recovery were better carotid artery compared with those of the middle cerebral artery. Brain in nonsmokers than in smokers. Hypertension, again, was of 93: 199-210, 1970 12. Fogelholm R, Vuolio M: Clinical and radiological analysis of 77 patients no prognostic value. with internal carotid artery thrombosis. Acta Neurol Scand 43 (Suppl It is also well known that patients with cerebrovascular 31): 120-121, 1967 Downloaded from http://stroke.ahajournals.org/ by guest on January 16, 2017 disease often die due to coronary heart disease.u-ao This also 13 Katz S, Ford AB, Chinn AB, et al: Prognosis after strokes. Part II. Long- term course of 159 patients. Medicine 45: 236-246, 1966 was noted in our series where equal numbers of deaths were 14. Robinson RW, Demirel M, LeBeau RJ: Natural history of cerebral due to cerebrovascular and coronary heart diseases. This thrombosis; nine to nineteen-year follow-up. J Chron Dis 21: 221-230, 1968 supports the concept of universal atherosclerosis as a basic 15. Torvik A, Jorgensen L: Thrombotic and embolic occlusions of the carotid etiology in ICA occlusion. arteries in an autopsy series: Part 2. J Neurol Sci 3: 410-432, 1966 16. Haerer AF, Smith RR: Cerebrovascular disease of young adults in a Mississippi teaching hospital. Stroke 1: 466-476, 1970 17. Rankin J: Cerebral vascular accidents in patients over the age of 60. II. References Prognosis. Scott Med J 2: 200-215, 1957 18. Kuller L, Anderson H, Peterson D, et al: Nationwide cerebrovascular Dalsgaard-Nielsen T: Survey of 1,000 cases of apoplexia cerebri. Ada disease morbidity study. Stroke 1: 86-99, 1970 Psychiat Scand 30: 169-185, 1955 19. Kannel WB, Blaisdell FW, Gifford R, et al: Risk factors in stroke due to Marquardsen J: The natural history of acute cerebrovascular disease. A cerebral infarction. Stroke 2: 423-428, 1971 retrospective study of 769 patients. Acta Neurol Scand 45 (Suppl 138) 20. Goldner JC, Whisnant JP, Taylor WF: Long-term prognosis of transient 1969 cerebral ischemic attacks. Stroke 2: 160-167, 1971 Prognosis of Patients With Middle Cerebral Artery Occlusion MARKKU KASTE, M.D., AND OLLI WALTIMO, M.D. S U M M A R Y The long-term prognosis of 78 stroke patients with as common as cardiovascular events as the cause of death. Seventy- occlusion of the middle cerebral artery ( M C A ) or its branches is two percent of the survivors became fully independent in activities of described. The mean age of the patients was 44 years. The mortality daily living (ADL), 27% required assistance, 1% was totally disabled, rate in the acute phase was 5%. The acute and total mortality rates of and 43% returned to work. Left-sided occlusion was overrepresented men were higher than those of women (p < 0.05). Life-table analysis in those who died (p < 0.001) and those who returned to work gave 94% probability for one year's survival, 84% for three years' sur- (p < 0.05), and right-sided occlusion was overrepresented in those vival, and 78% for five years' survival. Subsequent strokes were twice who required assistance in A D L (p < 0.05). Introduction frequently encountered. Therefore, we have analyzed the long-term prognosis of stroke patients with occlusion of the NUMEROUS STUDIES have dealt with long-term middle cerebral artery (MCA) or its branches. prognosis of stroke and various types of stroke, while little attention has been paid to the clinical entity of occlusion of Patients and Methods one major cerebral artery. It would be desirable in clinical routine work to know the stroke patient's long-term From the 1966 to 1973 files of the Department of prognosis evaluated on this basis, since this type of stroke is Neurology, University of Helsinki (Finland), 83 patients with ischemic brain infarction and occlusion of the MCA or Department of Neurology, University of Helsinki, Haartmaninkatu 4, its branches, verified angiographically or by autopsy, were 00290 Helsinki 29, Finland. found. Etiological causes other than ischemic were excluded

2 PROGNOSIS OF MCA OCCLUSION/Aasfe et al. 483 TABLE 1 Age and Sex Distributions TABLE 3 Location of MCA Occlusion Age Left Right

