99(M)TECHNETIUM-ETHYL-CYSTEINATE-DIMER SINGLE-PHOTON EMISSION CT CAN PREDICT FATAL ISCHEMIC BRAIN EDEMA

Background and Purpose-We sought to study the prognostic value of earl y (99m)technetium- ethyl-cysteinate-dimer single-photon emission CT (T c-99m-ECD SPECT) for fatal ischemic brain edema in patients with middl e cerebral artery (MCA) stroke compared with the prognostic value of C T and of clinical findings. Methods-We prospectively studied 108 patie nts clinically, with Tc-99m-ECD SPECT, and with CT within 6 hours of s ymptom onset (Scandinavian Stroke Scale <40 points) appropriate to MCA ischemia. The follow-up consisted of Scandinavian Stroke Scale and CT on days 1 and 7, Barthel Index, and Modified Rankin Scale after 3 mon ths, An activity deficit of the complete MCA territory on the SPECT ca ns and a parenchymal hypoattenuation of the complete MCA territory on CT scans were considered as predictors for a fatal MCA infarction due to mass effect and midbrain herniation. Results-In 11 of 108 patients (10%), the MCA infarction was the cause of death. The sensitivity of S PECT for fatal outcome was 82% in both visual and semiquantitative ana lyses, while specificity was 98% and 99''/a, respectively. The sensiti vity and specificity of baseline CT were 36% and 100%, respectively; t he sensitivity and specificity of clinical findings (Scandinavian Stro ke Scale, depressed level of consciousness, gaze deviation) varied fro m 36% to 73% and from 45% to 88%, respectively. Ln a multivariate logi stic regression model, only SPECT findings were found to be independen t predictors of malignant MCA infarction/death. Conclusions-We were ab le to identify patients with fatal MCA infarction with high accuracy b y using Tc-99m-ECD SPECT within 6 hours of stroke onset. This techniqu e offers great potential to select stroke patients For specific therap ies, eg, decompressive hemicraniectomy, soon after onset of symptoms.