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

2020 ◽  
Vol 33 (2) ◽  
pp. 118-133 ◽  
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.

scholarly journals The Role of Edema in Subacute Lesion Progression After Treatment of Acute Ischemic Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Praneeta Konduri ◽  
Katinka van Kranendonk ◽  
Anna Boers ◽  
Kilian Treurniet ◽  
Olvert Berkhemer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Water Uptake ◽  
Infarct Volume ◽  
Lesion Volume ◽  
Ischemic Lesion ◽  
Contrast Ct ◽  
Mr Clean

Background: Ischemic lesions commonly continue to progress even days after treatment, and this lesion growth is associated with unfavorable functional outcome in acute ischemic stroke patients. The aim of this study is to elucidate the role of edema in subacute lesion progression and its influence on unfavorable functional outcome by quantifying net water uptake.Methods: We included all 187 patients from the MR CLEAN trial who had high quality follow-up non-contrast CT at 24 h and 1 week. Using a CT densitometry-based method to calculate the net water uptake, we differentiated total ischemic lesion volume (TILV) into edema volume (EV) and edema-corrected infarct volume (ecIV). We calculated these volumes at 24 h and 1 week after stroke and determined their progression in the subacute period. We assessed the effect of 24-h lesion characteristics on EV and ecIV progression. We evaluated the influence of edema and edema-corrected infarct progression on favorable functional outcome after 90 days (modified Rankin Scale: 0–2) after correcting for potential confounders. Lastly, we compared these volumes between subgroups of patients with and without successful recanalization using the Mann–Whitney U-test.Results: Median TILV increased from 37 (IQR: 18–81) ml to 68 (IQR: 30–130) ml between 24 h and 1 week after stroke, while the net water uptake increased from 22 (IQR: 16–26)% to 27 (IQR: 22–32)%. The TILV progression of 20 (8.8–40) ml was mostly caused by ecIV with a median increase of 12 (2.4–21) ml vs. 6.5 (2.7–15) ml of EV progression. Larger TILV, EV, and ecIV volumes at 24 h were all associated with more edema and lesion progression. Edema progression was associated with unfavorable functional outcome [aOR: 0.53 (0.28–0.94) per 10 ml; p-value: 0.05], while edema-corrected infarct progression showed a similar, non-significant association [aOR: 0.80 (0.62–0.99); p-value: 0.06]. Lastly, edema progression was larger in patients without successful recanalization, whereas ecIV progression was comparable between the subgroups.Conclusion: EV increases in evolving ischemic lesions in the period between 1 day and 1 week after acute ischemic stroke. This progression is larger in patients without successful recanalization and is associated with unfavorable functional outcome. However, the extent of edema cannot explain the total expansion of ischemic lesions since edema-corrected infarct progression is larger than the edema progression.

scholarly journals Associations of Ischemic Lesion Volume With Functional Outcome in Patients With Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (5) ◽  
pp. 1233-1240 ◽  
Author(s):  
Amber Bucker ◽  
Anna M. Boers ◽  
Joseph C.J. Bot ◽  
Olvert A. Berkhemer ◽  
Hester F. Lingsma ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Lesion Volume ◽  
Ischemic Lesion

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

Stroke ◽  
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.

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

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Matt Parker ◽  
Andrew Matthews ◽  
Neal Rutledge ◽  
Kirk Conrad ◽  
Jeff Luci
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Ct Perfusion ◽  
Hemorrhagic Transformation ◽  
Permeability Change ◽  
Permeability Changes ◽  
Permeability Surface ◽  
Surface Product ◽  
Iv Tpa

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.

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

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.

scholarly journals Neutrophil-to-lymphocyte Ratio as a Risk Determinant of Hemorrhage Transformation in Acute Ischemic Stroke

2020 ◽  
pp. 8-16
Author(s):  
Shuang Ma ◽  
Bilal Muhammad ◽  
Shu Kan ◽  
Zhen-Ying Shang ◽  
Li Wang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multivariate Logistic Regression Analysis ◽  
Hemorrhagic Transformation ◽  
Neutrophil To Lymphocyte Ratio ◽  
Optimal Cutoff ◽  
Ischemic Lesion ◽  
Lymphocyte Ratio ◽  
Independent Risk Factors

Objective: The purpose of this study was to investigate the clinical significance between neutrophil-to-lymphocyte ratio (NLR) and classification of non-thrombolytic hemorrhagic transformation (HT) in acute ischemic stroke (AIS), to unravel new diagnostic approach. Methods: We recruited and selected 636 patients who did not undergo thrombolytic therapy between May 2018 and April 2019 at the Affiliated Hospital of Xuzhou Medical University. The laboratory and clinical data were collected within 24 h after the onset of AIS. Based on the status of HT development during hospitalization, all participants were divided into three groups, namely, the non-HT (NHT) group, hemorrhagic infarction (HI) group, and parenchymal hematoma (PH) group. Results: Multivariate logistic regression analysis showed that NLR and the ischemic lesion diameter are independent risk factors of HI and PH, while the score of National Institutes of Health Stroke Scale (NIHSS) and cardioembolism are considered to be independent risk factors for PH only. Receiver operating characteristic (ROC) analysis determined that the optimal cutoff values of NLR in HI group and PH group were 3.75 and 3.97, respectively. The optimal cutoff value can be used as the critical value for the unfavorable outcome. Conclusion: NLR values were significantly increased and correlated with both HI and PH groups and NLR could be used as a predictor of both HI and PH.

Impact of Collateral Status on Neuroprotective Effect of Cyclosporine A in Acute Ischemic Stroke

2019 ◽  
Vol 16 (2) ◽  
pp. 173-177
Author(s):  
Norbert Nighoghossian ◽  
Lucie Cornut ◽  
Camille Amaz ◽  
Omer Eker ◽  
Nathan Mewton ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cyclosporine A ◽  
Neuroprotective Effect ◽  
Additional Benefit ◽  
Lesion Volume ◽  
Dynamic Susceptibility ◽  
Collateral Flow ◽  
Dynamic Susceptibility Contrast ◽  
Ischemic Lesion

Background: Neuroprotection for acute ischemic stroke remains an elusive goal. Intracranial collaterals may favor neuroprotective drugs delivery at the acute stage of ischemic stroke. A recent phase 2 study showed that cyclosporine A (CsA) reduced ischemic damage in patients with a proximal occlusion who experienced effective recanalization. Collateral flow may improve this benefit. Materials & Methods: Collateral supply was assessed using dynamic susceptibility contrast MRI in 47 patients among the 110 patients from the original study and were graded in two groups: good collaterals and poor collaterals. Patients with good collaterals had significantly smaller initial infarct in both CsA group (p = 0.003) and controls (p = 0.016). Similarly, the final lesion volume was significantly lower in patients with good collaterals in both groups. Results: In patients with either good or poor collaterals CsA showed no additional benefit on ischemic lesion progression and final infarct size at day 30. Conclusion: We failed to demonstrate any significant additional benefit of CsA in patients with good collateral circulation.

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

2018 ◽  
Vol 53 (1) ◽  
pp. 25-30 ◽  
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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