Study on clinical and subclinical characteristics, computed tomography imaging of acute ischemic stroke after revascularization within 6 first hours

F is 8ml/100g /minute or under. 1.4. Clinical characteristics of stroke patients The clinical characteristics of ischemic stroke patients depend on the location of the affected brain part. 1.4.1. Cerebral artery thrombosis 1.4.1.1. Common clinical characteristics - Most patients have symptoms before the onset of ischemic stroke, this stage is very important for proper diagnosis of cerebral artery thrombosis. The sign is warning TIA attacks. Depending on the location of the thrombosis, TIA can cause different clinical symptoms. - Stroke onset context: Stroke usually occurs at night or early in the morning - Stroke onset: Most patients start with common symptoms of brain lesions (fatigue, dizziness, numbness in the limbs, etc) before the stroke onset from a few hours to a few days. - Process pattern: patients often describe gradually or rapidly progressive clinical symptoms. - Common neurological symptoms: headache, vomiting, convulsions, mild conciousness disorders, possible sphincter disorders, frequent urinary retention or urinary incontinence. - Localized neurological symptoms: Depending on the artery lesion, there are corresponding clinical symptoms: Speech disorders, seventh cranial nerve paralysis and hemiplegia on the side of the body opposite to the area of cerebral damage, cerebral palsy, brain stem and/or medulla damage (HC Weber, Benedickt, Foville, Milard - Gubler). 1.4.2. The cerebral artery syndrome - Internal carotid artery occlusion syndrome - Mid cerebral artery syndrome - Vertebrobasilar Insufficiency syndrome 1.5. Visual characteristics of cranial CT Scan in stroke patients within 6 hours after stroke onset 1.5.1. Computed tomography without contrast 1.5.1.1. Signs for early diagnosis of ischemic stroke Cranial CT scan allows early diagnosis of ischemic stroke, but does not give an accurate measurement of the volume of anemia, does not assess the vascular condition, does not assess the survival possibility of brain parenchyma, especially in the early stage. Five basic signs to early diagnose ischemic stroke on CT scan without contrast: hyperdensity of artery, hypodensity of brain parenchyma, hypodensity of lentiform nucleus, loss of insular ribbon, losing the distinction between gray matter and white matter, and unclear brain grooves. 1.5.1.2. ASPECT scale ASPECT scale has been widely used since 2000 in clinical practice to assess the degree of early ischemic changes on brain imaging. The ASPECT scale is a 10-point scoring system that is equivalent to 10 anatomical regions according to the blood supply region from the mid cerebral artery. 1.5.2. Computed tomography with contrast 1.5.2.1. Position the blocked artery 1.5.2.2. Assess brain parenchyma from scanned image 1.5.2.3. Assess the degree of collateral circulation 1.6. Thrombectomy and thrombolysis treatment in ischemic stroke patients 1.6.1. Thrombolysis 1.6.2. Thrombectomy CHAPTER 2 OBJECTS AND METHODS OF THE STUDY 2.1. Studied objects 2.1.1. Object, time, and place of study From June 2016 to July 2017, we conducted a study of 114 patients with acute cerebral ischemic stroke at Stroke Center, 108 Military Central Hospital. These patients were selected under the selection and exclusion criteria. 2.1.2. Selection criteria - The patient is diagnosed with acute ischemic stroke within the first 6 hours after the stroke onset to admission at 108 Military Central Hospital; Based on Guidelines for the Early Management of Patients With Acute Ischemic Stroke in 2015 by American Heart Association/American Stroke Association (AHA / ASA) + Clinical symptoms: face dropping, sudden weakness of the body, sudden trouble speaking, turning head and eyes towards the intact side. + Patient have: - CT scan without contrast to exclude hemorrhagic stroke. - CT scan with contrast to identify damaged brain artery. Classify subtypes of stroke: blocked large arteries or small artery (lacunar infarct). Identify the infarction happens on the anterior cerebral circulation or the posterior cerebral circulation. + If the patient has a history of brain stroke, mRS score exclude from 0 to 1 score + ≥ 18 years of age + Less than 6 hours after the stroke onset + patient or his/her legal protector approved to participate in the study. + Patients have been under treatment: thrombolysis, thrombonectomy or a combination of the two above treatments. 