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(Stroke. 1995;26:816-821.)
© 1995 American Heart Association, Inc.

Articles

Comparative Correlations of HMPAO SPECT Indices, Neurological Score, and Stroke Subtypes With Clinical Outcome in Acute Carotid Infarcts

Patrice Laloux, MD; Fabienne Richelle, MD; Jacques Jamart, MD; Patrick De Coster, MD Christian Laterre, MD, PhD

From the Departments of Neurology (P.L., C.L.) and Nuclear Medicine (F.R., P. De C.) and the Biostatistics Center (J.J.), Mont-Godinne University Hospital (Medical School of the University of Louvain), Yvoir, Belgium.

Correspondence to Patrice Laloux, MD, Mont-Godinne University Hospital, B-5530 Yvoir, Belgium.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose The prognostic value of single-photon emission computed tomography (SPECT) remains controversial. The aim of this study was to compare the prognostic value of stroke severity, stroke subtypes, and SPECT indices and to determine which predictive factors have an independent effect on clinical outcome.

Methods We studied 55 consecutive patients with acute (<12 hours) carotid infarct within 36 hours of symptom onset with SPECT. Clinical presentation was assessed by the Canadian Neurological Scale and stroke subtypes. SPECT indices were the degree and size of hypoperfusion and crossed cerebellar diaschisis as assessed by a semiquantitative analysis. Outcome was evaluated by the functional status and mortality (Rankin Scale score at 1 month).

Results The Rankin Scale score correlated with the degree (r=.580; P<.00001) and size (r=.616; P<.00001) of hypoperfusion. The mean degree and size of hypoperfusion were significantly higher in patients with poor outcome. Crossed cerebellar diaschisis had no significant predictive value. Statistical analysis determined threshold values for the Canadian Neurological Scale score and the degree and size of hypoperfusion for the functional status and mortality. The degree and size of hypoperfusion had no higher performance than the Canadian Neurological Scale score. The negative predictive value was excellent for both clinical and SPECT indices. Multivariate analysis selected only the size of hypoperfusion as an independent predictor for the functional status (P=.004) and the Canadian Neurological Scale score for mortality (P=.009).

Conclusions SPECT performed within 36 hours of onset predicts clinical outcome, but different clinical and SPECT indices with threshold values should be chosen according to the relevant outcome end point.

Key Words: cerebral ischemia • stroke assessment • stroke outcome • tomography, emission-computed

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
There is increasing interest in reliable prediction of neurological outcome in acute ischemic stroke, not only in clinical practice but also in the setting of therapeutic trials. Different clinical prognostic factors have been studied such as age, impaired consciousness, severity of deficit, conjugate gaze palsy, history of cardiac disease, neuropsychological impairment, diabetes, and stroke type.^{1 2 3 4 5 6 7 8 9} However, the respective predictive value of these factors remains controversial. Quantitative clinical scores such as Allen's score,^{10 11} the Canadian Neurological Scale (CNS) score,^{11 12 13 14} and National Institutes of Health Stroke Scale score,^{15 16 17} among many others,¹⁸ have shown some degree of correlation with different scales of outcome. If the size of infarct measured on brain computed tomography (CT) is useful as a predictor of outcome,^{19 20} the low sensitivity of CT within 48 hours after onset²¹ constitutes the main drawback for an early prognostic evaluation.

