Malignant profile detected by CT angiographic information predicts poor prognosis despite thrombolysis within three hours from symptom onset.

OBJECTIVE: A malignant profile of early brain ischemia has been demonstrated in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) trial. Patients with a malignant profile had a low chance for an independent functional outcome despite thrombolysis within 3-6 h. We sought to determine whether CT angiography (CTA) could identify a malignant imaging profile within 3 h from symptom onset. METHODS: We studied consecutive patients (04/02-09/07) with anterior circulation stroke who received CTA before intravenous thrombolysis within 3 h. We assessed the Alberta Stroke Program Early CT Score (ASPECTS) on CTA source images (CTASI). Intracranial thrombus burden on CTA was assessed with a novel 10-point clot burden score (CBS). We analyzed percentages independent (modified Rankin Scale score < or =2) and fatal outcome at 3 months and parenchymal hematoma rates across categorized combined CTASI-ASPECTS + CBS score groups where 20 is best and 0 is worst. RESULTS: We identified 114 patients (median age 73 years [interquartile range 61-80], onset-to-tPA time 129 min [95-152]). Among 24 patients (21%) with extensive hypoattenuation on CTASI and extensive thrombus burden (combined score < or =10), only 4% (1/24) were functionally independent whereas mortality was 50% (12/24). In contrast, 57% (51/90) of patients with less affected scores (combined score 11-20) were functionally independent and mortality was 10% (9/90; p < 0.001). Parenchymal hematoma rates were 30% (7/23) vs. 8% (7/88), respectively (p = 0.008). CONCLUSION: CTA identifies a large hyperacute stroke population with high mortality and low likelihood for independent functional outcome despite early thrombolysis.

Frequency and clinical course of stroke and transient ischemic attack patients with intracranial nonocclusive thrombus on computed tomographic angiography.

BACKGROUND AND PURPOSE: We sought to determine the frequency and clinical course of patients with acute ischemic stroke or transient ischemic attack (TIA) who had intracranial nonocclusive thrombus (iNOT) on CT angiography (CTA). METHODS: We retrospectively (June 2002-March 2007) reviewed consecutive patients with acute ischemic stroke or TIA who had CTA performed acutely for diagnostic work-up. A neuroradiologist reviewed all cases with potential iNOT. Criteria to diagnose iNOT rather than occlusive thrombus or atherosclerotic stenosis were: (1) residual lumen present and eccentric; (2) nontapering thrombus; (3) smooth and well-defined thrombus margins; and (4) absence of vessel wall calcification. We defined functional independence at discharge as modified Rankin scale score

Normal magnetic resonance perfusion-weighted imaging in lacunar infarcts predicts a low risk of early deterioration.

BACKGROUND: Current clinical tools to identify lacunar infarct patients at risk of deterioration are inadequate, and imaging techniques to predict fluctuation and deterioration would be of value. We sought to determine the occurrence of MRI perfusion-weighted imaging (PWI) abnormalities in lacunes, and whether they help predict clinical and radiological outcome. METHODS: Patients with lacunar stroke or TIA were selected from a prospective MR imaging study. MRI was performed within 24 h of the event and follow-up imaging completed at 30 or 90 days. Baseline perfusion maps were qualitatively assessed and infarct volumes measured. Early clinical deterioration (NIHSS worsening of > or = 3 points within 72 h of event) and 90-day modified Rankin Scale score (mRS) were recorded. RESULTS: Twenty-two patients were included. Fifteen (68.2%) had abnormal PWI at the site of the diffusion-weighted imaging lesion. Patients with abnormal PWI were more likely to have stroke than TIA as their index event (RR 2.2, 95% CI 0.9-5.2, p = 0.02). Early clinical deterioration occurred in 4 patients (18.2%), all of whom had abnormal PWI. PWI lesions were not associated with a higher 90-day NIHSS or mRS score, nor did they predict infarct volume growth. CONCLUSIONS: MR-PWI abnormalities are seen in two thirds of lacunar infarcts, and are associated with stroke rather than TIA. Normal PWI identifies patients at low risk of early clinical deterioration.

Does intravenous rtPA benefit patients in the absence of CT angiographically visible intracranial occlusion?

