99mtechnetium-ethyl-cysteinate-dimer single-photon emission CT can predict fatal ischemic brain edema

Background and Purpose-We sought to study the prognostic value of early (99m)technetium- ethyl-cysteinate-dimer single-photon emission CT (Tc-99m-ECD SPECT) for fatal ischemic brain edema in patients with middle cerebral artery (MCA) stroke compared with the prognostic value of CT and of clinical findings. Methods-We prospectively studied 108 patients clinically, with Tc-99m-ECD SPECT, and with CT within 6 hours of symptom onset (Scandinavian Stroke Scale <40 points) appropriate to MCA ischemia. The follow-up consisted of Scandinavian Stroke Scale and CT on days 1 and 7, Barthel Index, and Modified Rankin Scale after 3 months, An activity deficit of the complete MCA territory on the SPECT cans and a parenchymal hypoattenuation of the complete MCA territory on CT scans were considered as predictors for a fatal MCA infarction due to mass effect and midbrain herniation. Results-In 11 of 108 patients (10%), the MCA infarction was the cause of death. The sensitivity of SPECT for fatal outcome was 82% in both visual and semiquantitative analyses, while specificity was 98% and 99"/a, respectively. The sensitivity and specificity of baseline CT were 36% and 100%, respectively; the sensitivity and specificity of clinical findings (Scandinavian Stroke Scale, depressed level of consciousness, gaze deviation) varied from 36% to 73% and from 45% to 88%, respectively. Ln a multivariate logistic regression model, only SPECT findings were found to be independent predictors of malignant MCA infarction/death. Conclusions-We were able to identify patients with fatal MCA infarction with high accuracy by using Tc-99m-ECD SPECT within 6 hours of stroke onset. This technique offers great potential to select stroke patients For specific therapies, eg, decompressive hemicraniectomy, soon after onset of symptoms.