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Computed Tomography Perfusion Maps and Final Infarction with Hyper-acute Stroke Patients
indicated by the box-MTF method included tracer delay and overestimated
Figure 1: Chart Flow of the Study for Hyper-acute Stroke Patients
true prolonged MTT areas, and thus CBF was underestimated.
4–7,11,22–24 Pre-treatment Study
However, as was reported in a previous article,
8
in cases with MCA
Plain CT CTP (CBF) (CBV) (MTT)
occlusion without recanalisation by catheter thrombolysis, the prolonged
MTT areas were almost equal to the final infarction sites. CTA examination
of the patients with failure of MCA recanalisation showed the infusion of
contrast media from the posterior cerebral artery to the MCA occlusion
area by way of collateral vessels. The box-MTF method applied in the study
has shown no differentiation between the tracer delay areas and true
Catheter angiography Plain CT
prolonged MTT areas. We consider that if recanalisation with MCA
occlusion is not achieved in the prolonged MTT areas of the box-MTF
method, vascular flow through collateral vessels may be disturbed in the
Intra-arterial catheter thrombolysis →
timecourse, leading to the mechanism of CBV reduction beyond the
compensatory range that Powers et al. and others stated, and resulting in
final infarction.
25–27
Almost the same mechanism and collateral vessel
development might be suggested in BA or ICA occlusion cases but with
Figure 2: Estimation of the Intra-arterial Catheter Thrombolysis
different circulation factors. The patients who had CBV reduction areas in
Succeeded Partially succeeded Failed
the prolonged MTT areas had either haemorrhage or infarct, irrespective of
recanalisation after thrombolysis therapy. This agreed with the published
papers. However, it was difficult to estimate whether CBV reduction areas
of the prolonged MTT areas led to haemorrhage or infarct after
thrombolysis therapy.
In case four, for whom catheter thrombolysis therapy partly succeeded, the
prolonged MTT area and final infarction area coincided. Case four had no
complications of cardiac disease and received traumatic dissection of the CA
at the time of catheter thrombolysis therapy. A possibility of a creeping prolonged MTT areas are large in size on CTP study, with small decreased
thrombus into the partly recanalised MCA or the formation of embolus was CBV area and sometimes with large increased CBV area regarding
considered in this case. In some cases of BA occlusion, increased CBV areas collateral vessel development on CTA study, although careful
were identified in prolonged MTT areas. Final infarction areas were found consideration is necessary, catheter thrombolysis therapy is
only in the decreased CBV areas in the prolonged MTT sites. Although there recommended.
29–34
In summary, the current CTP study with the box-MTF
was no report about CBV change in the prolonged MTT areas with BA- method for hyper-acute stroke patients suggests that when recanalisation
occluded hyper-acute stroke patients, these facts might correlate with the of CBV reduction areas in the prolonged MTT areas is achieved by catheter
positive prognosis of BA-occluded patients. However, in case 15, who thrombolysis therapy, haemorrhage or infarct can occur, although it is
achieved recanalisation by the catheter thrombolysis, pontine haemorrhage limited to a localised CBV reduction area in size. Therefore, if the site of
occurred and the patient died. the decreased CBV area is in the prolonged MTT area with BA occlusion
on the brainstem, pontine haemorrhage after thrombolysis should be
When a decreased CBV area in the prolonged MTT areas is noticed before considered carefully. However, the outcome after catheter thrombolysis
thrombolysis, mortal pontine haemorrhage after recanalisation should be with full or partial recanalisation with BA occlusion seems to end in a
considered carefully. In the patients, the outcome of MCA occlusion and BA relatively positive outcome, with MRS from 0 to II after catheter
occlusion, both in ADL and MRS at the time of discharge from hospital, was thrombolysis. In this study, in the case of unsuccessful thrombolysis
relatively favourable in cases of successful thrombolysis except for two cases, therapy with MCA occlusion, final infarctions were identical to the
even though partial haemorrhage occurred, as the sites of haemorrhage and prolonged MTT area. With the box-MTF method, the prolonged MTT areas
final infarct were small. included tracer delay and the true prolonged MTT areas, which could not
be differentiated. It is considered necessary to investigate the possibility
As reported by Ueda et al.,
28
ICA occlusion cases had poor prognosis even that an entire tracer delay area of MTT with MCA occlusion may result in
with recanalisation. However, in cases of MCA or BA occlusion, when final infarction when recanalisation is not achieved. ■
1. The Japan Stroke Society, Japan Journal of Stoke, 12. Latchw RE, et al., Stroke, 2003;34:1084–1104. 23. Nambu K, et al., Acta Neurol Scand, 1996;166:28–31.
2005;27:330–51. 13. Sparacia G, et al., Radiol Med, 2007;112:113–22. 24. Koenig M, et al., Radiology, 1998;209:85–93.
2. Lee KH, et al., Arch Neurol, 2000;57:1000–1008. 14. Latchaw RE, J Vasc Interv Radiol, 2004;15:S29–46. 25. Powers WJ, et al., Ann Int Med, 1987;106:27–35.
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4. Eastwood JD, et al., Radiology, 2002;222:227–36. 16. Teksam M, et al., Diagn Interv Radiol, 2005;11:202–5. 27. Powers WJ, Ann Neurol, 1991;29:231–40.
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7. Kudo K, Japan J of Diagnostic Imaging, 2005;25:1487–97. 19. Simonsen CZ, et al., Radiology, 2002;225:269–75. 30. Lisboa RC, et al., Stroke, 2002;33:2866–71.
8. Yukari N, et al., Radiat Med, 2008;26:227–36. 20. Schaefer PW, et al., AJNR Am J Neuroradiol, 31. Furlan A, et al., JAMA, 1999;282:2003–11.
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EUROPEAN NEUROLOGICAL REVIEW 63
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