Brainstem Hyperperfusion Syndrome After Intravenous Thrombolysis: A Case Report

Lau, Chi Ieong; Lien, Li-Ming; Chen, Wei‐Hung

doi:10.1111/j.1552-6569.2010.00469.x

Cited by 5 publications

(6 citation statements)

References 16 publications

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“…[ 13 , 14 ] END classification criteria: (1) IS: MRI indicating enlargement of the original infarction area, or new infarction in other arterial regions (MRI-DWI) with a high signal and MRI-ADC showing a low signal, or continuous CT scan showing enlargement of the infarction area [ 15 , 16 ] ; (2) sICH: CT confirming intra-cerebral hematoma or subarachnoid hemorrhage or lateral ventricular hemorrhage [ 17 ] ; and (3) VCE: MRI showing a high signal in the infarcted area both in the MRI-DWI and ADC. [ 6 , 16 , 18 , 19 ]…”

Section: Methodsmentioning

confidence: 99%

“…[ 2 , 3 ] Perfusion abnormalities, hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play critical roles in END. [ 4 – 6 ]…”

Section: Introductionmentioning

confidence: 99%

“…Trans-cranial Doppler (TCD) has been used to assess the state of hyper-perfusion after successful re-canalization and END, through hemodynamic changes in intravenous thrombolysis. [ 6 – 9 ] A retrospective study on post-EVT TCD found that the increase in the mean flow velocity (MFV) index of the middle cerebral artery (MCA) after complete re-canalization was associated with an increased risk of intra-cranial hemorrhage within 24 h of therapy. [ 10 ] However, the significance of this tool in predicting the risk of END after EVT has not been further elucidated.…”

Section: Introductionmentioning

confidence: 99%

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Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Rajah

et al. 2020

Chinese Medical Journal

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Background Early neurologic deterioration (END) may occur in patients with anterior circulation ischemic stroke (ACIS) after receiving endovascular treatment (EVT). Hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play a critical role in END. We hypothesized that hemodynamic changes can predict END in patients with ACIS post-successful EVT using trans-cranial Doppler (TCD). Methods We utilized a prospectively maintained database of ACIS patients treated with EVT between September 2016 and June 2018 in the Xuanwu Hospital, Capital Medical University. TCD parameters including peak systolic velocity (PSV), bilateral mean flow velocity (MFV), and pulse index (PI) were determined via the middle cerebral arteries within 72 h post-EVT. A logistic regression model was applied to detect independent predictors for END. Results Totally, 112 EVT patients were included in this study and 80/112 patients experienced successful re-canalization with <50% residual stenosis, while 17/80 (21.3%) patients suffered END, for which vasogenic cerebral edema (11/17) was considered as a leading role and followed by symptomatic intra-cranial hemorrhage (4/17) and ischemia progression (2/17). For the 80 patients, the PSV (median: 127 cm/s vs. 116 cm/s, P = 0.039), the ratio of ipsilateral-MFV/contra-lateral-MFV (iMFV/cMFV) (median: 1.29 vs. 1.02, P = 0.036) and iMFV/mean blood pressure (MBP) (median: 0.97 vs. 0.79, P = 0.008) in END patients were higher than those of non-END. Using the receiver-operating characteristic curve to obtain cut-off values for PSV, PI, iMFV/cMFV, and iMFV/MBP for END, we found that PI ≥0.85 (odds ratio: 11.03, 95% confidence interval: 1.92–63.46, P = 0.007) and iMFV/MBP ≥0.84 (odds ratio: 9.20, 95% confidence interval: 2.07–40.84, P = 0.004) were independent predictors of END in a multivariate logistic regression model, with a sensitivity of 82.4% and 76.5% and a specificity of 42.9% and 66.7%, respectively, and had the positive predictive values of 29.0% and 38.2%, and negative predictive values of 90.0% and 91.3%, with an area under the receiver-operating characteristic curve of 0.57 and 0.71, respectively. Conclusion TCD examination of EVT patients may be used as a real-time tool to detect END predictors, such as the higher PI and iMFV/MBP, allowing for better post-thrombectomy management in ACIS patients.

