Predictors of hemorrhagic transformation occurring spontaneously and on anticoagulants in patients with acute ischemic stroke

Andrei Alexandrov, Sandra E. Black, Lisa E. Ehrlich, Curtis B. Caldwell, John W. Norris

Research output: Contribution to journalArticle

102 Citations (Scopus)

Abstract

Background and Purpose: Hemorrhagic transformation (HT) is a common evolution of large-volume ischemic lesions, particularly of cardioembolic origin. We used transcranial Doppler ultrasound (TCD), single-photon emission computed tomography (SPECT) with 99mTc-hexamethylpropyleneamine oxime (HMPAO), and the Toronto Embolic Scale (TES) to decide (1) whether TCD, HMPAO-SPECT, and TES can improve on clinical and CT tests to predict spontaneous HT and (2) whether SPECT can help to predict the outcome of symptomatic HT. Methods: Prognostic criteria included Canadian Neurological Scale (CNS) scores ≤50 on admission, early ischemic changes on CT, MI middle cerebral artery occlusion on TCD, the focal absence of brain perfusion on SPECT, and a high risk of cardiogenic embolism on TES. Results: In part 1, 85 consecutive patients admitted within the first 6 hours were studied. No patient received thrombolysis. HT was found in 11 patients (13%) at 3 to 5 days. Admission CNS and CT were not predictive of HT: odds ratios (95% confidence intervals) were 0.49 (0.18 to 1.23) (P=.1) and 0.88 (0.23 to 3.45) (P=.8), respectively. TCD, SPECT, and TES were significant predictors of HT (P<.05), as follows: TCD, 8.67 (1.42 to 70.59); SPECT. 17.40 (2.69 to 170.89); and TES, 18.13 (2.6 to 406.86). In part 2, 490 consecutive patients were studied and 21 (4%) had symptomatic HT, of which 12 had focal hypoperfusion on SPECT at 4 days after stroke onset and 9 had focal hyperperfusion. Patients with hypoperfusion had larger CT lesions (115±97 versus 42±29 cm3; P=.04) and poorer outcome at 2 weeks (CNS, 38±45 versus 96±10: P=.001), including death (6/12 versus 0/9; P=.04), compared with those with hyperperfusion on SPECT. Conclusions: High risk of cardioembolism, MI middle cerebral artery occlusion, and absence of collateral flow evaluated by TES, TCD, and SPECT help to identify patients at risk for spontaneous HT. Although TES was the most powerful predictor of HT, SPECT is the best single adjunct to the triage of clinical and CT tests. Patients with brain hyperperfusion on HMPAO-SPECT after symptomatic HT have better chances for recovery.

Original languageEnglish (US)
Pages (from-to)1198-1202
Number of pages5
JournalStroke
Volume28
Issue number6
DOIs
StatePublished - Jan 1 1997
Externally publishedYes

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Single-Photon Emission-Computed Tomography
Anticoagulants
Stroke
Doppler Ultrasonography
Middle Cerebral Artery Infarction
Triage
Brain
Embolism
Perfusion
Odds Ratio
Confidence Intervals

All Science Journal Classification (ASJC) codes

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Predictors of hemorrhagic transformation occurring spontaneously and on anticoagulants in patients with acute ischemic stroke. / Alexandrov, Andrei; Black, Sandra E.; Ehrlich, Lisa E.; Caldwell, Curtis B.; Norris, John W.

In: Stroke, Vol. 28, No. 6, 01.01.1997, p. 1198-1202.

