High-permeability region size on perfusion CT predicts hemorrhagic transformation after intravenous thrombolysis in stroke

PLoS One. 2017 Nov 28;12(11):e0188238. doi: 10.1371/journal.pone.0188238. eCollection 2017.


Objective: Blood-brain barrier (BBB) permeability has been proposed as a predictor of hemorrhagic transformation (HT) after tissue plasminogen activator (tPA) administration; however, the reliability of perfusion computed tomography (PCT) permeability imaging for predicting HT is uncertain. We aimed to determine the performance of high-permeability region size on PCT (HPrs-PCT) in predicting HT after intravenous tPA administration in patients with acute stroke.

Methods: We performed a multimodal CT protocol (non-contrast CT, PCT, CT angiography) to prospectively study patients with middle cerebral artery occlusion treated with tPA within 4.5 hours of symptom onset. HT was graded at 24 hours using the European-Australasian Acute Stroke Study II criteria. ROC curves selected optimal volume threshold, and multivariate logistic regression analysis identified predictors of HT.

Results: The study included 156 patients (50% male, median age 75.5 years). Thirty-seven (23,7%) developed HT [12 (7,7%), parenchymal hematoma type 2 (PH-2)]. At admission, patients with HT had lower platelet values, higher NIHSS scores, increased ischemic lesion volumes, larger HPrs-PCT, and poorer collateral status. The negative predictive value of HPrs-PCT at a threshold of 7mL/100g/min was 0.84 for HT and 0.93 for PH-2. The multiple regression analysis selected HPrs-PCT at 7mL/100g/min combined with platelets and baseline NIHSS score as the best model for predicting HT (AUC 0.77). HPrs-PCT at 7mL/100g/min was the only independent predictor of PH-2 (OR 1, AUC 0.68, p = 0.045).

Conclusions: HPrs-PCT can help predict HT after tPA, and is particularly useful in identifying patients at low risk of developing HT.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Humans
  • Male
  • Stroke / diagnostic imaging
  • Stroke / drug therapy*
  • Thrombolytic Therapy / adverse effects*
  • Tomography, X-Ray Computed / methods*

Grant support

This work was partially supported by grants from the Spanish Ministry of Health, Instituto de Investigación Carlos III (PI10/01309 and PI13/02258), the ERDF: European Regional Development Fund and the Spanish Stroke Research Network (INVICTUS), also financed by the Instituto de Salud Carlos III (RD12/0014/0001 and RD16/0019/0004). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.