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Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke

Simiao Wu, Grant Mair, Geoff Cohen, Zoe Morris, Anders von Heijne, Nick Bradey, Lesley Cala, Andre Peeters, Andrew J Farrall, Alessandro Adami, Gillian Potter, Ming Liu, Richard I Lindley, Peter A G Sandercock, Joanna M Wardlaw
DOI: 10.1136/svn-2020-000569 Published 27 November 2020
Simiao Wu
1Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Grant Mair
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Geoff Cohen
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Zoe Morris
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Anders von Heijne
3Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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Nick Bradey
4Neuroradiology, James Cook University Hospital, South Tees Hospital NHS Trust, Middlesbrough, UK
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Lesley Cala
5Division of Pathology and Laboratory Medicine, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Andre Peeters
6Department of Neurology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
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Andrew J Farrall
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Alessandro Adami
7Stroke Center, IRCCS Sacro Cuore Don Calabria, Verona, Italy
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Gillian Potter
8Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, Manchester, UK
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Ming Liu
1Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Richard I Lindley
9Westmead Applied Research Centre, Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
10The George Institute for Global Health, Newtown, New South Wales, Australia
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Peter A G Sandercock
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Joanna M Wardlaw
2Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
11UK Dementia Research Institute Centre at the University of Edinburgh, Edinburgh, United Kingdom
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  • Table 1

    Baseline characteristics and 7 day fatality of patients with and without symptomatic infarct swelling

    Symptomatic infarct swelling (n=107)No symptomatic infarct swelling (n=2854)P values
    Age, years, mean (SD)76.8 (12.5)77.4 (12.1)0.59
    Sex, n (%)*0.76
     Male50 (3.5)1377 (96.5)
     Female57 (3.7)1477 (96.3)
    Baseline NIHSS, median (IQR)19 (17–23)11 (6–17)<0.001
    NIHSS, n (%)*<0.001
     NIHSS ≥1588 (8.2)983 (91.8)
     NIHSS <1519 (1.0)1871 (99.0)
    Infarct size on pre-randomisation CT, n (%)*<0.001
     Large/very large55 (11.0)443 (89.0)
     None/small/medium52 (2.1)2411 (97.9)
    Hyperdense artery sign on prerandomisation CT, n (%)*<0.001
     HAS63 (8.8)653 (91.2)
     No HAS44 (2.0)2201 (98.0)
    Allocated treatment, n (%)*0.008
     Alteplase67 (4.5)1417 (95.5)
     Control40 (2.7)1437 (97.3)
    Death in first 7 days, n (%)†70 (65.4)192 (6.7)<0.001
    Time from onset to randomisation, hours, median (IQR)3.5 (2.7–4.2)3.9 (2.9–4.9)0.14
    • *The proportion of patients with/without infarct swelling in each row characteristic subgroup.

    • †The proportion of patients who died ≤7 days in patients with/without symptomatic infarct swelling.

    • HAS, hyperdense artery sign; NIHSS, National Institute of Health Stroke Scale.

  • Table 2

    Multivariable logistic regression for symptomatic infarct swelling

    FactorsBetaOR95% CIP values
    Age*−0.020.980.97 to 0.990.04
    NIHSS*0.141.151.11 to 1.18<0.001
    Large to very large infarct (vs small to medium infarct)0.892.441.57 to 3.79<0.001
    Allocated alteplase (vs control)0.531.691.11 to 2.570.01
    HAS presence (vs absence)0.792.211.42 to 3.44<0.001
    • *Entered as linear variables, where the OR reflected the expected change in odds for one-point increase in NIHSS or 1-year increase in age.

    • HAS, hyperdense artery sign; NIHSS, National Institute of Health Stroke Scale.

  • Table 3

    Effect of alteplase on the development of symptomatic infarct swelling by change in HAS between baseline and follow-up

    Baseline HASChanges in HAS at follow-upAlteplase n/N*Control n/N*Effect of alteplase on development of infarct swelling, OR (95% CI)P value for interaction
    Presence
    (n=673)
    Persistent (n=324)28/15218/1721.93 (1.02 to 3.66)0.62; d.f.=1
    Disappeared (n=349)9/1985/1511.39 (0.46 to 4.24)
    Subtotal37/35023/3231.54 (0.89 to 2.66)
    Absence
    (n=2057)
    Newly developed (n=196)8/905/1061.97 (0.62 to 6.25)0.98; d.f.=1
    None (n=1861)21/95710/9042.01 (0.94 to 4.28)
    Subtotal29/104715/10101.89 (1.01 to 3.55)
    TotalNA66/139738/13331.69 (1.13 to 2.54)0.96; d.f.=3
    • *N or n=number of patients in each subgroup of morphological changes in HAS presence, n/N: n=number of patients with infarct swelling.

    • d.f., degree of freedom; HAS, hyperdense artery sign; NA, not applicable.

Supplementary Materials

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    [svn-2020-000569supp001.pdf]

Additional Files

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    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    • Data supplement 1
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Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke
Simiao Wu, Grant Mair, Geoff Cohen, Zoe Morris, Anders von Heijne, Nick Bradey, Lesley Cala, Andre Peeters, Andrew J Farrall, Alessandro Adami, Gillian Potter, Ming Liu, Richard I Lindley, Peter A G Sandercock, Joanna M Wardlaw
Stroke and Vascular Neurology Nov 2020, svn-2020-000569; DOI: 10.1136/svn-2020-000569

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Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke
Simiao Wu, Grant Mair, Geoff Cohen, Zoe Morris, Anders von Heijne, Nick Bradey, Lesley Cala, Andre Peeters, Andrew J Farrall, Alessandro Adami, Gillian Potter, Ming Liu, Richard I Lindley, Peter A G Sandercock, Joanna M Wardlaw
Stroke and Vascular Neurology Nov 2020, svn-2020-000569; DOI: 10.1136/svn-2020-000569
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Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke
Simiao Wu, Grant Mair, Geoff Cohen, Zoe Morris, Anders von Heijne, Nick Bradey, Lesley Cala, Andre Peeters, Andrew J Farrall, Alessandro Adami, Gillian Potter, Ming Liu, Richard I Lindley, Peter A G Sandercock, Joanna M Wardlaw
Stroke and Vascular Neurology Nov 2020, svn-2020-000569; DOI: 10.1136/svn-2020-000569
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