2.1.3. Exclusion criteria - Hemorrhagic stroke - Ichemic stroke patients with a history of traumatic brain injury, encephalitis, and/or brain tumor. 2.2. Research Methods 2.2.1. Study design A prospective descriptive and cross-section study. 2.2.2. Clinical study 2.2.2.1 Questionaire * Create a unified registration form based on such criteria as: Age, gender, time of onset, nature of the onset, place of the onset, time of admission to Emergency Department. * Identify stroke signs of the patient: Sudden face dropping, numbness or weakness of one arm and/or one leg on one side of the body, difficulty speaking or communicating, sudden loss of vision in one or both two eyes, dizziness, loss of balance or movement coordination disorders. * Identify the time of stroke onset. * Collect patient's medical history and information. 2.2.2.2. Clinical examination - Access neurological symptoms (hemiplegia, cranial nerve palsy, sensory disorders, speech and language disorders, etc.), consciousness disorders, vital signs such as pulse, blood pressure, heart rate, breathing, SpO2, temperature. - Access patients’ situation based on: Glasgow, limb muscle strength MRC, NIHSS. 2.2.3. Subclinical study - Blood count, blood biochemistry, immunity, ECG, cardiac ultrasound. - CT scan of cranial brain imaging, Computed tomography angiography (CTA), right at the Emergency Department. - Digital Subtraction Angiography (DSA) to prepare for cerebral intervention. - Evaluate ASPECT scores, consider early signs on cranial CT, collateral circulation scale, occlusion location. 2.3. Study content 2.3.1. Describe the clinical features, CT images of brain in patients with ischemic stroke and recirculation done in 6 hours. 2.3.1.1. Common characteristicsof the studied objects - Identify age, gender, risk factors, time of stroke onset 2.3.1.2. Clinical and subclinical characteristics - Stroke onset symptoms, physical signs upon admission, blood count, biochemistry, echocardiogram, Electrocardiography - ECG, cranial CT scan, assess patients with ASPECT, pc-ASPECT score on cranial CT film. + Identify brain lesions on CT angiogram: lesion area, damaged artery location, assess the degree of collateral circulation. 2.3.2. Evaluate the relationship of clinical signs with CT images in ischemic patients who had recirculation in the first 6 hours - Assess the relationship between early signs on cranial CT scan according to time: less than 3 hours, 3 to 4,5 hours and from 4.5 to 6 hours. - Assess the relationship between clinical characteristics of patients with hypodensity of brain parenchyma and patients without hypodensity of brain parenchyma on CT scan film. - Assess the relationship between clinical features of patients with cerebral infarction due to damages on the anterior cerebral circulation and damages on the posterior cerebral circulation. - Assess the relationship between clinical characteristics of patients with ischemic stroke to ASPECT score. - Assess the relationship between the NIHSS score and the ASPECT score. - Assess the relationship between the limb muscle strength and the ASPECT score. - Assess the relationship between the NIHSS score and the collateral circulatory system score of the anterior cerebral circulation system. - Assess the relationship between Glasgow point and the collateral circulatory system score of the anterior cerebral circulation system. - Assess the relationship between the limb muscle strength and the collateral circulatory system score of the anterior cerebral circulation system. 