Abstract W P46: Permeability Surface Product as a Predictor of Hemorrhagic Transformation in Acute Ischemic Stroke Intervention

Introduction/purpose: A significant complication in the intervention of acute ischemic stroke is hemorrhagic transformation (HT). It has been postulated that perfusion permeability imaging showing increased blood brain barrier permeability can be used to predict hemorrhagic transformation and possibly alter therapies. Materials and Methods: We retrospectively reviewed 1040 sequential CT perfusion scans with permeability surface area product maps calculated using the Patlak model for all patients that exhibited stroke like symptoms between October 2011 and November 2012. The size of the permeability surface product was ranked on a qualitative three-part scale of small, moderate and large permeability changes. A change smaller than 25% of the image was considered a small result. A moderate result is a permeability change that is approximately 25% of the image. A large permeability change exceeds 25% of the image. Follow up non-contrast CT images (>24 hours but <15 days after initial perfusion imaging) were used to determine if HT had occurred in the cases where an increase in permeability surface product was observed. Results: There was a positive increase in permeability maps in 142 of the 1040 cases. The size of the permeability change was moderate to large in 101 of the positive cases (71%). Hemorrhagic transformation was observed in 12 patients that showed an increase in permeability surface product (8.4%). Of the cases that resulted in HT, nine (75%) resulted in an HI1 and HI2 subtypes. There were three (25%) of the more severe parenchymal hemorrhages (PH1, PH2) observed. Out of the 12 positive hemorrhagic transformations four (33%) were treated with iv-TPA and two (17%) received endovascular thrombectomies, while six (50%) did not receive TPA or endovascular intervention. Of the major parenchymal hemorrhages (PH1/2) two occurred after iv-TPA treatment of the stroke, with the other arising after endovascular thrombectomy. No difference was found in the size or degree of the permeability changes and the incidence of HT. Conclusions: Elevated permeability on CT perfusion imaging had no relevant predictive value for hemorrhagic transformation in acute ischemic stroke at our institution.

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Abstract W P63: Intravenous Thrombolysis for Acute Ischemic Stroke in Nonagenarians

Stroke ◽

10.1161/str.46.suppl_1.wp63 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Raul Guisado ◽

Reza Malek ◽

Ursula Kelly-Tolley ◽

Arash Padidar ◽

Harmeet Sachdev

Keyword(s):

Ischemic Stroke ◽

Mortality Rate ◽

Acute Ischemic Stroke ◽

Ct Perfusion ◽

Intravenous Thrombolysis ◽

Hemorrhagic Transformation ◽

Early Improvement ◽

Hospital Patients ◽

Contrast Ct ◽

Overall Mortality

The safety and effectiveness of intravenous thrombolysis for acute ischemic stroke (AIS) has been established for populations older than 80 years of age . However, management of AIS in nonagenerians is not clear. Previous reports suggest that the rate of ICH after i.v. alteplase is not increased and the rate of early improvement is similar in nonagenerians compared to younger groups, but there is concern with overall mortality and functional outcomes. We report on 20 consecutive patients with AIS treated with i.v. alteplase within 3 hours of onset in two Comprehensive Stroke Centers in San Jose, CA. Methods: Patients were immediately evaluated by members of the Stroke Team of each hospital. . Patients were eligible if they had disabling neurological symptoms, no contraindications for i.v.alteplase and were independent in ADLs prior to the index event. Non-contrast CT brain scan, CT perfusion and CT angiography of head and neck were used to determine the presence of potentially salvageable brain. Results (Table): Mean age was 91 years (range 90 - 98 years). The initial NIHSS was 15.7 ± 6.8. The median NIHSS at hospital discharge was 7.4 ± 8.4 (p <0.001). The median door to needle time was 50.5 minutes (range 36 - 74 minutes). There was no hemorrhagic transformation and no in-hospital mortality. The overall mortality rate at 90 days was 30% (6 of 20 patients) and the rate of good outcome in survivors, defined as mRS ≤ 3 at 90 days was 35.7% (5 of 14 patients). Comment: Intravenous thrombolysis for ischemic stroke in nonagenerians is safe and effective, with good rates of immediate improvement. However, the l90 days mortality rate is high and the long term functional outcome is poor. This data can be useful in helping families make treatment decisions in the most elderly patients with acute ischemic stroke.