We have previously reported that single-photon emission computed tomography (SPECT), a noninvasive technique readily available to study regional cerebral blood flow in the acute stage, may help to categorize patients by stroke subtypes that have a different outcome profile.²² Several studies with different methodological and technical approaches have supported the predictive value of SPECT in stroke prognosis,^{7 11 13 17 23 24 25 26 27} whereas others have not been conclusive.^{28 29 30 31 32} All studies have included patients with cortical infarct, and only three of them^{7 13 17} were performed within 24 hours. Only one study compared the prognostic value of SPECT with clinical determinants,¹¹ and none compared the different SPECT indices. Thus, the aim of our study was to assess and compare the prognostic value of stroke severity, stroke subtypes, crossed cerebellar diaschisis, and degree and size of hypoperfusion in predicting clinical outcome in a large group of consecutive patients with cortical and subcortical acute carotid infarct. After calculation of threshold values for each clinical and SPECT index, a multivariate analysis was performed to identify the predictive factors with an independent effect on outcome.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
From our stroke data bank we selected 55 consecutive patients (38 men, 17 women) aged 48 to 88 (mean, 71±9) years, without a stroke history, who presented with acute (<12 hours) carotid artery infarction and were studied with ^99mTc-labeled hexamethylpropyleneamine oxime (HMPAO) SPECT within the first 36 hours from onset. Patients with symptoms that resolved within 24 hours after onset (transient ischemic attacks) or brain stem infarcts were excluded. In 9 patients who awoke with the clinical deficit, we arbitrarily considered 4 AM as the time of onset. Thirty-four (62%) patients were admitted within 6 hours, and 21 (38%) were admitted within 6 to 12 hours after onset. Severity of clinical deficit at entry was measured by the CNS score.¹² To assess the distribution of patients with severe or mild deficit, patients were classified according to whether the CNS score was <6.5 or 6.5,³³ respectively. In addition, clinical stroke subtypes as defined by Bamford et al⁹ were classified according to presenting symptoms and signs at the time of maximum deficit (lacunar infarcts: pure motor stroke, pure sensory stroke, pure sensorimotor stroke, ataxic hemiparesis; total anterior circulation infarcts: combination of new higher cerebral dysfunction [eg, dysphasia, dyscalculia, visuospatial disorders], hemianopsia, and ipsilateral motor and/or sensory deficit of at least two areas of the face, arm, and leg [in cases of impaired consciousness and difficulty in testing higher cerebral function or visual fields, a deficit was assumed]; partial anterior circulation infarcts: combination of only two of the three components of the total anterior circulation infarct syndrome, with higher cerebral dysfunction alone or with a motor/sensory deficit more restricted than those classified as lacunar anterior circulation infarct [eg, confined to one limb or the face and hand but not to the whole arm]). All patients received standard treatment including hemodilution when hematocrit level was >45% and anticoagulant in case of stroke in progression or cardiac-source emboli.

An initial brain CT without contrast (Siemens DRH) was performed in 34 patients within the first 24 hours with a mean time interval of 7 hours 24 minutes (range, 1 hour 54 minutes to 24 hours). A CT scan with contrast was obtained in 47 patients at least 48 hours after onset with a mean time interval of 8 days (range, 2 to 21 days). Contiguous axial slices (matrix of 512 pixels) were obtained parallel to the canthomeatal line. Slice thickness was 4 mm (scan time, 7 seconds per slice) in the posterior fossa and 8 mm (scan time, 5 seconds per slice) in the cerebral hemispheres. Acute or subacute cerebral infarct was defined by the presence of at least one of the following CT characteristics: focal hypodensity, mass effect on adjacent ventricles and cerebral sulci and fissures, and peripheral contrast enhancement.³⁴ Topography of infarcts was classified according to the anatomic vascular territory.³⁵ The definition of cortical and subcortical infarcts was the same as that used in a previous study.²² When control CT scan was normal or could not be performed, superficial or deep carotid localization was clinically defined by the presence of cortical signs (hemiplegia with predominant brachiofacial involvement, monoplegia, neuropsychological impairment) or clinical deficit compatible with a deep localization (subcortical aphasia, pure motor stroke, pure sensorimotor stroke, pure sensory stroke, ataxic hemiparesis), respectively. Although pure sensory stroke has been depicted mainly in thalamic infarcts, it has been also reported in cortical³⁶ and capsular^{37 38 39 40} carotid infarcts. Consequently, patients with this syndrome were not excluded in our study.

