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The importance of brain infarct size and location in predicting outcome after stroke

Age and Ageing, Nov, 1995 by Y. Beloosesky, J.Y. Streifler, A. Burstin, J. Grinblat

Summary

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Fifty-six consecutive elderly ([greater than or equal to] 65 years) patients, admitted for acute stroke to a geriatric department were included in the study and underwent CT scanning. Functional status was graded according to the modified Rankin scale. Three patients had primary intra-cerebral haemorrhage, 22 deep hemispheric infarct, 17 had anterior circulation cortical infarcts, five had posterior circulation infarcts and in nine the CT scan was normal. Stroke risk factors were equally distributed among the different CT scan groups, and all three larger groups had similar rates of non-neurological major complications including death (41%). However, independence in ADL (Rankin 0-2) was observed in 72% of deep infarct survivors, but only 15% of the cortical infarct group (p = 0.0018). For the normal scan group, functional recovery was intermediate. In the cortical infarct group, patients with an infarct of [greater than or equal to] 50 mm mean diameter (five cases) showed worse functional recovery than did eight patients with small infarcts. The mean difference between pre- and post-stroke Rankin score (DR) was 3.4 for the larger infarct patients and 1.9 for the smaller infarct group (p = 0.-027). Pearson correlation revealed a direct relationship between the infarction size and DR (p = 0.039). Such a relationship was not observed for the deep hemispheric group.

Introduction

Stroke represents one of the main causes of invalidity in the elderly population [1-3]. The prognosis for function after brain infarct is mainly related to the severity of the paralysis [4-5], but other features such as decrease in cognition [6, 7], depression, incontinence [8, 9], sensory apraxia, and hemianopsia [10, 11] are also relevant to prognosis.

The relationship between the size and location of infarction and functional prognosis has not been extensively studied. In two previous reports [12, 13], infarct size was found to be inversely related to the rehabilitation ability.

In our study we tried to correlate the infarct size and location as measured by computerized tomographic (CT) scan with the functional outcome following stroke in elderly patients.

Subjects and Methods

The records of all patients over the age of 65 who were admitted to the Department of Geriatrics of Hasharon Hospital, Golda Medical Centre, during the period 1990-92 were reviewed. Three hundred and eighty-one patients had suffered cerebral infarction, but only 56 met the following criteria: 1. The cerebral infarction had developed within a few days before hospitalization; 2. Brain CT was performed 48 hours to 2 weeks after the event. Patients in coma or whose death was expected in the coming few weeks because of a terminal or other disease were excluded, as were patients whose functional ability before the event was not clear.

Neuroimaging: CT examinations were performed with an ELSCINT 2400 ELITE, fourth generation scanner. All the CT scans were reread by our neurologist who did not know the patients. In each case the vascular area of the infarction and its size were determined. In some cases, where the initial CT showed acute infarction without distinct borders, a second CT had been done several days later. The cases were divided into the following groups:

1. Cortical infarctions in the territory of anterior and middle cerebral artery (ACA and MCA), i.e. anterior circulation;

2. Subcortical or deep infarctions in the supply area of perforating arteries or in the internal border zone (Deep);

3. Infarction in the areas of the posterior cerebral and vertebro-basilar arteries (PVB);

4. Normal CT;

5. Intracerebral haemorrhage (ICH).

The maximum size of each infarction was determined from the CT scans as the mean of its length and width. Cortical infarcts of less than 50mm were categorized as small or medium. Deep infarcts of up to 14mm were classified as lacunar infarctions and those of 15 mm or more as large deep infarctions.

Functional evaluation: All our patients and their families were interviewed by physician, nurse and social worker in order to determine pre-stroke function. From the data in the patients' files, a functional score of 0 to 5 was determined using the modified Rankin scale [14]. Scores of 0 to 2 were given to patients with degrees of independence, and scores of 3 to 5 were given to dependent patients, Each patient received two scores. [R.sub.1] for the functional status before the stroke, and [R.sub.2] for the functional status after rehabilitation at the end of hospitalization. The functional difference (DR) was [R.sub.2] - [R.sub.1].

Inter-observer reliability of the Rankin score was assessed. When the Rankin scores were regrouped into three categories, the kappa value was 0.72, and the `R' value of Spearman correlation test between observers was 0.84.

Statistical analysis: The difference in the number of hospitalization days between groups was assessed by the Student's t test. The difference between groups for DR was calculated by the Mann-Whitney test. For determining the differences between groups regarding the degree of independence we used the [[chi].sup.2] test, and the Pearson correlation for assessing the relationship between the size of the infarction and the DR.

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The importance of brain infarct size and location in predicting outcome after stroke

Age and Ageing, Nov, 1995 by Y. Beloosesky, J.Y. Streifler, A. Burstin, J. Grinblat

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