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Intravenous thrombolysis in acute ischemic stroke patients with negative CT perfusion: a case series

Acta Radiologica Short Reports ◽

10.1177/2047981614543219 ◽

2014 ◽

Vol 3 (7) ◽

pp. 204798161454321

Author(s):

Ratnesh Mehra ◽

Chiu Yuen To ◽

Omar Qahwash ◽

Boyd Richards ◽

Richard D Fessler

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Perfusion ◽

Case Series ◽

Intravenous Thrombolysis ◽

Hemorrhagic Transformation ◽

Tissue Type ◽

Stroke Patients ◽

Radiographic Findings ◽

Type Plasminogen Activator

Background Computed tomography perfusion (CTP) is a commonly used modality of neurophysiologic imaging to aid the selection of acute ischemic stroke patients for neuroendovascular intervention by identifying the presence of penumbra versus infarcted brain tissue. However many patients present with evidence of cerebral ischemia with normal CTP, and in that case, should intravenous thrombolytics be given? Purpose To demonstrate if tissue-type plasminogen activator (tPA)-eligible stroke patients without perfusion defects demonstrated on CTP would benefit from administration of intravenous thrombolytics. Material and Methods We retrospectively identified patients presenting with acute ischemic symptoms who received intravenous tPA (IV-tPA) from January to June 2012 without a perfusion defect on CTP. Clinical and radiographic findings including the NIHSS at presentation, 24 h, and at discharge, symptomatic and asymptomatic hemorrhagic transformation, and the modified Rankin score at 30 days were collected. A reduction of NIHSS of greater than 4 points or resolution of symptoms was considered significant. Results Seventeen patients were identified with a mean NIHSS of 8.2 prior to administration of intravenous thrombolytics, 3.5 after 24 h, and 2.5 at discharge. Among them, 13 patients had significant improvement of NIHSS with a mean reduction of 6.15 points at 24 h. One patient initially improved but had delayed hemorrhagic transformation and died. Two patients had improvement in NIHSS but were not significant and two patients had increased in NIHSS at 24 h, although one eventually improved at discharge. There was no asymptomatic hemorrhagic transformation. Mean mRS at 3 months is 1.76. Conclusion The failure to identify a perfusion deficit by CTP should not be used as a contraindication for intravenous thrombolytics. Criteria for administration of intravenous thrombolytics should still be based on time from symptom onset as previously published by NINDS.

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Automated CT perfusion imaging for acute ischemic stroke

Neurology ◽

10.1212/wnl.0000000000008481 ◽

2019 ◽

pp. 10.1212/WNL.0000000000008481 ◽

Cited By ~ 4

Author(s):

Achala Vagal ◽

Max Wintermark ◽

Kambiz Nael ◽

Andrew Bivard ◽

Mark Parsons ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Perfusion Imaging ◽

Ct Perfusion ◽

Ct Perfusion Imaging

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Abstract WMP15: A Simple Tool to Predict Target Mismatch in Ischemic Stroke Patients with Anterior Circulation Occlusion

Stroke ◽

10.1161/str.48.suppl_1.wmp15 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Adam de Havenon ◽

Steve O’Donnell ◽

Alex Linn ◽

Scott McNally ◽

Bailey Dunleavy ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Perfusion Imaging ◽

Time Window ◽

Ct Perfusion ◽

Volumetric Analysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Ct Angiogram

Introduction: The efficacy of endovascular thrombectomy in an extended time window for acute ischemic stroke patients with Target Mismatch (TM) on perfusion imaging was shown in a recent study and the ongoing DEFUSE-3 trial is studying thrombectomy in a 6-16 hour window for TM patients. A limitation of TM is that perfusion imaging is not widely available. We sought to identify a tool to predict TM based on clinical factors and CT angiogram (CTA) imaging, which is available at most hospitals. Methods: We reviewed acute ischemic stroke patients from 2010-2014 with proximal middle cerebral artery occlusion, CTA and CT perfusion (CTP) at hospital admission. TM was identified on CTP using the Olea Sphere volumetric analysis software with Bayesian deconvolution. TM was defined by the DEFUSE-3 criteria. ASPECTS was derived from the non-contrast CT head and the CTA source images (CTA-ASPECTS). Two collateral scores were derived from CTA source images. Results: 61 patients met inclusion criteria. The mean±SD age was 61±18 years and 61% were male. Mean NIH Stroke Scale (NIHSS) was 14.1±8.0 and median (IQR) follow-up modified Rankin Scale was 3 (1,6). TM was present in 35/61 (57%), who had lower mRS at follow-up (z=3.5, p<0.001). The predictor variables are shown in Table 1. The best combination of predictors was CTA-ASPECTS >4 and NIHSS <16, which had a sensitivity of 80% and specificity of 85% for TM (Figure 1). Discussion: We report a reliable, accessible, and clinically useful tool for predicting TM. This score warrants further study as a tool to guide transfer decisions from primary or secondary stroke centers to tertiary centers where endovascular intervention would be possible for selected patients.

