Clot Burden Score on Admission T2*-MRI Predicts Recanalization in Acute Stroke

Background and Purpose— To propose a T2*-MR adaptation of the computed tomography angiography-clot burden score (CBS), and assess its value as predictor of 24-hour recanalization and clinical outcome in anterior circulation stroke treated by intravenous thrombolysis ⩽4.5 hours from onset. Methods— Two independent observers retrospectively analyzed pretreatment T2* images for evaluation of clot burden, using a 10-point scale T2*-CBS. Three points are subtracted for susceptibility vessel sign in the supraclinoid internal carotid artery, 2 points each for susceptibility vessel sign in the proximal and distal part of middle cerebral artery, and 1 point each for susceptibility vessel sign in middle cerebral artery branches (with a maximum of 2 points) and for susceptibility vessel sign in anterior cerebral artery. Associations with 24-hour recanalization and favorable outcome (3-month modified Rankin Scale score, ⩽2) were assessed in multivariate analyses. Results— We analyzed 184 consecutive patients (mean age, 67 years) with median (interquartile range) admission National Institutes of Health Stroke Scale score and onset-to-treatment time of 15 (9–19) and 151 (120–185) minutes, respectively. The intraclass correlation for T2*-CBS between observers was 0.97 (95% confidence interval, 0.97–0.98). In multivariate analyses, T2*-CBS >6 was significantly associated with 24-hour recanalization (adjusted odds ratio, 5.1 [1.9–13.5]; P=0.001) or with favorable outcome (adjusted odds ratio, 4.2 [1.7–10.8]; P=0.003). Conclusions— T2*-CBS, a new reproducible semiquantitative score adapted from the computed tomography angiography-CBS, is associated with 24-hour recanalization and 3-month outcome after intravenous thrombolysis. This score needs external validation and could be useful to identify poor responders to intravenous thrombolysis.

[1]  Zsolt Garami,et al.  Site of Arterial Occlusion Identified by Transcranial Doppler Predicts the Response to Intravenous Thrombolysis for Stroke , 2007, Stroke.

[2]  S. Warach,et al.  Diagnostic and prognostic value of early MR Imaging vessel signs in hyperacute stroke patients imaged <3 hours and treated with recombinant tissue plasminogen activator. , 2005, AJNR. American journal of neuroradiology.

[3]  Günther Deuschl,et al.  The Importance of Size: Successful Recanalization by Intravenous Thrombolysis in Acute Anterior Stroke Depends on Thrombus Length , 2011, Stroke.

[4]  N. Petitti The hyperdense middle cerebral artery sign. , 1998, Radiology.

[5]  G. Schroth,et al.  Comparison of Intraarterial and Intravenous Thrombolysis for Ischemic Stroke With Hyperdense Middle Cerebral Artery Sign , 2008, Stroke.

[6]  H. Chabriat,et al.  Intra-Arterial Thrombus Visualized on T2* Gradient Echo Imaging in Acute Ischemic Stroke , 2005, Cerebrovascular Diseases.

[7]  A. Demchuk,et al.  Intracranial Thrombus Extent Predicts Clinical Outcome, Final Infarct Size and Hemorrhagic Transformation in Ischemic Stroke: The Clot Burden Score , 2008, International journal of stroke : official journal of the International Stroke Society.

[8]  A. Demchuk,et al.  Role of Recanalization in Acute Stroke Outcome: Rationale for a CT Angiogram-Based “Benefit of Recanalization” Model , 2008, American Journal of Neuroradiology.

[9]  J. Grotta,et al.  Thrombus Burden Is Associated With Clinical Outcome After Intra-Arterial Therapy for Acute Ischemic Stroke , 2008, Stroke.

[10]  Manabu Inoue,et al.  MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study , 2012, The Lancet Neurology.

[11]  Takashi Inoue,et al.  Clinical and MRI Predictors of No Early Recanalization Within 1 Hour After Tissue-Type Plasminogen Activator Administration , 2011, Stroke.

[12]  J. Broderick,et al.  Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. , 1996, AJNR. American journal of neuroradiology.

[13]  T. Kinoshita,et al.  Changes in susceptibility signs on serial T2*-weighted single-shot echo-planar gradient-echo images in acute embolic infarction: comparison with recanalization status on 3D time-of-flight magnetic resonance angiography , 2012, Neuroradiology.

[14]  C. Oppenheim,et al.  Prevalence of MRI-defined recent silent ischemia and associated bleeding risk with thrombolysis , 2011, Neurology.

[15]  M. Cowan,et al.  American Heart Association. , 2018, P & T : a peer-reviewed journal for formulary management.

[16]  À. Rovira,et al.  Hyperacute ischemic stroke: middle cerebral artery susceptibility sign at echo-planar gradient-echo MR imaging. , 2004, Radiology.

[17]  A. Demchuk,et al.  CT Angiography Clot Burden Score and Collateral Score: Correlation with Clinical and Radiologic Outcomes in Acute Middle Cerebral Artery Infarct , 2009, American Journal of Neuroradiology.

[18]  W. Hacke,et al.  Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke , 1992, Annals of neurology.

[19]  N. Salamon,et al.  CT and MRI Early Vessel Signs Reflect Clot Composition in Acute Stroke , 2011, Stroke.

[20]  K. Kimura,et al.  M1 Susceptibility Vessel Sign on T2* as a Strong Predictor for No Early Recanalization After IV-t-PA in Acute Ischemic Stroke , 2009, Stroke.

[21]  Catherine Oppenheim,et al.  Diffusion Lesion Reversal After Thrombolysis: A MR Correlate of Early Neurological Improvement , 2012, Stroke.

[22]  I. Elovaara,et al.  The clot burden score, the Boston Acute Stroke Imaging Scale, the cerebral blood volume ASPECTS, and two novel imaging parameters in the prediction of clinical outcome of ischemic stroke patients receiving intravenous thrombolytic therapy , 2012, Neuroradiology.

[23]  H. Urbach,et al.  Middle cerebral artery (MCA) susceptibility sign at susceptibility-based perfusion MR imaging: clinical importance and comparison with hyperdense MCA sign at CT. , 2000, Radiology.

[24]  S. Kwon,et al.  Significance of Susceptibility Vessel Sign on T2*-Weighted Gradient Echo Imaging for Identification of Stroke Subtypes , 2005, Stroke.

[25]  Sang Joon Kim,et al.  Progression of middle cerebral artery susceptibility sign on T2*-weighted images: its effect on recanalization and clinical outcome after thrombolysis. , 2006, AJR. American journal of roentgenology.

[26]  K. Kimura,et al.  M 1 Susceptibility Vessel Sign on T 2 * as a Strong Predictor for No Early Recanalization After IV-tPA in Acute Ischemic Stroke , 2009 .

[27]  Jeffrey L Saver,et al.  The Impact of Recanalization on Ischemic Stroke Outcome: A Meta-Analysis , 2007, Stroke.

[28]  H. Urbach,et al.  Middle Cerebral Artery (MCA) Susceptibility Sign at Susceptibility-based Perfusion MR Imaging: Clinical Importance and Comparison with Hyperdense MCA Sign at CT 1 , 2000 .

[29]  P. Nederkoorn,et al.  Proximal and distal hyperattenuating middle cerebral artery signs at CT: different prognostic implications. , 2002, Radiology.