• Anna Kruetzelmann, Frank Hartmann, Christoph Beck, Eric Juettler, Oliver C Singer, Martin Köhrmann, Jan F Kersten, Jan Sobesky, Christian Gerloff, Arno Villringer, Jens Fiehler, Tobias Neumann-Haefelin, Peter D Schellinger, Joachim Röther, Götz Thomalla, and Clinical Trial Net of the German Competence Network Stroke.
• Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
• Int J Stroke. 2014 Feb 1; 9 (2): 210-4.

BackgroundA large diffusion-weighted imaging lesion ≤six-hours of symptom onset was found to predict the development of 'malignant' middle cerebral artery infarction with high specificity, positive predictive value, and negative predictive value, but sensitivity was low.HypothesisWe tested the hypothesis that sensitivity can be improved by adding information from clinical follow-up examination after 24 h.MethodsWe analyzed data from a prospective, multicenter, observational cohort study of patients with acute ischemic stroke and middle cerebral artery occlusion studied by stroke magnetic resonance imaging ≤six-hours of symptom onset. We used the National Institutes of Health Stroke Scale to assess severity of symptoms after 24 h. We used the Classification and Regression Trees analysis to define the optimal thresholds of diffusion-weighted imaging lesion volume and the National Institutes of Health Stroke Scale after 24 h in patients developing 'malignant' middle cerebral artery infarction. We calculated sensitivity, specificity, positive predictive value, and negative predictive value for two simple predictive models based on acute diffusion-weighted imaging lesion volume alone and acute diffusion-weighted imaging lesion volume together with the National Institutes of Health Stroke Scale after 24 h.ResultsOf 135 patients, 27 (20%) developed a 'malignant' middle cerebral artery infarction. The Classification and Regression Trees analysis identified acute diffusion-weighted imaging lesion ≥78 ml and the National Institutes of Health Stroke Scale score after 24 h ≥22 as optimal cut-offs. Inclusion of the National Institutes of Health Stroke Scale score after 24 h in a simple two-step decision tree increased sensitivity from 0·59 to 0·79, while specificity, positive predictive value, and negative predictive value remained largely unchanged.ConclusionClinical follow-up examination after 24 h helps identify patients at risk of 'malignant' middle cerebral artery infarction that are missed by predictive algorithms based on early diffusion-weighted imaging lesion volume alone.© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.

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