The study was done to test the hypothesis that imaging signs of ‘brain frailty’ and acute ischaemia predict clinical outcomes and sICH) after thrombolysis for AIS in the alteplase dose arm of ENCHANTED.

Blinded assessors coded baseline images for acute ischaemic signs and pre-existing changes. Logistic regression models assessed associations between imaging features and death at 7 and 90 days; good recovery and sICH. Data are reported with adjusted ORs and 95% CIs.

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 and 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) and 2.17 (1.48 to 3.18)) and 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)) and severe leukoaraiosis (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.

The study concluded that the non-expert-defined brain imaging signs of brain frailty and acute ischaemia contribute to the prognosis of thrombolysis-treated AIS patients for sICH and mortality.