Prospective evaluation of malignant middle cerebral artery infarction with blood-brain barrier imaging using Tc-99m DTPA SPECT

Background: Malignant middle cerebral artery (MMCA) infarction is associated with severe brain edema which may lead to a rapid deterioration of consciousness, increase of intracranial pressure, brain midline shift and finally, herniation. We examined the correlation between the degree of the blood-brain barrier (BBB) permeability and MMCA. Methods: Twenty-five consecutive patients (17 men and 8 women, mean age 62.1 ± 10.1) were included in the study. Each patient had a daily clinical examination, and the neurological deficits were scored using NIHSS score. A CT without contrast material was performed in all patients. ^99mTc-DTPA SPECT was performed at 36 h after the stroke. A quantitative index of BBB breakdown (disruption index) was calculated. Results: The mean volume of stroke was 138 ± 87 cm³. The mean DTPA disruption index was 6.6 ± 4.6 (range 1.0-21.0). The mean NIHSS score was 14 ± 4 (p = 0.2). Five of 25 patients had brain herniation as evidenced on brain CT. The volume of stroke was only marginally elevated in patients with herniation (p = 0.062). All patients showed significant, inverse correlation between NIHSS score and DTPA uptake (r = - 0.43, p = 0.033). There was a significant correlation between the extent of DTPA distribution (more than one vascular territory) and the occurrence of herniation (p < 0.001). Conclusions: DTPA-SPECT imaging is a reliable complementary predictive tool in patients with an MCA stroke. The specific pattern found on DTPA SPECT, compatible with diffuse BBB disruption, may be of value in predicting "malignant MCA.".