PREDICTORS OF HEMORRHAGIC TRANSFORMATION OCCURRING SPONTANEOUSLY AND ON ANTICOAGULANTS IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Background and Purpose Hemorrhagic transformation (HT) is a common evo lution of large-volume ischemic lesions, particularly of cardioembolic origin. We used transcranial Doppler ultrasound (TCD), single-photon emission computed tomography (SPECT) with Tc-99m-hexamethylpropyleneam ine oxime (HMPAO), and the Toronto Embolic Scale (TES) to decide (1) w hether TCD, HMPAO-SPECT, and TES fan improve on clinical and CT tests to predict spontaneous PIT and (2) whether SPECT can help to predict t he outcome of symptomatic HT. Methods Prognostic criteria included Can adian Neurological Scale (CNS) scores less than or equal to 50 on admi ssion, early ischemic changes on CT, M1 middle cerebral artery occlusi on on TCD, the focal absence of brain perfusion on SPECT, and a high r isk of cardiogenic embolism on TES. Results In part 1, 85 consecutive patients admitted within the first 6 hours were studied. No patient re ceived thrombolysis. HT was found in 11 patients (13%) at 3 to 5 days. Admission CNS and CT were not predictive of HT: odds ratios (95% conf idence intervals) were 0.49 (0.18 to 1.23) (P=.1) and 0.88 (0.23 to 3. 45) (P=.8), respectively. TCD, SPECT, and TES were significant predict ors of HT (P<.05), as follows: TCD, 8.67 (1.42, to 70.59); SPECT, 17.4 0 (2.69 to 170.89); and TES, 18.13 (2.6 to 406.86). In part 2, 490 con secutive patients were studied and 21 (4%) had symptomatic HT, of whic h 12 had focal hypoperfusion on SPECT at 4 days after stroke onset and 9 had focal hyperperfusion. Patients with hypoperfusion had larger CT lesions (115+/-97 versus 42+/-29 cm(3); P=.04) and poorer outcome at 2 weeks (CNS, 38+/-45 versus 96+/-10; P=.001), including death (6/12 v ersus 0/9; P=.04), compared with those with hyperperfusion on SPECT. C onclusions High risk of cardioembolism, M1 middle cerebral artery occl usion, and absence of collateral flow evaluated by TES, TCD, and SPECT help to identify patients at risk for spontaneous HT. Although TES wa s the most powerful predictor of HT, SPECT is the best single adjunct to the triage of clinical and CT tests. Patients with brain hyperperfu sion on HMPAO-SPECT after symptomatic PIT have better chances for reco very.