Evaluation of reperfusion and recovery of brain function before and after intracarotid arterial urokinase therapy in acute cerebral infarction with brain SPECT

Abstract

Purpose: Perfusion defects can be demonstrated reliably at an early stage with regional cerebral blood flow studies using SPECT. The administration of thrombolytic therapy in ischemic stroke is targeted at restoring cerebral perfusion immediately, leading to salvage of ischemic penumbra, smaller infarct size, and improved clinical outcome. This study considered the role of brain perfusion SPECT in the evaluation of reperfusion and brain function recovery of the infarcted area after early recanalization (less than 6 hours) of the occluded artery using intracarotid arterial urokinase therapy (ICAU).

Methods: Intracranial artery occlusion was confirmed in seven patients using emergency carotid angiography performed within the initial 6-hour period. Intracarotid arterial urokinase (500,000 to 800,000 units) was administered into the occluded arterial system (the left middle cerebral artery in four and the right middle cerebral artery in three patients). CT scanning was performed when the patients arrived in the emergency department and was repeated 24 to 48 hours after ICAU and at 7 days or earlier if clinically indicated. All patients had two SPECT studies, the first before urokinase administration and the second 24 or 48 hours later.

Results: Complete recanalization of the occluded vessels was seen in one patient after ICAU, effective partial recanalization was achieved in four patients, and minimal recanalization occurred in the other two. Before ICAU, Tc-99m HMPAO brain SPECT showed decreased uptake of the infarcted area in all patients, whereas the follow-up brain SPECT performed 24 or 48 hours after ICAU revealed improvement in the uptake of the recanalized area on qualitative and semiquantitative assessments using an asymmetry index, suggestive of brain function recovery and clinical improvement. Hemorrhagic transformation adjacent to the reperfused regions occurred in two patients with partial recanalization of the left middle cerebral artery.

Conclusions: Reperfusion of the recanalized area and brain function recovery could be achieved if the occluded artery is recanalized within the initial 6-hour period using ICAU, and this was documented using brain perfusion SPECT without a delay in the therapeutic time window. Because the number of patients we studied was limited, further study is necessary to evaluate the effect of ICAU and to determine its prognostic significance.