New therapeutic strategies (e.g., hemicraniectomy) must be developed to reduce mortality and improve the outcome for this subgroup of ischemic stroke patients. Mechanical ventilation is and will remain a crucial element within such new concepts.
Summary: The aim of this study was to define the accuracy of 99 mTc-ethyl cysteinate dimer-single photon emission com puted tomography e 9 mTc-ECD-SPECT) in distinguishing tran sient ischemic attack from completed ischemic stroke at early stages after the onset of symptoms. In a prospective study we examined 82 patients within 6 hours after the onset of symp toms (neurologic deficit caused by middle cerebral artery isch emia) using both 99 mTc-ECD-SPECT and computed tomogra phy (CT). The follow-up was based on Scandinavian Stroke Scale (SSS) 24 hours and 5-7 days, as well as on CT 7 days, after the event. SPECT evaluation was performed both visually and using semiquantitative region-of-interest (ROI) analysis.According to visual SPECT analysis, on admission 59 of 82 patients had activity deficits in the symptomatic hemisphere. After 7 days, all these patients had neurologic symptoms (SSS 28 ± 12 points), caused by a cerebral infarction as evidencedThe consideration of new and aggressive therapies in patients with acute focal cerebral ischemia calls for re liable diagnostic information within a short therapeutic window. Within this period the following specific infor mation is required: whether the symptoms are caused by stroke, where the stroke is located, and what subtype of stroke it is (Brass, 1997). Moreover, prognostication of the course of stroke is urgently required because it may range from complete neurologic restitution after a few
921with CT. Twenty-three of 82 patients displayed no early activ ity deficit despite clinical symptoms. None of these patients had neurologic symptoms after 7 days (indicating transient isch emic attack or prolonged reversible ischemic neurologic defi cit). In the semiquantitative SPECT analysis, all patients had abnormal count densities in the respective ROI (activity <90% compared with the contralateral side). All patients with tran sient ischemia (n = 23) had count rate densities more than 70% of the respective contralateral ROI, whereas all patients with subsequent infarction (n = 59) had values < 70%. Use of 99 mTc-ECD-SPECT allows transient ischemia to be distin guished from ischemic infarction using relative regional activ ity thresholds within the first 6 hours after onset of symptoms.
Background and Purpose-Extracorporeal rheopheresis is a safe method to optimize hemorheology. Our aim was to determine whether treatment with extracorporeal rheopheresis in patients with acute ischemic hemispheric stroke improves cerebral perfusion as assessed with serial 99m Tc-ethyl-cysteinate-dimer single-photon emission CT ( 99m Tc-ECD SPECT). We also investigated how clinical outcome is associated with treatment and imaging results. Methods-Thirty-three patients (mean age, 64Ϯ10 years) with acute ischemic hemispheric stroke were included in a prospective, randomized, parallel group pilot study. First treatment with or without extracorporeal rheopheresis took place within 12 hours after the onset of symptoms and was repeated 3 times at intervals of 24 hours. Hemorheological parameters were measured before and after each session. Each patient underwent 99m Tc-ECD SPECT immediately before treatment, 6 to 8 hours after treatment, and after 5 days. A semiquantitative SPECT graded scale was used to measure depth and extent of activity deficits and thus to quantify the perfusion deficit. Results-Seventeen patients were actively treated with extracorporeal rheopheresis, and 16 patients did not receive extracorporeal rheopheresis. After 3 months, no differences were found in the functional or neurological outcome. Despite a rapid, sustained decrease of plasma viscosity and erythrocyte aggregation in the rheopheresis group, there was no significant difference in the SPECT graded scale after therapy between the 2 groups. Patients with early reperfusion (decrease in the SPECT graded scale Ͼ25% 6 to 8 hours after therapy compared with the baseline examination) experienced a better functional outcome (Modified Rankin Scale) after 3 months compared with patients without reperfusion (Pϭ0.04). Conclusions-Since quantitative flow mapping and clinical follow-up did not reveal any differences between patients who were treated with extracorporeal rheopheresis and controls, it appears very unlikely that extracorporeal rheopheresis enhances reperfusion after acute cerebral ischemia. (Stroke. 1999;30:787-792.)
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