2.4. Data processing methods - Data collection and data input using SPSS 22.0 software. 2.5. Research ethics - Ensuring medical ethics during the study. CHAPTER 3 : RESULTS 3.2. Clinical features and CT scan images of acute ischemic stroke in the first 6 hours 3.2.1. Characteristics of clinical symptoms of patients at hospitalized time Table 3.4. Clinical signs at hospitalized time No. Onset symptoms Number of patients (n=114) Ratio (%) 1 Language disorder 104 91,2 2 Hemiplegia 110 96,5 3 Face dropping 105 92,1 4 Headache 31 27,2 5 Sensation disorders on one side of the body 20 17,5 6 Dizziness 15 13,2 7 Vomitting 10 8,8 8 Convulsion 1 0,9 Table 3.5. Glasgow at hospitalized time Group Glasgow Scale Number of patients (n = 114) Ratio (%) 15 29 25,4 9-14 71 62,3 6-8 12 10,5 3-5 2 1,8 Average Glasgow Scale: 11,98 ± 2,65 - Average Glasgow Scale of Stroke Patients was 11,98 ± 2,65. Table 3.6. Classification of muscle scaleat hospitalized time Group Muscle Scale- MRC Upper limb muscle strength n = 114 (%) Lower limb muscle strength n = 114 (%) 0 66 (57,9) 61 (53,5) 1 16 (14,0) 19 (16,7) 2 8 (7,0) 10 (8,8) 3 20 (17,5) 19 (16,7) 4 2 (1,8) 2 (2,6) 5 2 (1,8) 2 (1,8) Table 3.7. NIHSS scoreat hospitalized time NIHSS score group Number of patients (n = 114) Ratio (%) NIHSS group ≤ 5 9 7,9 6 – 15 38 33,3 16 – 20 30 26,3 21 – 42 37 32,5 Average 16,897,14 The average NIHSS score of patients in this study was 16.897.14 scores, the highest was 42 scores, the lowest was 2 scores. Table 3.8. Characteristics of blood pressure at hospitalized time Group Blood pressure Number of patients (n = 114) Systole (mmHg) Average 140,61  25,58 Lowest 85 Highest 217 Diastole (mmHg) Average 81,80  14,10 Lowest 48 Highest 140 Systolic HA group (mmHg) < 90 1 (0,9) 90 – 139 59 (51,8) 140 – 184 49 (43,0) ≥ 185 5 (4,4) 3.2.2. Hematological, biochemical, ultrasound and ECG characteristics of hospitalized patients Table 3.9. The composition of complete blood count Complete blood Counts General Group (n = 114) Red blood cell (T/l) 4,57 ± 0,55 Hematocrit (l/l) 0,41 ± 0,04 Platelets (G/l) 242,79 ± 76,73 Table 3.10. The basic coagulation components No. Coagulation components Test result 1 Prothrombin time (s) (n = 102) 11,98 ± 3,73 2 INR (n = 54) 1,11 ± 0,31 3 Fibrinogen concentration (g/l) (n = 93) 4,00 ± 1,25 Table 3.11. The basic biochemical components No. Biochemical components Test result 1 Cholesterol (mmol/L) (n=86) 4,93 ± 1,20 2 Triglycerid (mmol/L) (n=86) 2,05 ± 1,60 3 Blood Glucose (mmol/L) (n=110) 8,03 ± 3,02 Table 3.12. ECG characteristics No. Characteristics Number of patients (n=99) Ratio (%) 1 Atrial Fibrillation 40 35,1 2 No atrial fibrillation 59 51,8 Table 3.13. Doppler echocardiogram results No. Echocardiogramcharacteristics Number of patients (n=83) Ratio (%) 1 Normal 45 54,2 2 Heart failure 6 7,2 3 Mitral stenosis 18 21,7 4 Leaky heart valve 14 16,9 3.2.3. CT scan images features at hospitalized time Table 3.14. Features of early brain damage on CT scan of the anteriorcerebral circulation Group Signs Anteriorcerebral circulation n = 104 (%) Hypodensity ofthe cortex 57 (54,8) Unclear brain grooves 35 (33,7) Loss of insular ribbon 36 (34,6) Unclear lentiform nucleus 21 (20,2) Area of hypodensity >1/3 9 (8,7) Signs of “Hyperdensity of artery” 12(11,5) Most stroke patients come early with images of hypodensity ofthe cortex (54.8%). Early signs of damage were noted as unclear brain grooves (33.7%). Table 3.15. Characteristics of artery lesion sites Characteristics of injury Number of patient (n=114) Ratio (%) Internal carotid artery 40 35,1 Middle cerebral artery 61 53,5 Anterior cerebral artery 1 0,9 Vertebral artery 4 3,5 Basilar artery 6 5,3 Small cerebral artery 2 1,8 Table 3.16. ASPECT score for the blood supply area of the middle cerebral artery ASPECT score Number of patients (n=61) Ratio (%) ASPECT group ≤ 5 2 3,3 