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Relation between cardiac index and regional myocardial blood flow in the non-infarcted wall using PET with 13NH3 in healed myocardial infarction.

It is not clear whether there is any relationship between cardiac output and myocardial blood flow in the infarcted heart. We measured regional myocardial blood flow (RMBF) quantitatively by positron emission tomography (PET) with 13N-ammonia at rest in 18 patients with prior myocardial infarction. RMBF was calculated using the radioactivity in myocardial tissue measured by PET and the radioactivity of arterial blood. Cardiac output was determined by the dilution method using 13NH3 as an indicator, and the relation between cardiac output and RMBF was evaluated at the same time during PET study. There was a good linear correlation between cardiac index (C.I.) and mean RMBF in non-infarcted myocardium (r = 0.45, p < 0.05), and non-infarcted size (r = 0.74, p < 0.01). There was an even better linear correlation between C.I. and sigma RMBF (representing the product of mean RMBF and non-infarcted size) as follows: y = 0.016x + 1.94, r = 0.76 (p < 0.001). It was indicated that the value of C.I. may be related to RMBF of non-infarcted myocardium and its size.

Aged↗

Electrocardiographic changes during dobutamine stress testing in patients with recent myocardial infarction: relation with residual infarct artery stenosis and contractile recovery.

OBJECTIVE: The identification of viable but jeopardized myocardium after acute myocardial infarction (AMI) is of great importance for selecting patients who could benefit from a revascularization procedure. The aim of the study was to determine the accuracy of the dobutamine stress electrocardiogram (ECG) 1) for detecting significant stenosis of the infarct-related artery and 2) for predicting the occurrence of contractile recovery. METHODS AND RESULTS: Ninety-four patients underwent dobutamine stress ECG and quantitative angiography within the first week after AMI. A follow-up resting echocardiogram was obtained in all patients at 1 month. Significant stenosis of the infarct-related artery was detected in 76 patients and functional recovery occurred in 56 patients. Dobutamine stress induced ST-segment elevation in 44 patients, ST-segment depression in 17 and T-wave normalization in 34. Increase in QT dispersion and dobutamine ST elevation were more sensitive than chest pain and ST-segment depression (79% and 53% vs. 24% and 17%, respectively; p<0.05) for detecting significant infarct-related artery stenosis. Four independent variables were selected for predicting contractile recovery: > or = 20 ms increase in QT dispersion from baseline to low-dose dobutamine (p = 0.00016), dobutamine-induced ST-segment elevation (p = 0.0009), elective angioplasty of the infarct-related artery (p = 0.001) and T-wave normalization (p = 0.005). CONCLUSIONS: The analysis of predischarge dobutamine stress ECG is useful for predicting residual stenosis of the infarct-related artery and contractile recovery in the affected area. QT dispersion changes during the test are the most accurate parameter.

Coronary Angiography↗

Assessment of the safety and efficacy of the novel tetrapeptide ITF-1697 on infarct size after primary PTCA in acute myocardial infarction: a randomised, placebo-controlled pilot trial.

OBJECTIVE AND DESIGN: ITF-1697 is a chemically modified LYS-Pro tetrapeptide that corresponds to sequence 113-116 of C-reactive protein. Previous studies have demonstrated significant anti-ischaemic and antithrombotic activity of this tetrapeptide. The aim of this prospective, randomised, double-blind study in patients with acute myocardial infarction undergoing coronary revascularisation was to investigate the safety and efficacy of prolonged intravenous (i.v.) infusion of ITF-1697 at different doses on reduction of infarct size, as assessed by radionuclide imaging. PATIENTS AND METHODS: Injection of technetium-99m (Tc99m) was followed by injection of ITF-1697 or placebo bolus and 24-hour infusion in patients with acute myocardial infarction. Percutaneous transluminal coronary angioplasty (PTCA) was performed and succeeded by radionuclide imaging. A second Tc99m injection and radionuclide imaging was performed 7 days after the PTCA or at hospital discharge. The primary efficacy variable was set as the ratio between the myocardial salvage (size of the initial perfusion defect minus the final size of the infarct) and the initial area at risk (myocardial salvage index). Twenty-three patients were included in the study protocol, of whom nine were randomised to the ITF-1967 dose 1 group (loading dose 55 microg/kg i.v., infusion 0.5 microg/kg/min for 24 hours), a further nine to the ITF-1697 dose 2 group (loading dose 110 microg/kg i.v., infusion 1.0 microg/kg/min for 24 hours), and the remaining five to the placebo group. RESULTS: The defined safety variables (adverse events, laboratory parameters, vital signs and clinical outcome) exhibited no relationship to the application of ITF-1697. Comparison of myocardial salvage index revealed no statistical difference within the three groups (p = 0.65). Hypothesis testing on the myocardial salvage as well as the empirical and bias-correct confidence intervals (CIs) revealed significant differences between the ITF-1697 dose 2 group and the placebo group (95% CI 2.75, 18.07). CONCLUSION: The application of the tetrapeptide ITF-1697 during acute myocardial infarction to reduce infarct size was found to be feasible and safe in this pilot trial.