SPECT using ^99mTc-HMPAO (740 mBq; Ceretec, Amersham) was carried out with a rotating gamma camera (General Electric; 64 projections of 30 seconds each). Data were reconstructed to obtain consecutive axial slices every 12 mm parallel to and above the orbitomeatal line. Sixteen symmetrical regions of interest (ROIs) were considered, six over each cerebral hemisphere and two over each cerebellar hemisphere. With a computerized program developed in our laboratory, the ROIs (3x3 pixels; pixel size, 6 mm) were automatically located along the cortical ribbon, four in the anterior, middle, and posterior areas and four in the cerebellum. Because of the poor spatial resolution of our single-head gamma camera, ROIs were not placed in subcortical regions. The images in the inferior anterior temporal and high vertex cortical regions, as well as the cerebellum posteriorly, were excluded for analysis because of greater side-to-side variability.⁴¹ In each ROI, the difference in total count was expressed as a percentage of the value from the contralateral asymptomatic hemisphere with a normal cerebral blood flow. Interhemispheric difference of at least 10% was considered to be significant.^{41 42} For each patient, the degree of hypoperfusion was defined by the highest interhemispheric difference. We determined the size of hypoperfusion by the number of ROIs with an interhemispheric difference of at least 10% in the hemispheric slices selected for analysis as described above. Crossed cerebellar diaschisis was defined by the presence of at least 5% hypoperfusion^{43 44} in the cerebellar hemisphere contralateral to the hemispheric hypoperfusion. SPECT examinations took place within the first 36 hours in all patients with a mean time interval of 14 hours 54 minutes (range, 1 hour 4 minutes to 35 hours 38 minutes). SPECT was obtained within the first 24 hours in 45 (82%) patients.

Outcome evaluations were performed by neurologists blinded to SPECT data. Given that most patients in our tertiary-care hospital could not be systematically evaluated at 3 months, we studied only the short-term outcome at 1 month using the Rankin Scale.⁴⁵ The outcome parameters were (1) the functional status derived from the Rankin Scale classification of patients with good (score of 1 to 3) or poor (score of 4 and 5) outcome and (2) mortality.

Numerical parameters were expressed as mean±SD and medians. Categorical and continuous variables were compared using Fisher's exact test and Wilcoxon rank sum test, respectively. Correlations between numerical parameters were assessed by Spearman's rank correlation coefficient. The performance of degree and size of hypoperfusion and CNS score for the different parameters of outcome was studied by receiver operating characteristic (ROC) methodology. ROC curves were fitted by maximum-likelihood estimation under the binomial model using the LABROC1 program, and areas under curves were compared by z test using the CLABROC program.⁴⁶ ROC curves were used to define threshold values that maximized sensitivity plus specificity, and the performances of these newly defined dichotomous parameters for predicting outcome were assessed by sensitivity, specificity, and positive and negative predictive values. Logistic regression, with backward selection of variables using Wald's test performed with SPSS statistical software, was used to identify variables with an independent effect on outcome.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
On admission, 31 (56%) and 24 (44%) patients had a CNS score of <6.5 or 6.5, respectively. With regard to stroke subtypes, total anterior circulation infarct was found in 18 (33%) patients, partial anterior circulation infarct in 20 (36%), and lacunar anterior circulation infarct in 17 (31%). At 1 month, 7 (13%) patients had a poor outcome, and 41 (74%) had a good outcome. Seven (13%) patients died, 5 of transtentorial herniation, 1 of bronchopneumonia, and 1 of myocardial infarct. The overall CT sensitivity was 29% (10/34) within 24 hours after onset and 81% (38/47) after 48 hours. The topography of infarcts was cortical in 55% (21/38) of patients and subcortical in 45% (17/38). Six (35%) of the 17 subcortical infarcts were lacunar, representing 16% of all infarcts. SPECT showed a relevant cerebral hypoperfusion in 37 (67%) patients. The mean degree and size of hypoperfusion were 34±19% (range, 11% to 81%; median, 31%) and 8±6 (range, 1 to 26; median, 6), respectively. We noted crossed cerebellar diaschisis in 12 (32%) patients with a mean degree of hypoperfusion of 15±6% (range, 6% to 25%; median, 14%).