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Section: Methodsmentioning

confidence: 99%

“…[ 2 , 3 ] Perfusion abnormalities, hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play critical roles in END. [ 4 – 6 ]…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Rajah

et al. 2020

Chinese Medical Journal

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“…[ 2 9 ] Vasogenic CE (VCE): Swelling in infarction and its surrounding region verified by MRI (diffusion-weighted imaging showed high signal, while apparent diffusion coefficient mapping showed equal or high signal) or consecutive follow-up CT scan and TCD (CT showed extravasation of contrast medium and TCD showed the velocity of cerebral blood flow was normal or increased). [ 10 11 12 13 ] CT or MRI scan could be obtained at 24 h after recanalization treatment and when END occurred. TCD monitoring could be obtained within 24 h after recanalization treatment, and neurological imaging could be followed up continuously in END patients if necessary.…”

Section: Ethodsmentioning

confidence: 99%

Early Neurological Deterioration after Recanalization Treatment in Patients with Acute Ischemic Stroke

Zhang

et al. 2018

Chinese Medical Journal

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Background:Early neurological deterioration (END) is a prominent issue after recanalization treatment. However, few studies have reported the characteristics of END after endovascular treatment (EVT) as so far. This study investigated the incidence, composition, and outcomes of END after intravenous recombinant tissue plasminogen activator (IV rt-PA) and EVT of acute ischemic stroke, and identified risk factors for END.Methods:Medical records of patients who received recanalization treatment between January 1, 2014, and December 31, 2015 were reviewed. Patients were classified into IV rt-PA or EVT group according to the methods of recanalization treatment. The END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) ≥4 or an increase in Ia of NIHSS ≥1 within 72 h after recanalization treatment. Clinical data were compared between the END and non-END subgroups within each recanalization group.Results:Of the 278 patients included in the study, the incidence of END was 34.2%. The incidence rates of END were 29.8% in the IV rt-PA group and 40.2% in the EVT group. Ischemia progression (68.4%) was the main contributor to END followed by vasogenic cerebral edema (21.1%) and symptomatic intracranial hemorrhage (10.5%). Multivariate logistic regression showed that admission systolic blood pressure (SBP) ≥160 mmHg (odds ratio [OR]: 2.312, 95% confidence interval [CI]: 1.105–4.837) and large artery occlusion after IV rt-PA (OR: 3.628, 95% CI: 1.482–8.881) independently predicted END after IV rt-PA; and admission SBP ≥140 mmHg (OR: 5.183, 95% CI: 1.967–13.661), partial recanalization (OR: 4.791, 95% CI: 1.749–13.121), and nonrecanalization (OR: 5.952, 95% CI: 1.841–19.243) independently predicted END after EVT. The mortality rate and grave outcome rate at discharge of all the END patients (26.3% and 55.8%) were higher than those of all the non-END patients (1.1% and 18.6%; P < 0.01).Conclusions:END was not an uncommon event and associated with death and grave outcome at discharge. High admission SBP and unsatisfactory recanalization of occluded arteries might predict END.

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“…Incidence of CHS is 1–3% after carotid endarterectomy [ 1 ]. CHS after iv tPA in patients with acute ischemic stroke (AIS) has also been recognized [ 2 , 3 ]. However, radiographic evidence of CHS has not been described.…”

Section: Introductionmentioning

confidence: 99%

Imaging Evidence for Cerebral Hyperperfusion Syndrome after Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

Zhang

Kumar

Tezel

et al. 2016

Case Reports in Neurological Medicine

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Background. Cerebral hyperperfusion syndrome (CHS), a rare complication after cerebral revascularization, is a well-described phenomenon after carotid endarterectomy or carotid artery stenting. However, the imaging evidence of CHS after intravenous tissue plasminogen activator (iv tPA) for acute ischemic stroke (AIS) has not been reported. Case Report. Four patients were determined to have manifestations of CHS with clinical deterioration after treatment with iv tPA, including one patient who developed seizure, one patient who had a deviation of the eyes toward lesion with worsened mental status, and two patients who developed worsened hemiparesis. In all four patients, postthrombolysis head CT examinations were negative for hemorrhage; CT angiogram showed patent cervical and intracranial arterial vasculature; CT perfusion imaging revealed hyperperfusion with increased relative cerebral blood flow and relative cerebral blood volume and decreased mean transit time along with decreased time to peak in the clinically related artery territory. Vascular dilation was also noted in three of these four cases. Conclusions. CHS should be considered in patients with clinical deterioration after iv tPA and imaging negative for hemorrhage. Cerebral angiogram and perfusion studies can be useful in diagnosing CHS thereby helping with further management.

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Brainstem Hyperperfusion Syndrome After Intravenous Thrombolysis: A Case Report

Abstract: rtPA-associated hyperperfusion can occur at brainstem causing transient neurological deficits. It can be a cause of DFI in addition to reocclusion after recanalization.

Cited by 5 publications

References 16 publications

Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Early Neurological Deterioration after Recanalization Treatment in Patients with Acute Ischemic Stroke

Imaging Evidence for Cerebral Hyperperfusion Syndrome after Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

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