Edinburgh Imaging

19 Oct 20. Featured Paper

Brain imaging abnormalities & outcome after acute ischaemic stroke: the ENCHANTED trial

Link to paper on The Journal of Neurology, Neurosurgery, & Psychiatry



Candice Delcourt, Xia Wang, Zien Zhou, Joanna M Wardlaw, Grant Mair, Thompson G Robinson, Xiaoying Chen, Sohei Yoshimura, Takako Torii-Yoshimura, Cheryl Carcel, Zeljka Calic, Wee Yong Tan, Alejandra Malavera, Craig S Anderson, Richard I Lindley



Objective: To test the hypothesis that imaging signs of ‘brain frailty’ & acute ischaemia predict clinical outcomes & symptomatic intracranial haemorrhage (sICH) after thrombolysis for acute ischaemic stroke (AIS) in the alteplase dose arm of ENhanced Control of Hypertension ANd Thrombolysis strokE stuDy (ENCHANTED).

Methods: Blinded assessors coded baseline images for acute ischaemic signs (presence, extent, swelling & attenuation of acute lesions; & hyperattenuated arteries) & pre-existing changes (atrophy, leucoaraiosis & old ischaemic lesions).

Logistic regression models assessed associations between imaging features & death at 7 & 90 days; good recovery (modified Rankin Scale scores 0–2 at 90 days) & sICH.

Data are reported with adjusted ORs & 95% CIs.

Results: 2916 patients (67±13 years, National Institutes of Health Stroke Scale 8 (5–14)) were included.

Visible ischaemic lesions, severe hypoattenuation, large ischaemic lesion, swelling & hyperattenuated arteries were associated with 7-day death (OR (95% CI): 1.52 (1.06 to 2.18); 1.51 (1.01 to 2.18); 2.67 (1.52 to 4.71); 1.49 (1.03 to 2.14) & 2.17 (1.48 to 3.18)) & inversely with good outcome.

Severe atrophy was inversely associated with 7-day death (0.52 (0.29 to 0.96)).

Atrophy (1.52 (1.08 to 2.15)) & severe leucoaraiosis (1.74 (1.20 to 2.54)) were associated with 90-day death.

Hyperattenuated arteries were associated with sICH (1.71 (1.01 to 2.89)).

No imaging features modified the effect of alteplase dose.

Conclusions: Non-expert-defined brain imaging signs of brain frailty & acute ischaemia contribute to the prognosis of thrombolysis-treated AIS patients for sICH & mortality.

However, these imaging features showed no interaction with alteplase dose.


  • Acute ischaemic stroke (AIS)

  • Brain imaging

  • Stroke

  • Symptomatic intracranial haemorrhage (sICH)



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Featured paper: Brain imaging abnormalities & outcome after acute ischaemic stroke: the ENCHANTED trial @EdinUniBrainSci #stroke #imaging