(Stroke. 1997;28:1198-1202.)
© 1997 American Heart Association, Inc.
Articles |
Predictors of Hemorrhagic Transformation Occurring Spontaneously and on Anticoagulants in Patients With Acute Ischemic Stroke
From the Divisions of Neurology (A.V.A., S.E.B., J.W.N.), Nuclear Medicine (L.E.E.), and Medical Imaging (C.B.C.), Sunnybrook Health Science Center, University of Toronto (Ontario, Canada).
Correspondence to Dr Andrei Alexandrov, Stroke Program, Department of Neurology, University of Texas at Houston, MSB 7.044 6431 Fannin St, Houston, TX 77030. E-mail avalexandrov{at}worldnet.att.net
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, M1 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, M1 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.
Key Words: embolism • hemorrhagic stroke • tomography, emission computed • ultrasonics
This article has been cited by other articles:
 |
|
 |
|
  D. Summers, A. Leonard, D. Wentworth, J. L. Saver, J. Simpson, J. A. Spilker, N. Hock, E. Miller, P. H. Mitchell, and on behalf of the American Heart Association Counci Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement From the American Heart Association Stroke, August 1, 2009; 40(8): 2911 - 2944. [Full Text] [PDF]
|
|
|
|
|
|
M. Paciaroni, G. Agnelli, F. Corea, W. Ageno, A. Alberti, A. Lanari, V. Caso, S. Micheli, L. Bertolani, M. Venti, et al. Early Hemorrhagic Transformation of Brain Infarction: Rate, Predictive Factors, and Influence on Clinical Outcome: Results of a Prospective Multicenter Study Stroke, August 1, 2008; 39(8): 2249 - 2256. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Sarkar, S. Ghosh, S. K. Ghosh, and A. Collier Role of transcranial Doppler ultrasonography in stroke Postgrad. Med. J., November 1, 2007; 83(985): 683 - 689. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Khatri, L. R. Wechsler, and J. P. Broderick Intracranial Hemorrhage Associated With Revascularization Therapies Stroke, February 1, 2007; 38(2): 431 - 440. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. C. Alsop, E. Makovetskaya, S. Kumar, M. Selim, and G. Schlaug Markedly Reduced Apparent Blood Volume on Bolus Contrast Magnetic Resonance Imaging as a Predictor of Hemorrhage After Thrombolytic Therapy for Acute Ischemic Stroke Stroke, April 1, 2005; 36(4): 746 - 750. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Pfaffenberger, B. Devcic-Kuhar, C. Kollmann, S. P. Kastl, C. Kaun, W. S. Speidl, T. W. Weiss, S. Demyanets, R. Ullrich, H. Sochor, et al. Can a Commercial Diagnostic Ultrasound Device Accelerate Thrombolysis?: An In Vitro Skull Model Stroke, January 1, 2005; 36(1): 124 - 128. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Ribo, J. Montaner, C. A. Molina, J. F. Arenillas, E. Santamarina, M. Quintana, and J. Alvarez-Sabin Admission Fibrinolytic Profile Is Associated With Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Tissue Plasminogen Activator Stroke, September 1, 2004; 35(9): 2123 - 2127. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. A. Sloan, A. V. Alexandrov, C. H. Tegeler, M. P. Spencer, L. R. Caplan, E. Feldmann, L. R. Wechsler, D. W. Newell, C. R. Gomez, V. L. Babikian, et al. Assessment: Transcranial Doppler ultrasonography: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Neurology, May 11, 2004; 62(9): 1468 - 1481. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. S. Liebeskind Collateral Circulation Stroke, September 1, 2003; 34(9): 2279 - 2284. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Seitz, M. Hamzavi, U. Junghans, P. A. Ringleb, C. Schranz, and M. Siebler Thrombolysis With Recombinant Tissue Plasminogen Activator and Tirofiban in Stroke: Preliminary Observations Stroke, August 1, 2003; 34(8): 1932 - 1935. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. P. Adams Jr, R. J. Adams, T. Brott, G. J. del Zoppo, A. Furlan, L. B. Goldstein, R. L. Grubb, R. Higashida, C. Kidwell, T. G. Kwiatkowski, et al. Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke Association Stroke, April 1, 2003; 34(4): 1056 - 1083. [Full Text] [PDF]
|
|
|
|
|
|