Adult↗

The relationship between serum enzyme activity, infarct site, and cardiac complications after a first myocardial infarction. A follow-up study in general practice.

The aim of the present study was to relate the clinical course in patients after a first acute myocardial infarction with the site and size of infarct, estimated from standard enzyme measurements. One hundred and eight consecutive patients who suffered an acute myocardial infarction for the first time were followed-up after 30 months in general practice. Twenty-six patients had died and 8 had had another infarction. Sixty-two of the surviving patients had received treatment for ischaemic heart disease, usually for angina pectoris and less often for heart failure and arrhythmias. No correlation was found between ischaemic heart disease requiring treatment and the enzyme-estimated size or the site of the infarct. With anterior infarcts there was, however, an overweight of arrhythmias requiring treatment. Of the patients at work, 31% had changed job or job status because of ischaemic heart disease. At the end of the 30 month period, 50 patients were in functional class 1 and 2, and 32 in functional class 3 and 4 (New York Heart Association's classification).

Adult↗

Comparison of clinical outcomes for women and men after acute myocardial infarction. The Thrombolysis in Myocardial Infarction Investigators.

OBJECTIVES: To assess differences in morbidity and mortality between men and women with acute myocardial infarction treated with thrombolytic therapy and the relation of differences to baseline patient characteristics and clinical features. DESIGN: Secondary analysis of observational findings among women and men enrolled in a clinical trial. SETTING: Hospitals participating in the Thrombolysis in Myocardial Infarction Phase II trial. MEASUREMENTS: Recurrent infarctions and deaths were assessed. MAIN RESULTS: The 6-week mortality rate was greater for women than for men (9% compared with 4%; adjusted relative risk, 1.54; P = 0.01). Death or reinfarction occurred in 15.9% of women and 9.5% of men (adjusted relative risk, 1.33; P = 0.02). Among patients enrolled for treatment with 100 mg of recombinant tissue plasminogen activator and assigned to a conservative strategy of watchful waiting with appropriate backup, the 6-week incidence of death was 7.5% for women and 3.8% for men (P = 0.01). The 6-week incidences of death or reinfarction were 14.2% and 8.9% (P = 0.01) among women and men, respectively. CONCLUSIONS: Among patients in the Thrombolysis in Myocardial Infarction Phase II Trial, who all were diagnosed with myocardial infarction and were eligible to receive thrombolytic therapy, women had higher rates of mortality and morbidity than did men. Older age at the time of myocardial infarction and a history of diabetes accounted for much but probably not all of this difference.

Age Factors↗

[The CAPITOL study (Captopril Post Infarction Tolerance). A trial of progressive titration of captopril after myocardial infarct with left ventricular dysfunction].