3 484 STROKE VOL. 7, No. 5, SEPTEMBER-OCTOBER 1976 TABLE 5 Clinical Status at the Onset of Symptoms ADL Fully Requiring Totally Died in Returned independent assistance dependent acute phase to work Symptoms (n = 53) (n = 20) (n = 1) (n = 4) (n = 32) Hemiparalysis 7 3 Hemiparesis 31 20 Reduced consciousness 5 2 (p < 0.05). There was no statistically significant difference entire series. In general, according to the literature, the risk in the distribution of occlusion of the MCA or its branches of early fatality from stroke increases with age. Almost as between those who were able to return to work and those universally, the prognosis has been shown to be independent who were not. of sex. However, some authors have found a slightly higher Localization of MCA occlusions in relation to ADL is case fatality of men in most age groups. 11 ' 12 In other series, shown in table 7. Occlusions of the right MCA were more the poor prognosis of women has been explained by their in- common among those who required assistance in ADL than creased mean age.13' " In the present series, the mean age of among those who were fully independent (p < 0.05). Left the men was slightly higher than that of the women. The MCA occlusions were more common among those fully in- probability of survival in the present series (78% after five Downloaded from http://stroke.ahajournals.org/ by guest on January 16, 2017 dependent than among those requiring assistance in ADL years) seems to be better than that in earlier studies with (p < 0.05). their five-year survival rates between 38% and 66%> ' "1617 This difference may be explained by the selective factors Discussion mentioned in which the most severely ill and elderly patients Although this type of stroke is not uncommon, very little were underrepresented. attention has been paid to the functional recovery and long- The causes of death in the present series are similar to term prognosis of occlusion of the MCA or its branches.1 those in most earlier studies: subsequent strokes were twice The patients of the present series had either occlusion as common as cardiovascular disease.12'15 of the MCA or its branches which was verified by angiog- Functional recovery was excellent in our series: 72% of the raphy or autopsy. In considering the results we obtained, patients who survived the acute phase of stroke became fully one should reflect on our method of selecting patients: all independent in ADL, while 27% required assistance in ADL, patients with ischemic brain infarction admitted to our and only one (1%) was totally disabled. In earlier studies the hospital are not treated in the Department of Neurology; percentages of independent patients varied between 40% and quite often, and especially when they are elderly, they are 63%. ' * " 12 ' 1821 In some studies the percentage of survivors treated by the Departments of Medicine. There is also the with a good recovery has been particularly low, i.e., 12% to selection of those patients referred from other hospitals: 17%.2224 It is difficult to draw any solid conclusion from the elderly and seriously ill patients are preferentially treated in heterogenous literature. However, the reason for better the hospital of primary admission. Furthermore, all stroke functional recovery in this series is believed to be that the patients in the Department of Neurology are not examined patients were relatively young and had occlusion of only the by angiography; an elderly patient showing signs of univer- MCA or its branches. The significance of age also is evident sal arteriosclerosis often escapes angiographical examina- in the mean ages of the different ADL groups: the patients tion because of the risk of complications. This is why the who became fully independent were younger on the average mean age is only 44 years in the present series; however, it is than those who required assistance in ADL. almost identical with previous series.1*2 In the present series 43% of the survivors regained their The mortality rate (5%) in the acute stage is low compared working capacity, which agrees with earlier studies reporting with earlier hospital series reporting case fatalities of non- figures from 30% to 40%. 