Blood–brain barrier permeability derangements in posterior circulation ischemic stroke: Frequency and relation to hemorrhagic transformation

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Abstract

Background

Early disruption of the blood–brain barrier (BBB) due to severe ischemia can be detected by MRI T2* permeability imaging. In middle cerebral artery (MCA) infarction, pretreatment T2* permeability derangements have been found in 22% of patients and are powerful predictors of hemorrhagic transformation after revascularization therapy. The frequency, clinical correlates, and relation to hemorrhagic transformation of permeability derangements in posterior circulation have not been previously explored, and may differ as ischemia volume and collateral status are different between vertebrobasilar and MCA infarcts.

Methods

We analyzed clinical and pretreatment MRI data on consecutive patients undergoing recanalization therapy for acute vertebrobasilar ischemia at a medical center November 2001 through September 2009. Pretreatment MRI permeability images were derived from perfusion source imaging acquisitions. Permeability abnormality was detected as persisting increased signal intensity at later time points in perfusion MRI acquisition, indicating local accumulation of contrast caused by BBB leakage.

Results

Among the 14 patients meeting study entry criteria, mean age was 71.1 years and median pretreatment NIHSS was 20.5. Permeability imaging abnormality was present in 1 of the 14 patients (7%). Among 14 patients, post-treatment parenchymal hematoma occurred in one and more minor degrees of hemorrhagic transformation in four. The one patient with pretreatment permeability abnormality was the patient to develop post-treatment parenchymal hematoma (Fisher's exact test, P = 0.07).

Conclusion

Pretreatment permeability abnormality, an indicator of BBB derangements, is an infrequent finding in acute posterior circulation ischemic stroke and may be associated with an increased risk of parenchymal hematoma development undergoing recanalization therapy.

Introduction

Hemorrhagic transformation is a feared complication of recanalization therapy for acute ischemic stroke. Established clinical and laboratory predictors of hemorrhagic transformation in patients with ischemic stroke include greater neurologic deficit severity, hyperglycemia, and later time to treatment. Some studies have already identified clinical and laboratory predictors of hemorrhagic transformation after recanalization therapy for stroke [[1], [2], [3], [4], [5]]. Increasing use of multimodal magnetic resonance imaging (MRI) offers an additional source of data regarding tissue status and potential tendency for hemorrhagic transformation [6], [7]. Several pretreatment MRI parameters have variably been reported in association with an increased risk of hemorrhagic transformation after recanalization therapy: leukoaraiosis [8], prior cerebral microbleeds visualized with T2*-weighted MRI sequences [9], and severe diffusion and perfusion deficit [10], [11].

MRI permeability imaging is a promising potential additional and distinctive marker to identify patients with an increased tendency to hemorrhagic transformation. Dedicated MRI acquisitions have been used to identify blood–brain barrier permeability derangements in patients with brain tumors for grading [12], [13]. We previously reported that pretreatment permeability images derived from routine perfusion-weighted imaging source data, or slope images, may identify increased risk for hemorrhagic transformation in middle cerebral artery (MCA) stroke patients [14]. However, the frequency, clinical correlates, and relation to hemorrhagic transformation of permeability derangements in the posterior circulation stroke have not been previously explored, and may differ, as ischemic volume and collateral status are different, between vertebrobasilar and MCA infarctions. The objective of this study was to characterize the frequency and relation to hemorrhagic transformation of early disruption of the blood–brain barrier, detected by MRI T2* permeability imaging, in posterior circulation ischemic patients treated with recanalization therapy.

Section snippets

Patient selection

We analyzed clinical, laboratory and pretreatment MRI data on consecutive patients in a prospectively maintained database who received recanalization therapy for acute ischemic stroke within the posterior circulation at a university hospital from November 2001 to September 2009.

Imaging methods

All patients underwent brain MRI (1.5 Tesla; Siemens Medical Systems) before recanalization therapy. The MRI protocol included diffusion-weighted imaging, gradient-recalled echo (repetition time, 800 ms; echo time 15 ms),

Results

Among 21 patients with posterior circulation ischemic stroke who received recanalization therapy during the study period, pre-treatment perfusion-weighted imaging was not performed in 7 patients. The characteristics of the 14 patients meeting study entry criteria are shown in Table 1. Mean age was 71.1 years old and 5 patients (43%) were female. Median pretreatment National Institute of Health Stroke Scale (NIHSS) score was 20.5 (ranged 0–36). In the 13 patients with deficits at time of

Discussion

This study is the first to characterize the frequency of pretreatment permeability abnormalities in large artery posterior circulation ischemic stroke and their relation to hemorrhagic transformation. We found permeability derangement in 7% of patients, and the patient with this abnormality was the only patient to evolve a major parenchymal hematoma after recanalization therapy.

Most investigations of hemorrhagic transformation after recanalization therapy to date have focused on anterior

Contributors

JLS and DSL designed the study. ML, JLS, QH, SS, LKA, DK, BO, PMV, MTF, MST, NS, JPV, RJ, GRD, ST, NG, FV participated in the data collection and extraction. ML processed the perfusion imaging with guidance from JRA and DSL. ML did the statistical analysis with guidance from JLS and DSL. ML wrote the first draft of the report, and JLS and DSL did the major revision. All other authors commented on the draft and approved the final version.

Conflict of interest

None.

Disclosures

None.

Acknowledgments

Meng Lee (CMRPG 660311, Taiwan), Jeffrey L Saver and Jeffry Alger (NIH SPOTRIAS), and David S Liebeskind (NIH-NINDS Awards , ), Bruce Ovbiagele (UCLA-RCMAR under NIH/NIA Grant P30-AG021684).

Reference (19)

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