The objective of CAPITOL (Captopril Post Infarction Tolerance) multicentre open trial was to study the tolerance of a protocol of titration of Captopril in patients with recent myocardial infarction complicated by left ventricular dysfunction. Five hundred and four patients, with a mean age of 62 +/- 12 years, were included during the hospital period in the 74 participating intensive care units, 9 +/- 6 days after myocardial infarction (ejection fraction 34 +/- 6%). After a 6.25 mg test dose of Captopril, the dosage was progressively increased to the target dose of 150 mg at the end of the first month. Of the 504 patients included, 343 finished the trial and 161 stopped the trial prematurely. At the end of the hospital period, 73% received 75 mg/day: at the first follow-up visit (27 +/- 16 days after inclusion), 59% had attained 150 mg/day, this proportion increasing to 71% at the end of the trial (79 +/- 33 days after inclusion). There was no significant change in blood pressure for the whole study population. However, the systolic blood pressure of the patients receiving 150 mg/day of Captopril at the end of the trial was slightly higher than that observed at the end of the hospital period (126 +/- 17 mmHg and 116 +/- 17 mmHg respectively, p = 0.006). Severe Intercurrent events were observed in 89 patients: 24 deaths, 7 recurrent infarctions, 58 hospital admissions (21 for cardiac failure, 15 for recurrence of angina, 11 aorto-coronary bypass operations, 7 coronary angioplasties, 2 cerebro-vascular accidents, 2 systemic emboli). Of the benign complications, hypotension was observed in 25% of patients, nearly half of which occurred during the hospital admission. The drugs prescribed in association with Captopril were Aspirin (78%), betablockers (57%), nitrate derivatives (42%) and diuretics (27%). Multivariate analysis showed 3 factors associated with good tolerance of the 150 mg dosage of Captopril: Killip Class I or II on admission, an ejection fraction > 30% and an initial systolic blood pressure > 100 mmHg. In conclusion, in this trial of dose titration, 3 out of 4 patients with myocardial infarction and left ventricular dysfunction, tolerated the 150 mg/day dosage of Captopril. Patients in the trial could also be treated with drugs recommended after myocardial infarction, in particular the betablockers. Arch Mal Coeur 1999: 92: 395-403.

Adrenergic beta-Antagonists↗

Low molecular weight heparin for treatment of acute myocardial infarction (FAMI): Fragmin (dalteparin sodium) in acute myocardial infarction.

The benefit of using subcutaneous low molecular weight heparin for the treatment of acute myocardial infarction is not known. The aim of this study was to determine the efficacy of a low molecular weight heparin (dalteparin sodium) for the treatment of acute myocardial infarction in patients not treated with thrombolytic therapy. Twenty-nine cardiological centres from leading hospitals in India participated in this prospective, multicentre, double-blind, placebo-controlled study in two phases which included 1128 patients with acute myocardial infarction. In the acute phase (between day 1 and 3 of admission) all the patients received a weight-adjusted dose of subcutaneous dalteparin (120 IU/kg twice daily). In the second, double-blind phase of acute myocardial infarction, patients were randomised to receive a fixed dose of dalteparin (7,500 IU) or an identical placebo injection for 30 days. A composite primary endpoint of death, reinfarction, recurrence of angina and emergency revascularisation was used. All the 1128 patients with acute myocardial infarction were included in the trial. In the acute phase, the composite primary endpoint was observed in 58 (5.1%) patients. Of 1037 paients who were randomly assigned to receive a fixed dose of dalteparin (n=519) or placebo (n=518), the composite primary event rate was 6.7 percent and 7.0 percent, respectively (RR 0.97; 95% CI 0.62-1.52; p=0.90). To conclude, treatment with dalteparin administered subcutaneously in a weight-adjusted dose of 120 IU/kg twice daily resulted in a lower than expected mortality during the acute phase of myocardial infarction. A lower fixed once daily dose of 7,500 IU during the chronic phase did not confer additional protection.

Aged↗

[Results of 2-year study of morbidity of myocardial infarct (according to material of the myocardial infarction registry)].

The results of a two-year study conducted in accordance with the programme of the Myocardial Infarction Register in the Sokolniky district of Moscow with nearly 164,000 population are presented. The incidence of myocardial infarction in the 20-64 year age group comprises 2.87 and 3.08 among males and 1.52 and 1.44 among females, per 1,000 population for the 1st and 2nd years of the study respectively. The incidence of various clinical forms of myocardial infarction onset and of some complications developing in the acute phase of the disease was established. The typical variant of clinical manifestations is observed in 84.1% of the patients with the onset of myocardial infarction. The most frequently observed complication during the acute period of the disease (nearly in every 5th patient) is cardiac failure. Cardiogenic shock is observed only in 4.4-3.8% of the patients, aged under 64 years. Prior to the development of myocardial infarction 82.3% of the patients suffered angina pectoris, 55-62% arterial hypertension, 29-33% had survived another myocardial infarction earlier.

