Massive Cerebral Infarction with Severe Brain Swelling: A CLINICOPATHOLOGICAL STUDY

All cases of acute supratentorial cerebral infarction which came to postmortem examination over the past 10 years at the Philadelphia General Hospital were reviewed. Of a total of 353 such cases, 45 showed severe brain swelling. Seventy-eight percent of these 45 patients died within seven days of the acute infarction. The rapidly fatal outcome appeared to be directly related to the acute brain swelling with transtentorial herniation and brain-stem edema or hemorrhage. In those patients who survived longer than one week following onset of the ictus (22%), clinical and anatomic findings suggested that increased intracranial pressure probably did not develop until later in the course of the illness. A second massive infarct was probably superimposed upon an earlier one and produced the acute brain swelling noted at the time of postmortem examination. Complicating visceral diseases were more common in this group and seemed to contribute to death in the majority of these patients. Although it has been established that a large cerebral infarct may produce sufficient brain swelling and simulate an acutely expanding lesion, this is not widely recognized as playing an important part in determining the patient's clinical outcome. The role of increased intracranial pressure resulting from acute brain swelling should not be overlooked in the management of patients with severe strokes.