We found significant correlations between the Rankin Scale score and the degree (r=.580; P<.00001) and size (r=.616; P<.00001) of hypoperfusion (Table 1). The mean degree and size of hypoperfusion were higher in patients with poor outcome and in those who died early (Table 1). The functional status was not dependent on age and sex ratio, but mortality was significantly associated with higher age (77±4 versus 70±9; P=.045).

View this table: [in this window] [in a new window]   Table 1. Mean Degree and Size of Hypoperfusion and Outcome

The ROC curves for the degree and size of hypoperfusion and CNS score as related to the different outcome parameters are shown in the Figure. To discriminate between the patients with good or poor outcome, the threshold values derived from the ROC curves were 23.5% for the degree of hypoperfusion, 7.5 for the size of hypoperfusion, and 5.0 for the CNS score. Similarly, the threshold values were 21.5%, 3.5, and 5.0, respectively, to discriminate between the patients who died or survived. In terms of area index, we found no statistical difference between the degree and the size of hypoperfusion, and neither had higher performance than the CNS score. All results of SPECT and clinical indices in predicting the functional status and survival are presented in Table 2. Crossed cerebellar diaschisis predicted survival but not functional status; however, it did not reach statistical significance (P=.067). Regarding clinical stroke subtypes on admission, we found no significant difference in the outcome parameter between lacunar and partial anterior circulation infarcts. On the other hand, we noted significant differences between partial and total anterior circulation infarcts in predicting functional status (P<.001) and survival (P=.023). Significant differences were also found between lacunar and total anterior circulation infarcts for functional status (P=.001) and for survival, even though statistical significance was not reached (P=.064). All data regarding sensitivity, specificity, positive and negative predictive values of the degree and size of hypoperfusion, crossed cerebellar diaschisis, CNS score, and total anterior circulation infarct stroke subtype to predict the different parameters of outcome are shown in Table 3.

View larger version (16K): [in this window] [in a new window]   Figure 1. Graphs show the receiver operating characteristic curves related to the clinical outcome for the size of hypoperfusion (heavy line), degree of hypoperfusion (light line), and Canadian Neurological Scale score (dotted line).

View this table: [in this window] [in a new window]   Table 2. Prediction of Functional Status and Survival by SPECT and Clinical Indices

View this table: [in this window] [in a new window]   Table 3. Sensitivity, Specificity, Positive and Negative Predictive Value of SPECT Indices, Canadian Neurological Scale, and Stroke Subtypes

A multivariate analysis was performed to identify variables with an independent effect on outcome. The different variables studied were the degree and size of hypoperfusion, crossed cerebellar diaschisis, age, sex, CNS score, and stroke subtypes. The degree and size of hypoperfusion as well as the CNS score were considered as continuous values or as dichotomous variables according to the threshold value previously described for each parameter of outcome. Logistic regression selected only the size of hypoperfusion as a predictor of functional status (P=.004) and only the CNS score as a predictor of survival (P=.009).

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
HMPAO SPECT compared with positron-emission tomography²⁷ gives no assessment of neuronal function and studies cerebral blood flow only by a semiquantitative method. However, its availability in the acute phase and its low cost make this imaging technique potentially useful in predicting outcome routinely. Several SPECT indices have been studied: hyperperfusion,^{29 47} delayed N-isopropyl-p-[¹²³I]iodoamphetamine redistribution activity,^{24 30 32 48 49} SPECT to CT volume defect ratio,²⁶ degree and size of hypoperfusion in combination^{7 17 25} or not,^{11 13 24 32 50 51} and crossed cerebellar diaschisis.^{52 53} Previously, several studies failed to demonstrate the predictive value of SPECT because the time interval after stroke was too long (ie, several days or weeks).^{28 29 30 31 32} This is explained by the early appearance of postischemic hyperemia (absolute or relative luxury perfusion) due to spontaneous recanalization of occluded vessels.^{13 54 55 56 57 58} The flow-predictive time window as defined by Giubilei et al¹³ should be 6 hours after stroke onset and up to 24 hours as defined by others.^{7 17} However, in clinical practice, for various reasons, few patients are admitted within 6 hours⁵⁹ ; in our study, we included all patients admitted within 12 hours. SPECT was performed within 36 hours and, in most patients (82%), within 24 hours. Unlike other reports analyzing only cortical infarcts, our population, which included patients with different stroke subtypes in the same proportions, was more representative of routine clinical practice. The patients were evenly distributed according to the severity of neurological deficit, and the number of CT-proven cortical infarcts was mildly but not significantly higher than that of subcortical infarcts.