Research output: Contribution to journalArticle

Alexandrov, Andrei ; Black, Sandra E. ; Ehrlich, Lisa E. ; Caldwell, Curtis B. ; Norris, John W. / Predictors of hemorrhagic transformation occurring spontaneously and on anticoagulants in patients with acute ischemic stroke. In: Stroke. 1997 ; Vol. 28, No. 6. pp. 1198-1202.
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abstract = "Background and Purpose: Hemorrhagic transformation (HT) is a common evolution of large-volume ischemic lesions, particularly of cardioembolic origin. We used transcranial Doppler ultrasound (TCD), single-photon emission computed tomography (SPECT) with 99mTc-hexamethylpropyleneamine oxime (HMPAO), and the Toronto Embolic Scale (TES) to decide (1) whether TCD, HMPAO-SPECT, and TES can improve on clinical and CT tests to predict spontaneous HT and (2) whether SPECT can help to predict the outcome of symptomatic HT. Methods: Prognostic criteria included Canadian Neurological Scale (CNS) scores ≤50 on admission, early ischemic changes on CT, MI middle cerebral artery occlusion on TCD, the focal absence of brain perfusion on SPECT, and a high risk of cardiogenic embolism on TES. Results: In part 1, 85 consecutive patients admitted within the first 6 hours were studied. No patient received thrombolysis. HT was found in 11 patients (13{\%}) at 3 to 5 days. Admission CNS and CT were not predictive of HT: odds ratios (95{\%} confidence intervals) were 0.49 (0.18 to 1.23) (P=.1) and 0.88 (0.23 to 3.45) (P=.8), respectively. TCD, SPECT, and TES were significant predictors of HT (P<.05), as follows: TCD, 8.67 (1.42 to 70.59); SPECT. 17.40 (2.69 to 170.89); and TES, 18.13 (2.6 to 406.86). In part 2, 490 consecutive patients were studied and 21 (4{\%}) had symptomatic HT, of which 12 had focal hypoperfusion on SPECT at 4 days after stroke onset and 9 had focal hyperperfusion. Patients with hypoperfusion had larger CT lesions (115±97 versus 42±29 cm3; P=.04) and poorer outcome at 2 weeks (CNS, 38±45 versus 96±10: P=.001), including death (6/12 versus 0/9; P=.04), compared with those with hyperperfusion on SPECT. Conclusions: High risk of cardioembolism, MI middle cerebral artery occlusion, and absence of collateral flow evaluated by TES, TCD, and SPECT help to identify patients at risk for spontaneous HT. Although TES was the most powerful predictor of HT, SPECT is the best single adjunct to the triage of clinical and CT tests. Patients with brain hyperperfusion on HMPAO-SPECT after symptomatic HT have better chances for recovery.",
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AU - Black, Sandra E.

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AU - Caldwell, Curtis B.

AU - Norris, John W.

PY - 1997/1/1

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N2 - Background and Purpose: Hemorrhagic transformation (HT) is a common evolution of large-volume ischemic lesions, particularly of cardioembolic origin. We used transcranial Doppler ultrasound (TCD), single-photon emission computed tomography (SPECT) with 99mTc-hexamethylpropyleneamine oxime (HMPAO), and the Toronto Embolic Scale (TES) to decide (1) whether TCD, HMPAO-SPECT, and TES can improve on clinical and CT tests to predict spontaneous HT and (2) whether SPECT can help to predict the outcome of symptomatic HT. Methods: Prognostic criteria included Canadian Neurological Scale (CNS) scores ≤50 on admission, early ischemic changes on CT, MI middle cerebral artery occlusion on TCD, the focal absence of brain perfusion on SPECT, and a high risk of cardiogenic embolism on TES. Results: In part 1, 85 consecutive patients admitted within the first 6 hours were studied. No patient received thrombolysis. HT was found in 11 patients (13%) at 3 to 5 days. Admission CNS and CT were not predictive of HT: odds ratios (95% confidence intervals) were 0.49 (0.18 to 1.23) (P=.1) and 0.88 (0.23 to 3.45) (P=.8), respectively. TCD, SPECT, and TES were significant predictors of HT (P<.05), as follows: TCD, 8.67 (1.42 to 70.59); SPECT. 17.40 (2.69 to 170.89); and TES, 18.13 (2.6 to 406.86). In part 2, 490 consecutive patients were studied and 21 (4%) had symptomatic HT, of which 12 had focal hypoperfusion on SPECT at 4 days after stroke onset and 9 had focal hyperperfusion. Patients with hypoperfusion had larger CT lesions (115±97 versus 42±29 cm3; P=.04) and poorer outcome at 2 weeks (CNS, 38±45 versus 96±10: P=.001), including death (6/12 versus 0/9; P=.04), compared with those with hyperperfusion on SPECT. Conclusions: High risk of cardioembolism, MI middle cerebral artery occlusion, and absence of collateral flow evaluated by TES, TCD, and SPECT help to identify patients at risk for spontaneous HT. Although TES was the most powerful predictor of HT, SPECT is the best single adjunct to the triage of clinical and CT tests. Patients with brain hyperperfusion on HMPAO-SPECT after symptomatic HT have better chances for recovery.

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