Adult↗

[Left ventricular function and infarction size after primary angioplasty for acute myocardial infarction].

BACKGROUND: There is little information available on long-term changes in left ventricular function and infarct size after acute myocardial infarction treated with primary angioplasty. MATERIAL AND METHODS: From 1996 to 1998, 100 consecutive patients were treated with primary angioplasty for acute ST-elevation myocardial infarction. Left ventricular ejection fraction was determined by radionuclide ventriculography before discharge, after six weeks and after a mean follow-up time of 20 months (range 11-37). Infarct size was assessed by technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) at rest, performed at the same time intervals. RESULTS: Mean ejection fraction was 56% at discharge, 55% after six weeks and 57% after 20 months of follow-up. A mean perfusion defect of 19% was measured by SPECT after one week. After six weeks and 20 months of follow-up, the mean perfusion defects were reduced to 14% (p < 0.001) and 15%, respectively. INTERPRETATION: Left ventricular function was well preserved and infarct sizes small to moderate 20 months (range 11-37) after primary angioplasty for acute myocardial infarction, demonstrating that the initial successful effect of the treatment was maintained.

Aged↗

[The prognosis of the course and outcome of small-focus myocardial infarct depending on the T-index values on the ECG based on data from the Novosibirsk Myocardial Infarct Registry program].

Overall 342 patients with small-focal myocardial infarction were analyzed for hospital complications and for outcomes during one- and four-year observation periods in groups with different magnitudes of the T parameter. The latter one is the negative T wave on the ECG computed similarly to the Z. L. Dolabchian's index for Q and R waves on days 1-2 and 28 of myocardial infarction. The use of the T parameter allows predicting the most frequently occurring complications during the hospital observation period and recurrent myocardial infarction and cardial death during the period indicated. In the acute stage, the magnitudes of the T parameter from 1 to 24 conventional units are predictors of the complications: lung edema, cardiogenic shock, rhythm disorders, myocardial infarction relapses, particularly in able-bodied men. If the T parameter amounts from 78 to 648 conventional units in the acute stage and on day 28, this suggests a high risk of repeated myocardial infarction and cardial death for one- and 4-year observation periods in accordance with materials of the "Myocardial Infarction Register" program in Novosibirsk.

Age Factors↗

[Thrombolytic treatment of myocardial infarction. Data on the limitation of infarction size and left ventricular function].

Since its introduction in cardiovascular therapeutics, thrombolysis has established itself as an effective procedure of coronary reperfusion during the acute phase of myocardial infarction. Large scale clinical trials have demonstrated a clear cut reduction in mortality providing that the treatment is administered sufficiently early after the onset of symptoms. This reduced mortality is probably related to the limitation of infarct size and the conservation of ventricular function even though this relationship is not always analysed. Studies of infarct size and left ventricular function are difficult to perform and this is reflected in the number of different methods proposed. Apart from coronary reperfusion and its timing, other factors influence the definite size of the infarct, such as the development of a collateral circulation, the existence of cellular reperfusion lesions and the occurrence of reocclusion. The infarct size may be assessed by a number of methods, some simple (enzymes, electrocardiogram) but relatively inaccurate, others more promising but difficult to perform and more costly. Thallium 201 scintigraphy seems to be the best available method and our experience is based on these results. The reference method for the evaluation of left ventricular function is angiography but angioscintigraphy also provides information on global and regional function, the regional study being particularly valuable in the analysis of thrombolytic drug efficacy. A review of the literature shows that thrombolysis is associated with a reduction in infarct size compared with conventional therapy and with conservation of left ventricular function whichever thrombolytic agent is used.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

[Study on the effect and mechanism of puerarin on the size of infarction in patients with acute myocardial infarction].