In our study, the high sensitivity of SPECT (67%) compared with that of CT (29%) in the acute phase confirms its better prognostic potential. As did others,^{7 11 13 17 50} we found a strong correlation between cerebral blood flow measured by the degree and size of hypoperfusion and clinical outcome. As in other series,^{11 13} the mean degree and size of hypoperfusion permitted significant differentiation of patients for functional status and mortality. However, these results are of limited practical worth for the individual patient. Therefore, determination of threshold values is of great interest in predicting outcome in clinical practice. In a series of 32 cases, Giubilei et al¹³ determined a 40% threshold value of perfusion defect to discriminate between patients with a poor or good prognosis. Likewise, a threshold score combining the degree and size of hypoperfusion was reported by Hanson et al¹⁷ and Limburg et al⁷ in 15 and 26 patients, respectively. However, the performance of these cutoff levels has not been statistically calculated, and the number of patients was small. To our knowledge, no studies have assessed and compared by the statistical method of ROC curves the level of performance of clinical and SPECT indices in prognostic evaluation. Our study showed that the level of prediction performance of the degree and size of hypoperfusion and CNS score was excellent for functional status and intermediate for mortality, probably because of the small number of deaths in our series. Threshold values could be derived for the CNS score and the degree and size of hypoperfusion, but it must be stressed that these values were different according to the outcome parameters. As previously mentioned by Giubilei et al,¹³ these SPECT threshold values are in keeping with positron-emission tomography studies that also show a cerebral blood flow threshold below which outcome is poor⁶⁰ because the cerebral tissue is no longer viable.⁶¹

Crossed cerebellar diaschisis, which has been shown to be related to infarct topography and size,⁶² could be considered as a potential predictive factor of outcome. We found that it could predict survival, but without reaching statistical significance, and that it was not predictive of functional status, contrary to other previous studies.^{53 63}

Regarding stroke subtypes, our results are similar to those reported by Bamford et al⁹ in that total anterior circulation infarct was significantly associated with a worse prognosis than lacunar or partial anterior circulation infarct. However, the main drawback of this clinical classification in our study was the inability to find significant differences between lacunar and partial infarct to predict outcome.

Sensitivity and specificity of the different clinical and SPECT indices were excellent except for crossed cerebellar diaschisis, which showed a low sensitivity, particularly in predicting functional status. For mortality and functional status, the negative predictive value of different indices was very high, while the positive predictive value appeared to be low. In light of these results, these predictive values should be cautiously interpreted in clinical practice.

Logistic regression was performed to determine which clinical or SPECT indices could be considered independent predictive factors of outcome. The analysis selected only the CNS score for mortality and the size of hypoperfusion for functional status. Age, sex, and stroke subtypes were not selected. Thus, the threshold values of each of these independent predictive factors may be appropriately used in therapeutic trials to analyze separately those patients with mild defects who are likely to improve spontaneously and those with severe defects and poor outcome. As an example, according to our findings, subgroups of patients with poor (CNS score <6.5, size >7.5) or excellent (CNS score >6.5, size <7.5) outcome can be specified and evaluated separately.

In conclusion, SPECT performed within 24 hours may be helpful in predicting outcome in clinical practice and in appropriately categorizing patients into subgroups for therapeutic trials. Different clinical and SPECT indices should be chosen according to the relevant outcome end point.

	Acknowledgments

 
The authors wish to thank Dr Gian Luigi Lenzi for reading the manuscript and for his many helpful suggestions.

Received November 29, 1994; revision received January 16, 1995; accepted February 3, 1995.

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