BACKGROUND: In patients with acute stroke receiving intravenous tissue plasminogen activator (tPA), we postulated that the presence of intracranial occlusion on CT angiography (CTA) modifies the benefit of thrombolysis. MATERIALS AND METHODS: Using a retrospective cohort design, we identified patients with acute ischemic stroke in our CTA database between May 2002 and August 2007. All the patients had a CTA within 12 h of onset, a premorbid modified Rankin scale (mRS) < or = 1, and a baseline National Institute of Health Stroke Scale score(NIHSS)f > or = 6. The primary outcome was early effectiveness of tPA defined as an NIHSS score of < or = 2 at 24 h or a 4-point NIHSS improvement at 24 h. Secondary outcome included mRS < or = 1 at 90 days. The relationship between intracranial occlusion on CTA and benefit of tPA was assessed using a test for interaction. RESULTS: A total of 287 patients met the criteria [occlusion present N =168; (98 with tPA; 70 without tPA) and occlusion absent N = 119; (52 with tPA; 67 without tPA)]. Those with intracranial occlusion were likely to have more severe strokes (NIHSS > or = 15; P < 0.001) and abnormal brain imaging (ASPECTS < or =7; P < 0.001). For outcome of 4-point NIHSS score improvement at 24 h, benefit from tPA was observed only among patients with a visible occlusion (absolute difference in favor of tPA: 20.4% vs. 0.7%; P = 0.06). CONCLUSION: In patients with acute ischemic stroke, thrombolysis produced a better early clinical response among patients with intracranial occlusion, which needs to be confirmed in stroke thrombolysis trials.

Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion.

BACKGROUND AND PURPOSE: Quantification of early ischemic changes (EIC) may predict functional outcome in patients with basilar artery occlusion (BAO). We tested the validity of a novel CT score, the posterior circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS). METHODS: Pc-ASPECTS allots the posterior circulation 10 points. Two points each are subtracted for EIC in midbrain or pons and 1 point each for EIC in left or right thalamus, cerebellum or PCA-territory, respectively. We studied 2 different populations: (1) patients with suspected vertebrobasilar ischemia and (2) patients with BAO. We applied pc-ASPECTS to noncontrast CT (NCCT), CT angiography source images (CTASI), and follow-up image by 3-reader consensus. We calculated sensitivity for ischemic changes and analyzed the predictivity of pc-ASPECTS for independent (modified Rankin Scale [mRS] score /=8 but only 4% (1/23) with a score <8 had favorable functional outcome (RR 12.1; 95% CI, 1.7 to 84.9). This difference was consistent in 21 patients with angiographic recanalization (RR 7.7; 95% CI, 1.1 to 52.1). CONCLUSIONS: The CTASI pc-ASPECTS score may identify BAO patients unlikely to have a favorable outcome despite recanalization.

Influence of adiposity and physical activity on arterial stiffness in healthy children: the lifestyle of our kids study.

Childhood obesity is increasingly prevalent in the community and is related to adverse cardiovascular outcomes during adulthood. In this study of healthy children, we evaluated the influence of adiposity and physical activity on carotid-femoral pulse wave velocity (PWV), an index of arterial stiffness and a marker of cardiovascular risk in adults. In 573 community-based children (mean age: 10.1+/-0.3 years; 51% boys), we measured body mass index and waist circumference. Percentage body fat was quantitated by dual-energy x-ray absorptiometry. Cardiorespiratory fitness (CRF) and physical activity levels were assessed using a 20-m shuttle run and 7-day pedometer count, respectively. PWV was estimated by applanation tonometry. In univariate analysis, PWV was positively correlated with body mass index (r=0.34), waist circumference (r=0.32), and percentage body fat (r=0.32; P<0.001 for all) and negatively correlated with CRF (r=-0.23; P<0.001) and pedometer count (r=-0.08; P=0.046). In separate multivariable linear regression models, body mass index, waist circumference, and percentage of body fat were independently and positively associated with PWV (P<0.01 for all) after adjusting for age, sex, systolic blood pressure, mean arterial pressure, heart rate, and CRF (P<0.01 for all). The influence of CRF on PWV was attenuated after adjusting for adiposity. In conclusion, increased body mass and adiposity and decreased CRF are associated with arterial stiffening in healthy prepubescent children.

Intracranial thrombus extent predicts clinical outcome, final infarct size and hemorrhagic transformation in ischemic stroke: the clot burden score.

BACKGROUND: In ischemic stroke, functional outcomes vary depending on site of intracranial occlusion. We tested the prognostic value of a semiquantitative computed tomography angiography-based clot burden score. METHODS: Clot burden score allots major anterior circulation arteries 10 points for presence of contrast opacification on computed tomography angiography. Two points each are subtracted for thrombus preventing contrast opacification in the proximal M1, distal M1 or supraclinoid internal carotid artery and one point each for M2 branches, A1 and infraclinoid internal carotid artery. We retrospectively studied patients with disabling neurological deficits (National Institute of Health Stroke Scale score >or=5) and computed tomography angiography within 24-hours from symptom onset. We analyzed percentages independent functional outcome (modified Rankin Scale score