6 – 7 14 23,0 ≥ 8 45 73,8 Average: 8,30 ± 1,52 Table 3.17. Collateral circulation score of the anteriorcerebral circulation Level of collateral circulation Number (n=102) Ratio (%) Good 24 23,5 Average 48 47,0 Bad 30 29,5 3.3. Relationship betweencranial CT scan and clinical features of patients with acute ischemic strokein the first 6 hours 3.3.1. Relationship with onset time Table 3.21. Relationship with onset time of stroke CT scan images < 3 hours n (%) 3 - 4,5 hours n (%) >4,5 - 6 hours n (%) p No hypodensity (n=55) 24 (54,5) 21 (48,8) 10 (37,0) >0,05 Hypodensity (n = 59) 20 (45,5) 22 (51,2) 17 (63,0) >0,05 Total (n=114) 44 (100) 43 (100) 27 (100) - ASPECT score ( X  SD) (n = 61) 25 (8,68 1,31) 26 (8,12 1,37) 10 (7,80 2,20) < 0,05 Anterior cerebral circulation (n=104) 39 (88,6) 41 (95,3) 24 (88,9) >0,05 Posteriorcerebral circulation (n=10) 5 (11,4) 2 (4,7) 3 (11,1) >0,05 The ASPECT score of patients with ischemic stroke had a tendency to decrease over time from the stroke onset to admission time, the difference was statistically significant. Table 3.22. Relationship between early signs on cranial CT scan and time of stroke onset The image of cranial CT scan < 3 hours n =44(%) 3 - 4,5 hours n = 43 (%) >4,5 – 6 hours n = 27 (%) p Unclearbrain grooves (n=36) 10 (22,7) 14 (32,6) 12 (44,4) >0,05 Loss of insular ribbon(n=36) 8 (18,2) 18 (41,9) 10 (37,0) <0,05 Unclear lentiform nucleus (n=21) 4 (9,1) 8 (18,6) 9 (33,3) <0,05 Area of hypodensity >1/3(n = 9) 2 (4,5) 3 (7,0) 4 (14,8) >0,05 Signs of “Hyperdensity of artery” (n=12) 5 (11,4) 5 (11,6) 2 (7,4) >0,05 The image of loss of insular ribbon and unclear lentiform nucleushas a significant relationship with the time from the onset of brain stroke. 3.3.2. Relationship withhypodensity of brain parenchyma Table 3.23. The relationship between clinical symptoms and the density of brain parenchyma Group Signs General n = 114 (%) Hypodensity n = 59 (%) No hypodensity n = 55 (%) p Headache 31 (27,2) 15 (25,4) 16 (29,1) > 0,05 Vomitting 10 (8,8) 3 (5,1) 7 (12,7) > 0,05 Dizziness 15 (13,2) 5 (8,5) 10 (18,2) > 0,05 Turning of head and eyes towards the intact side 11 (9,6) 9 (15,3) 2 (3,6) < 0,05 Sensation disorders on one side of the body 20 (17,5) 7 (11,9) 13 (23,6) > 0,05 Hemiplegia 110 (96,5) 58 (98,3) 52 (94,5) > 0,05 Central seventh nerve palsy 105 (92,1) 56 (94,9) 49 (89,1) > 0,05 Language disorders 104 (91,2) 56 (94,9) 48 (87,3) > 0,05 Sensory disorders 85 (74,6) 47 (79,7) 38 (69,1) >0,05 3.3.3. Relationship with ASPECT score Table 3.24. The relationship between clinical symptoms and ASPECT score ASPECT score Signs ≤ 5 n = 2 (%) 6-7 n = 14 (%) ≥ 8 n = 45 (%) p Headache 1 (50,0) 2 (14,3) 14 (31,1) > 0,05 Vomitting 0 (0) 1 (7,1) 7 (15,6) > 0,05 Dizziness 0 (0) 1 (7,1) 7 (15,6) > 0,05 Turning of head and eyes towards the intact side 1 (50,0) 2 (14,3) 3 (6,7) > 0,05 Sensation disorders on one side of the body 0 (0) 2 (14,3) 13 (28,9) > 0,05 Hemiplegia 2 (100) 14 (100) 45 (100) < 0,01 Central seventh nerve palsy 1 (50,0) 14 (100) 43 (95,6) < 0,05 Language disorders 2 (100) 14 (100) 40 (88,9) > 0,05 Sensory disorders 2 (100) 12 (85,7) 30 (66,7) >0,05 Table 3.25. The relationship between NIHSS score and ASPECT score (n=61) ASPECT score NIHSSscore ≤ 5 n = 2 (%) 6-7 n = 14 (%) ≥ 8 n = 45 (%) p NIHSS Group ≤ 5 (n=2) 0 (0) 1 (7,1) 1 (2,2) <0,05 6 – 15(n=28) 0 (0) 2 (14,3) 26 (57,8) 16 – 20(n=14) 0 (0) 6 (42,9) 8 (17,8) 21 – 42(n=17) 2 (100) 5 (35,7) 10 (22,2) Average 22,0  1,41 18,93  6,25 15,07  5,82 <0,05 3.3.4. The relationship with collateral circulation score Table 3.27. The relationship between NIHSS and collateral circulation score(n=102) NIHSS Good (n=24) Average (n=48) Bad (n=30) p ≤ 5 (n=6) 4 (16,7) 2 (4,2) 0 (0) - 6-15 (n=36) 14 (58,3) 15 (31,3) 7 (23,3) <0,05 16-20 (n=27) 4 (16,7) 13 (27,1) 10 (33,3) <0,05 21-42 (n=33) 2 (8,3) 18 (37,5) 13 (43,3) <0,05 Tabel 3.28. The relationship between Glasgow and Collateralcirculationscore (n=102) Glasgow Good (n=24) Average (n=48) Bad (n=30) p 15 (n=25) 12 (50,0) 9 (18,8) 4 (13,3) <0,05 9-14 (n=66) 11 (45,8) 34 (70,8) 21 (70,0) <0,05 6-8 (n=10) 1 (4,2) 4 (8,3) 5 (16,7) <0,05 3-5 (n=1) 0 (0) 1 (2,1) 0 (0) - Collateral circulation Collateral circulation Table 3.29. Relationship between limb muscle strengthand collateral circulation Muscle Scale- MRC Good (n=24) Average (n=48) Bad (n=30) p Upper limb muscle strength 0 (n = 63) 8 (33,3) 31 (64,6) 24 (80,0) < 0,05 1 (n = 13) 2 (8,3) 7 (14,6) 4 (13,3) < 0,05 2 (n = 7) 4 (16,7) 1 (2,1) 2 (6,7) < 0,05 3 (n=17) 8 (33,3) 9 (18,8) 0 (0) < 0,05 4 (n=2) 2 (8,3) 0 (0) 0 (0) - 5 (n =0) 0 (0) 0 (0) 0 (0) - Lower limb muscle strength 0 (n = 58) 8 (36,0) 29 (60,4) 21 (70,0) < 0,05 1 (n = 16) 2 (8,3) 8 (16,7) 6 (20,0) < 0,05 2 (n = 8) 3 (12,5) 2 (4,2) 3 (10,0) < 0,05 3 (n=17) 9 (37,5) 8 (16,7) 0 (0) < 0,05 4 (n=3) 2 (8,3) 1 (2,1) 0 (0) - 5 (n =0) 0 (0) 0 (0) 0 (0) - Collateral circulation 1 CHAPTER 4: DISCUSSION 4.2. Clinical features and CT scan of the skull in patients with acute cerebral infarction within the first 6 hours 4.2.1. Characteristics of clinical symptoms when patients are hospitalized Survey of common clinical symptoms in patients with acute ischemic stroke in the first 6 hours shows that most patients with hemiplegia accounts for 96.5%, ;palsy of the central seventh nerve when hospitalized is 92.1%, language disorder is 91.2%, consciousness disorder from drowsiness and coma is 74.6%. Symptoms of hemiplegia Similar to the research results of Do Duc Thuan et al. (2017): Hemipleigia in patients with acute ischemicstroke who came earlyare treated by thrombolytics accounting for 79.24% [75], followed by language disorder 75.47% and consciousness disorder 35.85%. Thus, classic symptoms such as hemiplegia and language disorders are noted. At higher rates than other symptoms, these are easily recognizable symptoms and highly specific for ischemic stroke. Symptoms of language disorders In our study, the common language disorder is difficulty speaking, lisp, speech loss that appear immediately after the patients have had cerebral infarction, which accounts for 91.2%. Other studies also show that a high proportion of patients with cerebral infarction in the first 6 hours have language disorders. Glasgow coma scale upon hospital admissions Glasgow coma scale is a quantitative scale to assess a patient's consciousness. The scoring scale has three factors: eye opening response, verbal and motor response. The lowest total GCS score is 3 points (deep 2 coma) and the highest one is 15 points (absolute consciousness). In this study, we found that 62.3% of patients have GCS score from 9-14, the number of patients with a Glasgow score below 8 points accounted for 12.3%. There was a significant proportion (25.4%) of conscious patients. All research objects had an average GCS score of 11.98 ± 2.65. Classification of muscle strength upon admissions Basing on the muscle strength grading upon admission, they can prognosis the levels of patients’ cerebral infarction well. In our study, a large proportion of patients were hospitalized with complete paralysis of hands (57.9%) and legs (53.5%). The result corresponds to the author Nguyen Van Phuong’sresearch of 103 cases of large vessel occlusion re- opened by mechanical devices, in which the percentage of patients with complete paralysis of hands and feet when hospitalized were 52% and 46% respectively. General nerve damage on the NIHSS scale The average NIHSS score of patients in this study was 16.89 ± 6.91 points (the highest was 42 points, the lowest was 2 points), most patients have NIHSS score ≥6 points (93.3%). The proportion of patients with an NIHSS score below 6 accounts is small approx. 6.7%. Studies by Do Duc Thuan, Pham Dinh Dai and Dang Minh Duc (2017) at Military Hospital 103 [75], Sarver J.L (2012) [88] all recorded an average NIHSS score of 17 points. In our results, the patients with basilar artery occlusion went into deep coma upon admission, among them, the highest NIHSS score recorded was 42 points. 