Tc99m-HMPAO Neuro--SPECT Assessment of Ischemic Penumbra in Acute Brain Infarct: Control of Intra-arterial Thrombolysis Treatment.
Article N° AJ26-1
Results
Overall, 7 of 16 patients made good clinical recovery (mR 0-1) after the thrombolysis treatment. 7 of 16 patients made a moderate to poor clinical recovery (mR 2-4) and 2 of 16 patients died.Table 1.
There was a significant reduction of hypoperfusion with the treatment of thrombolysis as depicted by the results of the pre and post treatment examinations. There were three different level of hypoperfusion analyzed. Normal perfusion was defined at 72% +/-6% of maximal brain cortical uptake. "Superficial hypoperfusion", defined as areas with perfusion < 60% of maximum in the brain, < 2 SD below normal, was found on average in 41 voxels per patients before thrombolysis and remained unchanged after thrombolysis. "Moderate hypoperfusion", defined as uptake < 50% of maximum in the brain, < 4 SD below normal, was found on average in 34 voxels per patient and was reduced to an average 9 voxels after thrombolysis p < 0.006. "Severe hypoperfusion", namely < 30% uptake, < 8 SD below the normal mean, occupied an average 15 voxels before the thrombolysis and was reduced to 5 voxels after thrombolysis. Table 2. Figures 6, 7,8, 9.
Table 2 NeuroESPECT results. Notice all but three patients diminished the number
of voxels in very deep penumbra, namely < 8 SD, or < 30% of maximun
Basal
Post Trom
Basal
Post Trom
Basal
Post Trom
ROIS
1
2 - 28
75
39
16
69
0
0
76
57
0
0
2
5 - 25
63
39
43
63
30
30
57
36
30
12
3
14 - 27
42
7
71
42
0
0
28
12
0
0
4
40 - 60
59
35
61
36
0
0
0
0
0
0
5
5 - 30
78
58
23
75
10
6
73
57
0
0
6
20-y 22
9
6
100
9
0
0
-
0
0
0
7
29 - 31
30
15
83
28
60
12
10
3
20
3
8
2- 18
39
33
69
36
0
0
23
9
0
0
9
39 - 55
22
42
18
4
5
2
0
0
0
0
10
4 - 16
39
39
8
3
18
7
-
0
0
0
11
24 - 30
21
19
90
19
31
6
0
0
0
0
12
41 - 48
24
24
33
8
50
12
-
0
0
0
13
38 - 50
39
39
38
39
39
7
61
24
92
36
14
13 - 26
45
42
73
45
47
42
26
12
43
18
-
-
--
---
-
-
-
-
-
-
---
-
Mean
41,78
31,21
34
8,85
15
4,92
St
Dev
-
-
20,65
14,92
-
23,83
-
12,48
-
20,75
-
10,20
p Value
-
-
-0,13
--
-
0,0067
-
-
-
0,11
-
-
-
-
--
- ---
-
-
---
--
-
-
---
-
15
35 - 61
100
--
100
100
-
-
100
100
--
--
16
9 - 28
60
-
60
90
-
-
6
10
-
-
---
GOOD Clinical Outcome 9/14
Figure 6
Pt # 1 (Please see Table 1) after arterial thrombolysis 2 hrs after onset of symptoms. Notices residual superficial ischemia at 60% of maximum in right temporal lobe, orbitofrontal are and left medial temporal lobe.
Figure 7
Residual ischemia at 2, 3 and 4 St Dev below normal in right lateral temporal lobe. Notice one focus suspicious of infarction: color black < 5 SD.
Figure 8
Residual ischemia in same patient at 8 SD demonstrates penumbra at 2-3 and 4-5 SD below the Normal without infarction.
Figure 9
Transaxial plane same patient, at 3 mm above AC-Post Commissural plane, after TPA arterial thrombolysis. Notice normalization of perfusion of cortical and subcortical structures.
Figure 10
Pre and Post arterial Thrombolysis NeuroSPECT images demonstrating the extent of damage recovery. (Pt.# 1 Table 1).
The relationship between of recovery of severe hypoperfusion, degree of recanalization and clinical outcome are as follows. 4 of 10 patients that presented with severe hypoperfusion had their uptake values normalized after a successful recanalization of the occluded vessel (TIMI 2-3), Fig. 5. 3 of which had a good clinical outcome (mR 0-1) and 1 had a moderate outcome (mR 2). 1 of 10 patients had only a partial reduction of the severe hypoperfusion after successful thrombolysis (TIMI 3) and this patient also had a good clinical recovery (mR 1). Now 5 of 10 patients either did not improve their severe hypoperfusion post-thrombolysis or didn't have a control examination[2] due to their poor clinical state. 2 of these patients died and the other 3 only made moderate recoveries (mR 2). 4 of these 5 patients had a poor o no recanalization post thrombolysis (TIMI 0-1). 1 patient had a successful recanalization (TIMI 3) but had a subsequent massive hemorrhage.
Figure 5
Right MCA angiography demonstrates complete occlusion of M1 segment completely corrected after thrombolysis with tPA. Notice immediate visualization of arterial branches previously ischemic. (Pt. 1. Table 1)
The two patients that were not tested after thrombolysis were as follows. The first had a large left MCA infarct with voxels in the infarct zone registering < 30% uptake, and died shortly after the thrombolysis. The second patient presented with a right MCA occlusion, had 10 voxels in the < 30% range, was successfully treated with the thrombolysis but expired shortly after due to a large intracerebral hemorrhage.
The 6 patients that presented with only superficial to moderate hypoperfusion, 3 patients made an excellent recovery (mR 0) associated with a complete satisfactory recanalization (TIMI 2-3), 2 only a moderate recovery (mR 2) related to one patient having a poor recanalization of the occluded vessel (TIMI 1) and the other had a good recanalization (TIMI 3) but suffered a brainstem infarct. Finally the last 1 patient a poor recovery (mR 4) due to also a brainstem infarct.
The clinical outcome related to the recanalization results of the thrombolysis were as follows. 10 of 16 patients had successful recanalization of the occluded vessel (TIMI 2-3) and of these patients, 6 patients had good clinical recovery (mR 0-1), 3 patients had a moderate to poor recovery (mR 2-4) secondary to brainstem infarcts and 1 patient died secondary to a intracranial hemorrhage. 6 of 16 patients had a poor recanalization results post thrombolysis (TIMI 0-1) and of these 1 made a good recovery (mR 0), 4 patients made a moderate to poor recovery (mR 2-3) and 1 patient died.
