THE PREDICTIVE VALUE OF EARLY CT AND ANGIOGRAPHY FOR FATAL HEMISPHERIC SWELLING IN ACUTE STROKE

PURPOSE: Our goal was to analyze the predictive value of early CT and arteriographic morphologic criteria to achieve a more reliable predict ion of fatal outcome in patients undergoing fibrinolytic stroke treatm ent. METHODS: In 74 patients with acute carotid artery stroke, early s igns of cerebral ischemia were determined by CT, The site of vascular occlusion was identified by digital subtraction angiography (DSA), The patients were subsequently treated by intraarterial (n = 68) or intra venous (n = 6) fibrinolysis by means of recombinant tissue plasminogen activator (rt-PA), urokinase, or rt-PA combined with lys-plasminogen and followed-up for a period of 3 months, CT and DSA data were compare d with the clinical course, with special emphasis on signs of early fa tal deterioration (ie, death by intracranial mass effect) as determine d by corresponding CT and clinical observations, occurring within 7 da ys after stroke, RESULTS: Seventeen patients died, all of intracranial mass effect, and all within a week after stroke. In nine of these fat alities, DSA revealed carotid ''T'' occlusion (CTO), which affected 19 patients. In five of the fatalities, a major early sign of ischemia ( MESI, referring to cortical hypodensity in more than a third of the te rritory of the middle cerebral artery, as seen in 14 patients) was rec ognizable on the initial CT scan, This led to a higher predictive valu e and sensitivity of CTO relative to MESI for estimating early fatalit y. CONCLUSION: CTO as determined by DSA is a substantially better pred ictor of fatal outcome in patients undergoing intraarterial thrombolyt ic therapy than is MESI as determined by CT.