Increased Blood–Brain Barrier Permeability on Perfusion CT Might Predict Malignant Middle Cerebral Artery Infarction

Abstract

Background and Purpose Perfusion computerized tomography (PCT) has been used to assess the extent of blood brain barrier (BBB) breakdown. The purpose of this study was to determine the predictive value of (BBB) permeability (BBBP) measured using PCT for development of malignant middle cerebral artery infarction (MMCA) requiring hemicraniectomy (HC). Methods We retrospectively identified patients from our stroke registry that had MCA infarction and were evaluated with admission PCT. BBBP and cerebral blood volume (CBV) maps were generated and infarct volumes calculated. Clinical and radiographic characteristics were compared between those who underwent HC versus those who did not undergo hemicraniectomy (NHC). Results 122 patients (12 (HC), 110 (NHC)) were identified. 12 patients who underwent HC had developed edema, midline shift or infarct expansion. Infarct permeability area (IParea), infarct CBV area (ICBVarea), and infarct volumes were significantly different (p<0.018, p<0.0211, p<0.0001, p<0.0014) between HC and NHC groups. Age (p=0.03) and admission National Institutes of Health Stroke Scale (NIHSS) (p=0.0029) were found to be independent predictors for HC. Using logistic regression modeling, there was an association between increased IParea and HC. The odds ratio for HC based on a 5, 10, 15 or 20 cm2 increase in IParea were 1.179, 1.390, 1.638 or 1.932, respectively (95% CI 1.035-1.343, 1.071-1.804, 1.108-2.423, 1.146-3.255). Conclusion Increased IParea is associated with an increased likelihood for undergoing HC. Since early HC for MMCA has been associated with better outcomes, the IParea on admission PCT might be a useful tool to predict MMCA and need for HC.

Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts

“…This finding is in agreement with a retrospective study of 120 patients (with 12 patients treated with a hemicraniectomy for prominent space-occupying edema) that showed an association between increased infarct permeability surface area and prominent spaceoccupying edema occurrence. 9 A relation between the duration of ischemia and the extent of damage to the BBB has also been shown previously. 31,32 The time between symptom onset and the scan series was shorter in our data (100 minutes versus 310 minutes).…”

“…8 The extent of the disturbance of the blood-brain barrier may play a role in the development of prominent space-occupying edema. 9 A measure of the BBB permeability is the permeability surface-area product, which can be obtained from an extended CTP acquisition. 10 Other known risk factors for the development of prominent space-occupying edema include proximal occlusion site, greater infarct size, involvement of Ͼ1 vascular territory, basal ganglia involvement, increased ratio of CBV lesion volume/CSF volume, female sex, and higher NIHSS score on admission.…”

Neurological Diseases in Relation to the Blood–Brain Barrier

“…In one study, CT showed disruption of the BBB in the early stages of stroke, which was proposed as an aid in deciding when it was safe to give tPA, which has a risk of inducing hemorrhage (Hom et al, 2011). Another CT study showed that increased permeability indicated a higher risk for hemorrhagic transformation and suggested that it could be used to select patients for hemicraniectomy ( Figure 2) (Bektas et al, 2010). The disadvantage of the CT method is the relatively large amount of radiation delivered to the patient, which is not generally a problem in the elderly patient, who is getting a CT angiogram as part of the diagnostic work-up, but would be one in younger individuals.…”

Radiochemotherapy-induced changes of tumour vascularity and blood supply estimated by dynamic contrast-enhanced CT and fractal analysis in malignant head and neck tumours

“…This allows the estimation of transendothelial transfer constant during the end of the first passage of contrast but avoids erroneous elevation of transendothelial transfer constant values secondary to delayed arrival of contrast, which would occur in a standard application of the Patlak model to PCT data, at least in the setting of acute cerebral ischaemia. 37,38 …”