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Dynamic CT Perfusion Imaging for the Detection of Crossed Cerebellar Diaschisis in Acute Ischemic Stroke

Korean Journal of Radiology ◽

10.3348/kjr.2012.13.1.12 ◽

2012 ◽

Vol 13 (1) ◽

pp. 12 ◽

Cited By ~ 22

Author(s):

Young Wook Jeon ◽

Seo Hyun Kim ◽

Ji Yong Lee ◽

Kum Whang ◽

Myung Soon Kim ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Perfusion Imaging ◽

Ct Perfusion ◽

Dynamic Ct ◽

Crossed Cerebellar Diaschisis ◽

Ct Perfusion Imaging ◽

Cerebellar Diaschisis

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Radiological predictors of hemorrhagic transformation after acute ischemic stroke: An evidence-based analysis

The Neuroradiology Journal ◽

10.1177/1971400919900275 ◽

2020 ◽

Vol 33 (2) ◽

pp. 118-133 ◽

Cited By ~ 1

Author(s):

Nada Elsaid ◽

Wessam Mustafa ◽

Ahmed Saied

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Perfusion ◽

Treatment Plan ◽

Hemorrhagic Transformation ◽

Lesion Volume ◽

Ischemic Lesion ◽

Blood Brain Barrier Disruption

Hemorrhagic transformation (HT) is one of the most common adverse events related to acute ischemic stroke (AIS) that affects the treatment plan and clinical outcome. Identification of a sensitive radiological marker may influence the controversial thrombolytic decision in the setting of AIS and may at a minimum indicate more intensive monitoring or further prophylactic interventions. In this article we summarize possible radiological biomarkers and the role of different radiological modalities including computed tomography (CT), magnetic resonance imaging, angiography, and ultrasound in predicting HT. Different radiological indices of early ischemic changes, large ischemic lesion volume, severe blood flow restriction, blood-brain barrier disruption, poor collaterals and high blood flow velocities have been reported to be associated with higher risk of HT. The current levels of evidence of the available studies highlight the role of the different CT perfusion parameters in predicting HT. Further large standardized studies are recommended to compare the sensitivity and specificity of the different radiological markers combined and delineate the most reliable predictor.

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Clinical application value of brain CT perfusion imaging in the treatment of acute ischemic stroke thrombolytic therapy

Experimental and Therapeutic Medicine ◽

10.3892/etm.2019.7431 ◽

2019 ◽

Cited By ~ 2

Author(s):

Shiming Xu ◽

Li Wang ◽

Lidong Zhao

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Clinical Application ◽

Perfusion Imaging ◽

Ct Perfusion ◽

Brain Ct ◽

Ct Perfusion Imaging

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Infarct-core CT perfusion parameters in predicting post-thrombolysis hemorrhagic transformation of acute ischemic stroke

Radiology and Oncology ◽

10.2478/raon-2018-0048 ◽

2018 ◽

Vol 53 (1) ◽

pp. 25-30 ◽

Cited By ~ 2

Author(s):

Crt Langel ◽

Katarina Surlan Popovic

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Receiver Operating Characteristic ◽

Operating Characteristic ◽

Receiver Operating Characteristic Analysis ◽

Ct Perfusion ◽

Hemorrhagic Transformation ◽

Characteristic Analysis ◽

Infarct Core ◽

Receiver Operating

Abstract Background Intravenous thrombolysis (IVT) is the method of choice in reperfusion treatment of patients with signs and symptoms of acute ischemic stroke (AIS) lasting less than 4.5 hours. Hemorrhagic transformation (HT) of acute ischemic stroke is a serious complication of IVT and occurs in 4.5–68.0% of clinical cases. The aim of our study was to determine the infarct core CT perfusion parameter (CTPP) most predictive of HT. Patients and methods Seventy-five patients with AIS who had undergone CT perfusion (CTP) imaging and were treated with IVT were enrolled in this retrospective study. Patients with and without HT after IVT were defined as cases and controls, respectively. Controls were found by matching for time from AIS symptom onset to IVT ± 0.5 h. The following CTPPs were measured: cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), relative CBF (rCBF) and relative CBV (rCBV). Receiver operating characteristic analysis curves of significant CTPPs determined cut-off values that best predict HT. Results There was a significant difference between cases and controls for CBF (p = 0.004), CBV (p = 0.009), rCBF (p < 0.001) and rCBV (p = 0.001). Receiver operating characteristic analysis revealed that rCBF < 4.5% of the contralateral mean (area under the curve = 0.736) allowed prediction of HT with a sensitivity of 71.0% and specificity of 52.5%. Conclusions CTP imaging has a considerable role in HT prediction, assisting in selection of patients that are likely to benefit from IVT. rCBF proved to have the highest HT predictive value.

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