9 ' 12 - 20 ' 26 The mean age of the embolic and/or embolic brain infarction in the acute phase patients who were able to return to work was 38 years. between 10% and 35%.3"9 This most likely was due to the fact Younger patients are more likely to regain their working that in this series the patients were quite young and all had capacity since they are better able to compensate for the lost occlusion of the MCA which supplies only part of one function of the infarcted regions of the brain. hemisphere; there was no severe brain edema, which in Left-sided occlusion of the MCA was more common severe stroke is the main reason for patient deaths.10 among those who were able to return to work (p < 0.05), All those patients who died in the acute phase of stroke and right-sided occlusion among those who required were men; their mean age was slightly higher than that of the assistance in ADL (p < 0.05). Marquardsen 12 suggested the TABLE 6 Location of MCA Occlusion in Those Patients Who TABLE 7 Location of MCA Occlusion in Each ADL Group Returned to Work and Those Who Did Not Left Right Left Right Branch Branch Branch Branch ADL occlusion Occlusion Total occlusion Occlusion Total occlusion Occlusion Total occlusion Occlusion Total 1 1 to Fully independent 23 15 38 13 15 Returned to work 17 7 24 8 8 Requiring Did not return assistance 7 3 10 10 10 to work 14 11 25 15 2 17 Totally dependent 1 1

4 CEREBRAL INFARCTION IN THE MONGOLIAN GERBlL/McGraw et al. 485 reason for this was that the lesions of the right hemisphere Incidence and survival rates in a defined population, Middlesex county, Connecticut. JAMA 189: 883-888, 1964 affect the functions of visuomotor, temporal and spatial con- 12. Marquardsen J: The natural history of acute cerebrovascular disease. A cepts. retrospective study of 769 patients. Acta Neurol Scand 45 (Suppl 138) 1969 References 13. Brummer P: Klinisch-Statische Untersuchungen uber die Apoplexie des Gehirns und Seiner Haute. Acta Soc Med Fenn Duodecim (Series B) 31 1. Lindgren SO: Course and prognosis in spontaneous occlusions of cerebral (#2) 1941 arteries. Acta Psych Neurol Scand 38: 343-358, 1958 14. Robinson RW, Demirel M, LeBeau RJ: Natural history of cerebral 2. Sindermann F, Bechinger D, Dichgans J: Occlusion of the middle thrombosis; nine to nineteen year follow-up. J Chron Dis 2 1 : 221-230, cerebral artery and its branches: Angiographic and clinical correlates. 1968 Brain 92: 607-620, 1969 15. Marshall J, Shaw DA: The natural history of cerebrovascular disease. Br 3. Robinson RW, Cohen WD, Higano N, et al: Life-table analysis of sur- Med J 1: 1614-1617, 1959 vival after cerebral thrombosis ten-year experience. JAMA 169: 16. Katz S, Ford AB, Chinn AB, et al: Prognosis after stroke. Part II. Long- 1149-1152, 1959 term course of 159 patients. Medicine 45: 236-246, 1966 4. David NJ, Heyman A: Factors influencing the prognosis of cerebral 17. Rankin J: Cerebral vascular accidents in patients over the age of 60. II. thrombosis and infarction due to atherosclerosis. J Chron Dis 11: Prognosis. Scott Med J 2: 200-215, 1957 394-404, 1960 18. Jarrel RJ: A prospective study of stroke. Preliminary report. JFMA 47: 5. Gormsen J, Dyrbye M, Eiken M, et al: Acute cerebral infarct. Extra- 529-533, 1960 cerebral genesis with particular reference to cardiovascular status. Acta 19. Wolkerstorfer H: Untersuchungen uber das Fruhschicksal von Med Scand 169: 455-466, 1961 Apoplektikern. Munch Med Wschr 27: 1333-1337, 1961 6. Carter AB: Strokes. Natural history and prognosis. Proc Roy Soc Med 20. Matsumoto N, Whisnant JP, Kurland LT, et al: Natural history of stroke 56: 483-486, 1963 in Rochester, Minnesota, 1955 through 1969: An extension of a previous 7. Louis S, McDowell F: Age: Its significance in nonembolic cerebral in- study, 1945 through 1954. Stroke 4: 20-29, 1973 Downloaded from http://stroke.ahajournals.org/ by guest on January 16, 2017 farction. Stroke 1: 449-453, 1970 21. Shafer SQ, Bruun B, Richter RW: The outcome of stroke at hospital dis- 8. McDowell F, Louis S: Improvement in motor performance in paretic and charge in New York City blacks. Stroke 4: 782-786, 1973 paralyzed extremities following nonembolic cerebral infarction. Stroke 2: 22. Adams GF, McComb SG: Assessment and prognosis in hemiplegia. 