Selection Criteria for Intra-Arterial Thrombolytic Therapy by Initial SPECT

Abstract

We determined the selection criteria for intra-arterial thrombolytic therapy by initial single-photon emission-computed tomography (SPECT) using 99mTc-HMPAO. We studied 30 patients who were obtained early complete recanalization of the internal carotid territory occlusion. The residual CBF of non-infarction, infarction and hemorrhagic lesions judged by follow-up CT scan was evaluated semiquantitatively by calculating two parameters with pretherapeutic SPECT: the ischemic regional activity to cerebellar activity ratio (R/CE ratio) and asymmetry index (AI). The patient's neurological exam was evaluated according to the NIH stroke scale score. The patients were classified by follow-up CT into three groups: A) nine patients who had no or small infarction; B) fourteen patients who had medium or large cortical infarction; C) seven patients who had hemorrhagic transformation. No significant difference was observed in the interval from onset, UK doses, or site of occlusion between each group. However, the residual CBF and the NIH scores 1 month later in group C were significantly worse than those in group A or B. Forty-two lesions were identified (22 reversible ischemia, 13 infarction, and 7 hemorrahge). The residual CBF and neurological outcome were significant among three types of lesions. Tissue reversibility at any given time rather than duration of ischemia remains the most important factor to influence outcome. Pretreatment SPECT can assess tissue reversibility and increase the efficacy of intra-arterial thrombolysis for acute stroke patients.

Keywords

acute stroke cerebral ischemia thrombolytic therapy SPECT therapeutic window

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References

Hacke

Kaste

: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: The European Cooperative Acute Stroke Study (ECASS). JAMA 274: 1017–1025, 1995.

Multicentre Acute Stroke Trial-Italy (MAST-I) Group. Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischemic stroke. Lancet 346: 1509–1514, 1995.

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333: 1581–1587, 1995.

Ueda

Hatakeyama

: Evaluation of risk of hemorrhagic transformation in local intra-arterial thrombolysis in acute ischemic stroke by initial SPECT. Stroke 25: 298–303, 1994.

Ueda

Ohta

: Relationship between residual care-bral blood flow and neurological outcome in patients with intra-arterial thrombolysis for acute ischemic stroke. In: Taki

: Advances in interventional neuroradiology and intravascular neurosurgery. Amazon, Seattle 1996: 487–490.

Ueda

Sakaki

: Outcome in acute stroke with successful intra-arterial thrombolysis and predictive value of initial SPECT. J Cereb Blood Flow Metab 1998 (in press).

Lassen

Anderson

: The retention of [99mTc]-d,l-HMPAO in the human brain after intracarotid bolus injection: A kinetic analysis. J Cereb Blood Flow Metab 8: S13–S22, 1988.

Brott

Adams

: Measurements of acute cerebral infarction: A clinical examination scale. Stroke 20: 864–870, 1989.

Yuh

Maeda

: Fibrinolytic treatment of acute stroke: Are we treatimg reversible cerebral ischemia? Am J Neuroradiol 16: 1994–2000, 1995.

10.

Furlan

MGM

Viader

: Spontaneous neurological recovery after stroke and the fate of the ischemic penumbra. Ann Neurol 40: 216–226, 1996.

11.

Shimosegawa

Hatazawa

: Cerebral infarction within six hours of onset: Prediction of completed infarction with technetium-99m-HMPAO SPECT. J Nucl Med 35: 1097–1103, 1994.

12.

Sasaki

Takeuchi

: Complete recanalization via fibrinolytic therapy can reduce the number of ischemic territories that progress to infarction. Am J Neuroradiol 17: 1661–1668, 1996.