Failed Recovery from Thrombolysis Is Predicted by the Initial Diffusion Weighted Imaging Lesion

Abstract

Background: The clinical response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA) is thought to depend on an early recanalization. We sought to investigate the effect of early recanalization on stroke lesion development as assessed with magnetic resonance imaging (MRI). Methods: Thirty-seven consecutive stroke patients (66 ± 13 years) treated with systemic thrombolysis with rtPA and tirofiban were grouped according to successful or failed recanalization as assessed on angiographic imaging. Infarct lesions were determined volumetrically in MRI prior to treatment and after 4 days. Results: Patients were severely affected (median National Institutes of Health Stroke Scale 14) and had significantly larger perfusion (PWI) than diffusion weighted imaging (DWI) lesion volumes. Ten patients with failed recanalization of the internal carotid or the middle cerebral artery did not improve. Their PWI and DWI lesion volumes were larger and the apparent diffusion coefficient more depressed than in the 27 patients with significant improvement and successful recanalization (p < 0.001). The DWI lesion volumes increased profoundly in the patients with failed recanalization (p < 0.001) but only little in the patients with successful recanalization. Multivariate regression analysis showed a relation of the initial DWI lesion volumes to the DWI lesion volumes at follow-up and the neurological recovery. Conclusions: The ischemic brain damage was particularly severe in patients with no recanalization already before systemic thrombolysis and predicted further lesion growth and failed recovery.

Beyond the Lesion: Neuroimaging Foundations For Post-Stroke Recovery

“…The immediate changes of ischemia are apparent from perfusion imaging and completely disappear upon reperfusion [14]. The first structural changes of the brain due to cytotoxic cell swelling can be shown with diffusion-weighted MRI within 2 h after the ischemic event and largely predict the remaining infarct lesion [15][16][17]. The structural brain lesions undergo a dynamic evolution owing to secondary changes, such as tissue degradation and brain edema formation, and a subsequent lesion shrinkage accompanied by atrophy of the ventricles and the cerebral or cerebellar cortex [18].…”

MRI Follow-Up after 24 h Is an Accurate Surrogate Parameter for Treatment Success after Thrombolysis

“…Differences in baseline lesion volume could be an important factor for the outcome, as shown in previous studies [5]. This might contribute to smaller final lesion volumes in late recanalizers even compared to the early recanalizers (online suppl.…”

“…The subgroup of late recanalizers experiences a similar outcome as the early recanalizers. Persistent vessel occlusion until 24 h was associated with considerably larger day 5 FLAIR volumes and poor outcome [3,5]. …”

Utility of Early Post-treatment Single-Photon Emission Computed Tomography Imaging to Predict Outcome in Stroke Patients Treated with Intravenous Tissue Plasminogen Activator

“…Seitz et al demonstrated that DWI lesion volumes and perfusion weighted image (PWI) lesion volumes obtained by MRI modalities on admission were significantly correlated with the final lesion volumes in 37 patients treated with intravenous tPA thrombolysis. 11 8 Their multiple regression analysis revealed that the initial PWI lesion volumes did not predict well the final lesion volumes and neurological deficit, compared with the initial DWI lesion volume. 11 Although Seitz's data showed that perfusion image was not a strong biomarker of outcome in tPA-treated patients, we think that the results would be different if perfusion image was obtained by SPECT early after tPA therapy, as performed in the present study.…”

“…11 8 Their multiple regression analysis revealed that the initial PWI lesion volumes did not predict well the final lesion volumes and neurological deficit, compared with the initial DWI lesion volume. 11 Although Seitz's data showed that perfusion image was not a strong biomarker of outcome in tPA-treated patients, we think that the results would be different if perfusion image was obtained by SPECT early after tPA therapy, as performed in the present study. Since perfusion status can be changed after thrombolysis, it is highly likely that perfusion evaluation after treatment provides more reliable estimation of lesion extent than that before treatment.…”