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8 Background: Late secondary injury following vessel  recanalization, recently observed in animal stroke models, may limit  the benefit of reperfusion therapy. The frequency and clinical  correlates of secondary injury in humans have not been previously  characterized.Methods: Diffusion-perfusion MRIs were  performed prior to treatment, early after recanalization (median 4  hrs), and at day 7 in patients undergoing vessel recanalization with  intra-arterial (IA) thrombolytics. Post-treatment MRIs were  co-registered to the pretreatment scan to allow a voxel-by-voxel  analysis of tissue fate over time.Results: Eighteen  patients (13 females, 5 males) were studied. Mean age was 71 and median  entry NIHSS score 13. Early after recanalization, partial or complete  normalization of DWI abnormalities occurred in 8/18 (44%) patients,  and of apparent diffusion coefficient (ADC) abnormalities in 13/18  (72%). Among the 8 patients with early DWI reversal, late secondary  injury on day 7 (on DWI or T2W sequences) occurred in 5 (63%), and  sustained normalization of all reversed tissue in 3 (38%). Across all  patients, of tissues showing pretreatment DWI abnormality, 41% of  voxels showed no early reversal, 33% early reversal with sustained  normalization at day 7, and 18% early reversal but late secondary  injury. Pretreatment ADC values were lowest in regions experiencing no  reversal (mean ADC 624 um2/sec), intermediate in regions with reversal  and secondary decline (641), and highest in regions with sustained  reversal (677). Evolution of neurologic deficit (NIHSS) did not differ  in patients with secondary injury vs. those with sustained reversal,  nor did age, time to recanalization, degree of recanalization, or  presence of post-ischemic hyperperfusion.Conclusions: Following vessel recanalization with IA thrombolysis, partial or  complete reversal of initial DWI abnormality occurs in ∼40% of  patients. A late, secondary signature of injury compromising some or  all of the initially normalized tissue occurs in over 50% of these  patients, but is not associated with clinical worsening.

stroke

Late Secondary Injury in Patients Undergoing Vessel Recanalization with Intra-arterial Thrombolysis: Visualization with MRI, Frequency, and Clinical Correlates