395-399, 1971 Lancet 2: 226-269, 1953 9. Aho K: Incidence, profile and early prognosis of stroke. Epidemiological 23. Dalsgaard-Nielsen T: Survey of 1,000 cases of apoplexia cerebri. Acta and clinical study of the 286 persons with onset of stroke in 1972 and 1973 Psychiat Scand 30: 169-185, 1955 in a South-Finnish urban area. Thesis, Espoo, Meder-Offset, 1975 24. Glynn A A: Vascular diseases of the nervous system. A series of 315 cases. 10. Ng LKY, Nimmannitya J: Massive cerebral infarction with severe brain Br Med J 1: 1216-1219, 1956 swelling. A clinicopathological study. Stroke 1: 158-163, 1970 25. Florin AA, Rosenthal AM: The Camden County demonstration stroke 11. Eisenberg H, Morrison JT, Sullivan P, et al: Cerebrovascular accidents. project. A preliminary report. J Med Soc NJ 60: 109-114, 1963 Cerebral Infarction in the Mongolian Gerbil Exacerbated by Phenoxybenzamine Treatment C. PATRICK M C G R A W , PH.D.,*f ANNETTE G. PASHAYAN, A.B.,* AND O. T. WENDEL, P H . D . * S U M M A R Y In a double-blind study, the effects of a large dose (20 treatment schedule. Morbidity and mortality were recorded for mg per kilogram) and a small dose (2 mg per kilogram) of phenoxy- one week and then all surviving animals were killed. All brains benzamine ( P B Z ) on cerebral infarction were evaluated in 120 were studied for signs of infarction. Of the saline-treated animals, Mongolian gerbils. The left common carotid artery was ligated in 100 32% had cerebral infarction and 81% of these died. Of the animals animals; a sham operation was done in 20 animals. One hour later, 25 treated with phenoxybenzamine, 36% of those receiving 2 mg per animals were given 2 mg per kilogram of P B Z , 25 animals were given kilogram and 68% (p < 0.05) of those receiving 20 mg per kilo- 20 mg per kilogram of phenoxybenzamine, and 50 animals were given gram had cerebral infarction and all of those with infarction died 0.5 cc of normal saline, all doses being repeated at 24, 48, and 72 during the observation period. The animals receiving phenoxy- hours. Five sham-operated animals were given 2 mg per kilogram of benzamine had a larger stroke index than those treated with saline. phenoxybenzamine, five were given 20 mg per kilogram of phenoxy- The authors concluded that phenoxybenzamine is harmful in post- benzamine and ten were given 0.5 cc of normal saline on the same ischemic treatment of strokes. WHEN ISCHEMIA develops after brain or spinal cord neuronal function, produce cerebral edema,4"8 cause cere- trauma or hemorrhage, monoamine neurotransmitters may bral arterial vasospasm2'3- ' l0 and increase platelet ag- leak from neurons that have lost their structural integrity as gregation."- " Mechanisms that normally inactivate these a result of that ischemia.1"3 These neurotransmitters have neurotransmitters, namely presynaptic re-uptake and oxida- been postulated to alter nerve cell metabolism, depress tive deamination, are attenuated due to the lack of oxygen, and the accumulation of these substances in the extra- From the 'Department of Neurology, and the tSection on Neurosurgery, cellular space exacerbates the damage caused by the initial Department of Surgery, Bowman Gray School of Medicine of Wake Forest ischemia.'3-7 University, Winston-Salem, North Carolina 27103. This information suggests several approaches to the phar- This study was supported in part by North Carolina Heart Association Grant No. 871-664-76. macological therapy of stroke: (1) inhibition of neurotrans- Reprint requests to Dr. McGraw. mitter synthesis, (2) suppression of the release of neuro-

5 Prognosis of patients with middle cerebral artery occlusion. M Kaste and O Waltimo Stroke. 1976;7:482-485 Downloaded from http://stroke.ahajournals.org/ by guest on January 16, 2017 doi: 10.1161/01.STR.7.5.482 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright 1976 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://stroke.ahajournals.org/content/7/5/482 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Stroke is online at: http://stroke.ahajournals.org//subscriptions/

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