Multiple hypointense vessels on susceptibility-weighted imaging predict early neurological deterioration in acute ischaemic stroke patients with severe intracranial large artery stenosis or occlusion receiving intravenous thrombolysis

Abstract

Background and purpose: Early neurological deterioration (END) is a common feature in patients with acute ischaemic stroke (AIS) receiving thrombolysis. This study aimed to investigate whether the presence of multiple hypointense vessels (MHVs) on susceptibility-weighted imaging (SWI) could predict END in patients with the anterior circulation AIS treated with recombinant tissue plasminogen activator (r-tPA).

Methods: This was a retrospective study focusing on AIS patients suffering from symptomatic stenosis or occlusion of the middle cerebral artery or internal carotid artery with r-tPA treatment. We collected clinical variables and initial haematological and neuroimaging findings. MHVs were measured on SWI performed after intravenous thrombosis and were defined as the presence of a greater number of veins or veins of a larger diameter with greater signal loss on SWI than those of the contralesional haemisphere. The degree of hyperintensity of MHVs was classified into four grades: none, subtle, moderate and extensive. END was defined as an increase in the National Institutes of Health Stroke Scale score by 2 points during the first 48 hours after the onset of symptoms. Multivariate logistic regressions were conducted to investigate the predictors of END.

Results: The study included 61 patients (51 males and 10 females) with a mean age of 62.4±12.6 years. Thirty-five (57.4%) patients presented with MHVs: 8 (13.1%) were graded as subtle MHVs, while 23 (37.7%) and 4 (6.6%) were graded as moderate or extensive MHVs, respectively. Twenty patients (32.8%) presented with END. Logistic regression analysis showed that compared with patients without MHVs, moderate MHVs (adjusted OR 5.446, 95% CI 1.360 to 21.800; p=0.017) and extensive MHVs (adjusted OR 15.240, 95% CI 1.200 to 193.544; p=0.036) were significantly associated with END.

Conclusions: MHVs might be a useful predictor of END in AIS patients with symptomatic large artery stenosis or occlusion after r-tPA treatment.

Keywords: MRI; stroke.

Figure 1

Flow chart of the process used to select subjects. AIS, acute ischaemic stroke; END, early neurological deterioration; ILASO, intracranial large artery stenosis or occlusion; IVT, intravenous thrombolysis; SWI, susceptibility-weighted imaging; PH, parenchymatous haemorrhage.

Figure 2

(1) The case of a 74-year-old woman who suffered from AIS for 2 hours. In the left haemisphere, MHVs in M1 (A), M4 and M5 (B) were evident on SWI, and defined as subtle MHVs. (2) The case of a 68-year-old woman who suffered from AIS for 3 hours. In the left haemisphere, MHVs in M1, M2, M3 (C) and M4, M5, M6 (D) were evident on SWI, and defined as moderate MHVs. (3) The case of a 42-year-old man who suffered from AIS for 2 hours. In the left haemisphere, MHVs in M1, M2, M3 (E) and M4, M5, M6, Deep (F) were evident on SWI, and defined as extensive MHVs. AIS, acute ischaemic stroke; Deep, deep white matter; MHVs, multiple hypointense vessels; M1, anterior MCA cortex; M2, MCA cortex lateral to the insular cortex; M3, posterior MCA cortex; M4, M5, M6, the anterior, lateral and posterior MCA territories immediately superior to M1, M2 and M3; MCA, middle cerebral artery; SWI, susceptibility-weighted imaging.