title: Malignant profile detected by CT angiographic information predicts poor prognosis despite thrombolysis within three hours from symptom onset.
abstract: 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).
  
  
  CONCLUSIONS
  CTA identifies a large hyperacute stroke population with high mortality and low likelihood for independent functional outcome despite early thrombolysis.
authors.affiliation: Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany. volker.puetz@neuro.med.tu-dresden.de
authors.forename: Volker
authors.initials: V
authors.lastname: Puetz
authors.forename: Imanuel
authors.initials: I
authors.lastname: Dzialowski
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.forename: Nikolai
authors.initials: N
authors.lastname: Steffenhagen
authors.forename: Shelagh B
authors.initials: SB
authors.lastname: Coutts
authors.forename: Christine
authors.initials: C
authors.lastname: O'Reilly
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Demchuk
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy* / Q000473:pathology*; D002533:Cerebral Angiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D007091:Image Processing, Computer-Assisted; D020767:Intracranial Thrombosis / Q000188:drug therapy / Q000473:pathology; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011994:Recombinant Proteins / Q000627:therapeutic use; D020127:Recovery of Function; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000628:therapy; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator