(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
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