Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke
Open Access
- 27 November 2020
- journal article
- research article
- Published by BMJ in Stroke and Vascular Neurology
- Vol. 6 (2), 238-243
- https://doi.org/10.1136/svn-2020-000569
Abstract
Background Alteplase improves functional outcomes of patients with acute ischaemic stroke, but its effects on symptomatic infarct swelling, an adverse complication of stroke and the influence of CT hyperdense artery sign (HAS) are unclear. This substudy of the Third International Stroke Trial aimed to investigate the association between HAS and symptomatic infarct swelling and effect of intravenous alteplase on this association. Methods We included stroke patients whose prerandomisation scan was non-contrast CT. Raters, masked to clinical information, assessed baseline (prerandomisation) and follow-up (24–48 hours postrandomisation) CT scans for HAS, defined as an intracranial artery appearing denser than contralateral arteries. Symptomatic infarct swelling was defined as clinically significant neurological deterioration ≤7 days after stroke with radiological evidence of midline shift, effacement of basal cisterns or uncal herniation. Results Among 2961 patients, HAS presence at baseline was associated with higher risk of symptomatic infarct swelling (OR 2.21; 95% CI 1.42 to 3.44). Alteplase increased the risk of swelling (OR 1.69; 95% CI 1.11 to 2.57), with no difference between patients with and those without baseline HAS (p=0.49). In patients with baseline HAS, alteplase reduced the proportion with HAS at follow-up (OR 0.67; 95% CI 0.50 to 0.91), where HAS disappearance was associated with reduced risk of swelling (OR 0.25, 95% CI 0.14 to 0.47). Conclusion Although alteplase was associated with increased risk of symptomatic infarct swelling in patients with or without baseline HAS, it was also associated with accelerated clearance of HAS, which in return reduced swelling, providing further mechanistic insights to underpin the benefits of alteplase.Keywords
Funding Information
- UK Medical Research Council (EME-09-800-15, MRC G0400069)
- National Natural Science Foundation of China (81701156)
- Stroke Association (SA L-SMP 18\1000)
- Key Research and Development Program, Science & Technology Department of Sichuan Province (2017SZ0007)
- Major International (Regional) Joint Research Project, National Natural Science Foundation of China (81620108009)
- National Key Research and Development Program of China, Ministry of Science and Technology of China (2016YFC1300500-505)
- the 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (ZYGD18009)
- The UK Dementia Research Institute
- British Heart Foundation Centre for Research Excellence Award III (RE/18/5/34216)
- the Fondation Leducq (16 CVD 05)
This publication has 33 references indexed in Scilit:
- Protocol for the Perfusion and Angiography Imaging Sub-Study of the Third International Stroke Trial (IST-3) of Alteplase Treatment within Six-Hours of Acute Ischemic StrokeInternational Journal of Stroke, 2013
- The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trialThe Lancet, 2012
- Cerebral Edema in Acute Ischemic Stroke Patients Treated with Intravenous ThrombolysisInternational Journal of Stroke, 2012
- Neurological complications of acute ischaemic strokeThe Lancet Neurology, 2011
- A Large Web-Based Observer Reliability Study of Early Ischaemic Signs on Computed Tomography. The Acute Cerebral CT Evaluation of Stroke Study (ACCESS)PLOS ONE, 2010
- The third international stroke trial (IST-3) of thrombolysis for acute ischaemic strokeTrials, 2008
- Factors Influencing the Detection of Early CT Signs of Cerebral IschemiaStroke, 2007
- Large middle cerebral artery infarctions and the hyperdense middle cerebral artery sign in patients with atrial fibrillationActa Radiologica, 2001
- Attenuated Corticomedullary Contrast: An Early Cerebral Computed Tomography Sign Indicating Malignant Middle Cerebral Artery InfarctionStroke, 1999
- Does Early Reperfusion of a Cerebral Infarct Influence Cerebral Infarct Swelling in the Acute Stage or the Final Clinical Outcome?Cerebrovascular Diseases, 1993