OBJECTIVE: To observe the effect of puerarin on infarction size, fatty acids metabolism, inflammatory response and atherosclerotic plaque stability in patients with acute myocardial infarction (AMI). METHODS: Sixty-one patients with AMI were randomly divided into two groups, the control group (n = 30) and the treated group (n = 31). All were treated with conventional treatment, but to the treated group, puerarin injection was given additionally by injecting 500 mg per day for 2 weeks. Before and after treatment, blood levels of free fatty acids (FFA), matrix metalloproteinases-9 (MMP-9) and C-reactive protein (CRP) were assayed, and the size of infarction was determined by Ideker QRS scoring method. RESULTS: Before treatment, the size of infarction was positively correlated to the levels of FFA, MMP-9 and CRP (r = 0.43, 0.42 and 0.39, respectively, all P<0.01). As compared with those before treatment, after treatment, the three parameters lowered by 30%, 41% and 23%, respectively and the size of infarction significantly reduced in the treated group (P<0.01), while in the control group, no significant change was found (P>0.05). CONCLUSION: Puerarin treatment could significantly reduce the size of infarction in patients with AMI, the mechanism is possibly related with its effects in lowering plasma levels of FFA, inhibiting inflammation and stabilizing atherosclerotic plaque.

Aged↗

[Clinical classification for lacunar infarct. An investigation of 130 consecutive cases of lacunar infarctions].

A lacunar infarct is defined as the occlusion of a single perforating artery. Certain researchers have proposed that patients with lacunar infarcts can be classified into two clinically distinct entities: patients with a single, symptomatic lacunar infarct, and patients with multiple lacunar infarcts together with hypertension and leukoaraiosis. The present study attempted to delineate the characteristics of lacunar infarcts and evaluate the validity of the aforementioned hypothesis. A total of 130 consecutive patients with first-time symptomatic lacunar infarct were studied. All patients were dichotomized into two groups according to two different kinds of models as follows. Model-1: patients with a single lacune and patients with multiple lacunes; and Model-2: patients with large lacune and patients with small lacune. Associated factors for the multiple lacune group compared with the single lacune group as well as the large lacune group compared with the small lacune group, were analyzed by multivariate logistic regression analysis. Associated factors included age, sex, hypertension, diabetes mellitus, dyslipidemia, smoking, extracranial and intra-cranial vascular lesions, extent of lacunes and white matter lesions, progression status and blood pressure in the acute stage, and coagulation markers such as fibrinogen, thrombin-antithrombin complex, D-dimer, beta-thromboglobulin, platelet factor 4. Results for Model-1: hypertension (age-and sex-adjusted OR: 2.58, p = 0.017) and elevated systolic blood pressure (>160mmHg for the mean value during the first post-ictal week; OR: 2.55, p = 0.016) were significantly associated with the multiple lacune group. Large lacunes (>10mm in diameter) were negatively associated with the multiple lacune group (OR: 0.38, p = 0.017). Association between confluent white matter lesions and the multiple lacune group approached significance (OR: 2.16, p = 0.056). Results for Model-2: female sex (OR: 0.39, p = 0.021), mild stenosis of intracranial and extracranial arteries (<25%) (intracranial; OR: 5.42, p = 0.0042, extracranial; OR: 3.30, p = 0.016), progressing stroke (OR: 6.77, p<0.0001), and high levels of TAT (>3ng/ml) (OR: 2.80, p = 0.039) were significantly associated with the large lacune group. Multiple lacunes (OR: 0.38, p = 0.016) and confluent white matter lesions (OR: 0.28, p = 0.007) exhibited a significant negative association with the large lacune group. In conclusion, underlying vasculopathy in the presence of multiple lacunes may correspond to lipohyalinosis resulting from hypertension. Moreover, large lacune may correspond to microatheroma at the orifice of penetrating arteries.

Aged↗

[Depressive disorders after cerebral infarct. Relations to infarct site, brain atrophy and cognitive deficits].

We studied the effects of the localisation and size of ischemic brain infarcts and the influence of potential covariates (gender, age, time since infarction, physical handicap, cognitive impairment, aphasia, cortical atrophy and ventricular size) on 'post-stroke depression'. During an 18-months period all patients who underwent a CT-scan at the Central Institute of Mental Health and who had a single unilateral ischemic hemisphere infarct were initially included. Patients with severe aphasia or cognitive impairment who could not communicate well enough for the administration of depression rating scales were excluded. This led to a selection bias towards larger infarct sizes in the right hemisphere. In order to overcome this potentially critical selection artefact all patients with infarct sizes over 23 cm2 and/or with 'mini Mental State Scores' under 20 were excluded. The data from the remaining 30 patients (mean age 68 years; 15 male; 13 left hemisphere infarcts were used for the analysis. Their scores on the Hamilton depression rating scale, the Zung self rating depression scale and the von Zerssen clinical self-rating depression scale correlated significantly with one another (r greater than 0.73; p less than 0.001). Backward stepwise regression analysis carried out on the covariates mentioned above demonstrated a significant relationship only between cognitive impairment or cortical atrophy and a higher depression score.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

[Myocardial infarct trial of Düsseldorf. Short- and long-term results after intracoronary stem cell transplantation in acute and chronic myocardial infarction].