A.K. Gilligan, R. Markus, S. Read, V. Srikanth, T. Hirano, G. Fitt, M. Arends, B.R. Chambers, S.M. Davis, and G.A. Donnan Baseline Blood Pressure but Not Early Computed Tomography Changes Predicts Major Hemorrhage After Streptokinase in Acute Ischemic Stroke Stroke, September 1, 2002; 33(9): 2236 - 2242. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Selim, J. N. Fink, S. Kumar, L. R. Caplan, C. Horkan, Y. Chen, I. Linfante, and G. Schlaug Predictors of Hemorrhagic Transformation After Intravenous Recombinant Tissue Plasminogen Activator: Prognostic Value of the Initial Apparent Diffusion Coefficient and Diffusion-Weighted Lesion Volume Stroke, August 1, 2002; 33(8): 2047 - 2052. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Nighoghossian, M. Hermier, P. Adeleine, K. Blanc-Lasserre, L. Derex, J. Honnorat, F. Philippeau, J.F. Dugor, J.C. Froment, and P. Trouillas Old Microbleeds Are a Potential Risk Factor for Cerebral Bleeding After Ischemic Stroke: A Gradient-Echo T2*-Weighted Brain MRI Study Stroke, March 1, 2002; 33(3): 735 - 742. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Sugawara, T. Ueda, T. Kikuchi, N. Yamamoto, Y. Semba, S. Nakata, T. Mochizuki, and J. Ikezoe Hyperactivity of 99mTc-HMPAO Within 6 Hours in Patients with Acute Ischemic Stroke J. Nucl. Med., September 1, 2001; 42(9): 1297 - 1302. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. A. Molina, J. Montaner, S. Abilleira, B. Ibarra, F. Romero, J. F. Arenillas, and J. Alvarez-Sabin Timing of Spontaneous Recanalization and Risk of Hemorrhagic Transformation in Acute Cardioembolic Stroke Stroke, May 1, 2001; 32(5): 1079 - 1084. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Shibata, S. R. Kumar, A. Amar, J. A. Fernandez, F. Hofman, J. H. Griffin, and B. V. Zlokovic Anti-Inflammatory, Antithrombotic, and Neuroprotective Effects of Activated Protein C in a Murine Model of Focal Ischemic Stroke Circulation, April 3, 2001; 103(13): 1799 - 1805. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. C. Tong, A. Adami, M. E. Moseley, and M. P. Marks Prediction of Hemorrhagic Transformation Following Acute Stroke: Role of Diffusion- and Perfusion-Weighted Magnetic Resonance Imaging Arch Neurol, April 1, 2001; 58(4): 587 - 593. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Umemura, T. Suzuka, and K. Yamada Quantitative measurement of cerebral blood flow by 99mTc-HMPAO SPECT in acute ischaemic stroke: usefulness in determining therapeutic options J. Neurol. Neurosurg. Psychiatry, October 1, 2000; 69(4): 472 - 478. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. C. Tong, A. Adami, M. E. Moseley, and M. P. Marks Relationship Between Apparent Diffusion Coefficient and Subsequent Hemorrhagic Transformation Following Acute Ischemic Stroke Stroke, October 1, 2000; 31(10): 2378 - 2384. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Isaka, S. Furukawa, H. Etani, E. Nakanishi, Y. Ooe, and M. Imaizumi Noninvasive Measurement of Cerebral Blood Flow With 99mTc-Hexamethylpropyleneamine Oxime Single-Photon Emission Computed Tomography and 1-Point Venous Blood Sampling Stroke, September 1, 2000; 31(9): 2203 - 2207. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. E. Mayer, G. F. Hamann, J. Baranczyk, B. Rosengarten, E. Klotz, M. Wiesmann, U. Missler, G. Schulte-Altedorneburg, and H. J. Brueckmann Dynamic CT Perfusion Imaging of Acute Stroke AJNR Am. J. Neuroradiol., August 1, 2000; 21(8): 1441 - 1449. [Abstract] [Full Text]
|
|
|
|
|
|
A. Jaillard, C. Cornu, A. Durieux, T. Moulin, F. Boutitie, K. R. Lees, and M. Hommel Hemorrhagic Transformation in Acute Ischemic Stroke : The MAST-E Study Stroke, July 1, 1999; 30(7): 1326 - 1332. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Juni and Spicer Paradoxical Hyperfixation of HMPAO in Cerebral AJNR Am. J. Neuroradiol., May 1, 1999; 20(5): 732 - 733. [Full Text]
|
|
|
|
|
|
A. V. Alexandrov, J. C. Masdeu, M. D. Devous Sr, S. E. Black, and J. C. Grotta Brain Single-Photon Emission CT With HMPAO and Safety of Thrombolytic Therapy in Acute Ischemic Stroke : Proceedings of the Meeting of the SPECT Safe Thrombolysis Study Collaborators and the Members of the Brain Imaging Council of the Society of Nuclear Medicine Stroke, September 1, 1997; 28(9): 1830 - 1834. [Abstract] [Full Text]
|
|