4.2.3. CT scans of patients hospitalized Most stroke patients with early-stage cerebral stroke usually show no obvious damage on CT scans, and at a certain point, it is not until the lesions of hypodensity corresponds to the controlling cerebral artery area 3 become apparent that the signs become obvious. However, there are early signs that help clinicians detect lesions of cerebral infarction on CT scans. Other studies also noted that the sensitivity on without-contrast CT scans ranges from 40-73% for patients with cerebral infarction in the first 6 hours. Thus, many studies have recorded a significant proportion of images of early parenchymal injury in computerized tomography. Characteristics of location of artery lesion Regarding to the location of embolization in the study, we mainly see patients with acute cerebral infarction in the anterior cerebral artery system, the majority of which was in mid cerebral artery (53.5%) and internal carotid artery (35.1%). The posterior arterial system including basilar artery, vertebral artery and posterior artery accounts for negligible proportion. Therefore, in this study, we observed that patients with occlusion of major branch were mostly recanalized with mechanical devices. ASPECT The ASPECT was only calculated for patients with acute anemia in the mid-arterial blood supply region, including 61 patients. In the first 6 hours, only 2 patients had the ASPECT below 5 points, accounting for 3.3%. Most patients have an ASPECT above 6. This rate is quite similar to the previous study of Nguyen Hoang Ngoc et al at Central Military Hospital 108. The ASPECT that systematizes the early signs on CT scan of brain are applied to diagnosis and prognosis for patients by the authors in the world. The score has 10 points that are equivalent to 10 anatomic regions according to the blood supply region of the middle cerebral artery, i.e. for each location of lesion, one point will be subtracted , ASPECT ≥ 8 is a good prognosis, ASPECT score ≤ 5 is severe prognosis. 4 The characteristics of collateral circulation for the blood supply area of the anterior cerebralcirculation system Regarding the collateral circulation point on vascular CT scan, the system of application points of the Albecta Academy of Canada is quite easy when done directly on the computer with 3-stroke scanning. Assessing the collateral circulation on CTA images in stroke patients in the first 6 hours is a relatively new idea compared to the reports in Vietnam. Many researches in the world confirm that evaluating collateral circulation is the best way to select patients for intervention for mechanical thromboembolism such as IMS III. Our results show that the majority of patients with moderate collateral circulation score accounted for 47.0%. Only 23.5% of patients had good collateral circulation points. 4.3. Relationship between CT scan of brain and clinical features of patients with acute cerebral stroke within the first 6 hours 4.3.1. Relationship with prodromal period The period from prodromal period to admission is an important factor; therefore, we evaluate whether different periods relates to the lesions showned on cranial CT scan or not? Our chosen time frames are less than 3 hours, from 3 to 4.5 hours and more than 4.5 to 6 hours. These are important period of time in making decisions on either the treatment of fibrinolysis or mechanical interventions. Our results show that the ASPECT of patients with brain stroke tends to decrease over time from prodromal period to hospitalization, the difference is statistically significant with p <0.05. 4.3.2. Relationship with hypodensity of brain parenchyma density We tried to find out if there was any difference in clinical signs in patients with and without lesions on brain CT. In fact, these also right the patient coming sooner or later but we did not find such really strong relat