Adult autologous bone marrow-derived cells contribute to the healing of myocardial infarction. At the author's institution patients after acute myocardial infarction and patients with chronic coronary heart disease and old infarction were treated. In both patient groups a significant decrease of the infarct area, an improvement of regional contractility and global left ventricular function could be demonstrated. Additional tests with SPECT and positron emission tomography could show an improved myocardial perfusion and an increased glucose uptake in the infarcted area after intracoronary bone marrow cell transplantation. Long-term controls of both patient groups could demonstrate, that the left ventricular pump function was not only increased after 3 months, but also after 12 and 24 (-36) months, respectively. These results demonstrate that functional and metabolic regeneration of infarcted and chronically avital tissue can be released in humans by bone marrow-derived cell transplantation.

Bone Marrow Cells↗

[The effect of a limited area of infarction on the course of ischemic heart disease in patients with a history of myocardial infarct].

Results are described on the effect of limitation of the infarction zone on the course of IHD during the first year of observation in 320 patients with a history of myocardial infarction (MI). The clinical course of the disease and changes of tolerance of physical load were studied in two groups of patients. In one of the groups limitation of the infarction zone was realized during the first ten days. It was found that limitation of the infarction zone is of importance only in the acute period of MI reducing the frequency of fibrillations and lethal outcomes. Limitation of the infarction zone did not effect the course of IHD during the first postinfarction period. Infarction in the involved zone showed no increases in frequency.

Coronary Disease↗

[Expansion of the infarct area in anterior myocardial infarct: a short-term clinical and echocardiographic study].

Forty-five patients with a first anterior myocardial infarction were studied by serial two-dimensional echocardiographic examinations to evaluate the incidence, short-term evolution and clinical significance of infarct expansion. Infarct expansion was found in 26 patients (58%); in 22 cases it was detected at the first examination 24 hours after the onset of symptoms, while in the other 4 it developed later. In 20 (77%) patients expansion involved only the septal and apical regions, while in 6 (23%) it extended to the antero-lateral wall. Two out of 22 patients with early expansion died of cardiogenic shock; expansion of the infarcted area progressively increased in 10 of the remaining 20 patients and remained stable in the other 10. Compared to the patients without expansion those with expansion had a higher CK peak level, a greater number of pathological Q waves and a greater echocardiographic asynergy score; moreover, in-hospital mortality and the incidence of left ventricular failure were higher in the group with expansion (8% vs 0% and 54% vs 10% respectively). Thus our results show that in patients with anterior infarction, expansion is a frequent event which usually develops early and may have a progressive course; infarct expansion, especially when it is large and progressive, is associated with a high incidence of early left ventricular failure and has a poor prognostic significance.

Adult↗

Determination of infarct size of acute myocardial infarction in dogs by magnetic resonance imaging and gadolinium-DTPA: comparison with indium-111 antimyosin imaging.

Acute myocardial infarctions were produced in nine dogs by ligation of the left anterior descending coronary artery. Twenty-four hours after ligation, 0.5 mM/kg of gadolinium (Gd)-DTPA was injected intravenously, followed by cardiectomy 30 min later. Indium-111 antimyosin was administered intravenously 6 hr before cardiectomy to compare the infarct size with Gd-DTPA contrast enhancement. Areas of Gd-DTPA contrast enhancement were closely correlated with those of indium-111 antimyosin uptake (r = .86), although the former showed slightly greater than the latter. Partial and complete enhancements were observed in three and six dogs, respectively. In the T1 and T2 maps, T1 relaxation times of the infarcted area showed greater T1 shortening compared with normal myocardium, whereas T2 relaxation times were not different between infarcted and normal myocardium. Thus, Gd-DTPA showed significant contrast enhancement of the infarcted area because of greater T1 shortening and the extent of Gd-DTPA contrast enhancement expressed the infarct size precisely.

Animals↗