(Stroke. 2000;31:610.)
© 2000 American Heart Association, Inc.
Original Contributions |
High Rate of Complete Recanalization and Dramatic Clinical Recovery During tPA Infusion When Continuously Monitored With 2-MHz Transcranial Doppler Monitoring
From the Center for Noninvasive Brain Perfusion Studies (A.V.A., R.A.F., I.C., W.S.B., M.M., A.W.W., J.C.G.), Stroke Treatment Team, University of Texas–Houston Medical School; and Department of Clinical Neurosciences (A.M.D., P.A.B.), University of Calgary, Alberta, Canada.
Correspondence to Dr A. Alexandrov, MSB 7.044 6431 Fannin St, University of Texas, Houston, TX 77030. E-mail avalexandrov{at}worldnet.att.net
Background and Purpose—Clot dissolution with tissue plasminogen activator (tPA) can lead to early clinical recovery after stroke. Transcranial Doppler (TCD) with low MHz frequency can determine arterial occlusion and monitor recanalization and may potentiate thrombolysis.
Methods—Stroke patients receiving intravenous tPA were monitored during infusion with portable TCD (Multigon 500M; DWL MultiDop-T) and headframe (Marc series; Spencer Technologies). Residual flow signals were obtained from the clot location identified by TCD. National Institutes of Health Stroke Scale (NIHSS) scores were obtained before and after tPA infusion.
Results—Forty patients were studied (mean age 70±16 years,
baseline NIHSS score 18.6±6.2, tPA bolus at 132±54 minutes from
symptom onset). TCD monitoring started at 125±52 minutes and continued
for the duration of tPA infusion. The middle cerebral artery was
occluded in 30 patients, the internal carotid artery was occluded in 11
patients, the basilar artery was occluded in 3 patients, and occlusions
were multiple in 7 patients; 4 patients had no windows; and 1 patient
had a normal TCD. Recanalization on TCD was found
at 45±20 minutes after tPA bolus: recanalization
was complete in 12 (30%) and partial in 16 (40%) patients. Dramatic
recovery during tPA infusion (total NIHSS score <3) occurred in 8
(20%) of all patients (baseline NIHSS range 6 to 22; all 8 had
complete recanalization). Lack of improvement or
worsening was associated with no recanalization,
late recanalization, or reocclusion on TCD
(C=0.811, P
0.01). Improvement by 
10 NIHSS points or
complete recovery was found in 30% of all patients at the end of tPA
infusion and in 40% at 24 hours. Improvement by 4 NIHSS points was
found in 62.5% of patients at 24 hours.
Conclusions—Dramatic recovery during tPA therapy occurred in 20%
of all patients when infusion was continuously monitored with TCD.
Recovery was associated with recanalization on TCD,
whereas no early improvement indicated persistent occlusion or
reocclusion. At 24 hours, 40% of all patients improved by 10 NIHSS
points or recovered completely. Ultrasonic energy transmission by TCD
monitoring may expose more clot surface to tPA and facilitate
thrombolysis and deserves a controlled trial as a way
to potentiate the effect of tPA therapy.
Key Words: outcome • stroke, acute • thrombolysis • ultrasonography, Doppler, transcranial
This article has been cited by other articles:
 |
|
 |
|
  K. Kimura, Y. Iguchi, K. Shibazaki, M. Watanabe, T. Iwanaga, and J. Aoki M1 Susceptibility Vessel Sign on T2* as a Strong Predictor for No Early Recanalization After IV-t-PA in Acute Ischemic Stroke Stroke, September 1, 2009; 40(9): 3130 - 3132. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Brekenfeld, P. Tinguely, G. Schroth, M. Arnold, M. El-Koussy, K. Nedeltchev, J.V. Byrne, and J. Gralla Percutaneous Transluminal Angioplasty and Stent Placement in Acute Vessel Occlusion: Evaluation of New Methods for Interventional Stroke Treatment AJNR Am. J. Neuroradiol., June 1, 2009; 30(6): 1165 - 1172. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Kaul Sonothrombolysis: A Universally Applicable and Better Way to Treat Acute Myocardial Infarction and Stroke? Who Is Going to Fund the Research? Circulation, March 17, 2009; 119(10): 1358 - 1360. [Full Text] [PDF]
|
|
|
|
|
|
A. V. Alexandrov Ultrasound Enhancement of Fibrinolysis Stroke, March 1, 2009; 40(3_suppl_1): S107 - S110. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Kimura, Y. Iguchi, K. Shibazaki, Y. Terasawa, J. Aoki, and N. Matsumoto The Presence of a Right-to-Left Shunt Is Associated With Dramatic Improvement After Thrombolytic Therapy in Patients With Acute Ischemic Stroke Stroke, January 1, 2009; 40(1): 303 - 305. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Stolz, F. Cioli, J. Allendoerfer, T. Gerriets, M. Del Sette, and M. Kaps Can Early Neurosonology Predict Outcome in Acute Stroke?: A Metaanalysis of Prognostic Clinical Effect Sizes Related to the Vascular Status Stroke, December 1, 2008; 39(12): 3255 - 3261. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Saqqur, G. Tsivgoulis, C. A. Molina, A. M. Demchuk, M. Siddiqui, J. Alvarez-Sabin, K. Uchino, S. Calleja, A. V. Alexandrov, and For the CLOTBUST Investigators Symptomatic intracerebral hemorrhage and recanalization after IV rt-PA: A multicenter study Neurology, October 21, 2008; 71(17): 1304 - 1312. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R.I. Aviv, J. Mandelcorn, S. Chakraborty, D. Gladstone, S. Malham, G. Tomlinson, A.J. Fox, and S. Symons Alberta Stroke Program Early CT Scoring of CT Perfusion in Early Stroke Visualization and Assessment AJNR Am. J. Neuroradiol., November 1, 2007; 28(10): 1975 - 1980. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Mikulik, M. Ribo, M. D. Hill, J. C. Grotta, M. Malkoff, C. Molina, M. Rubiera, R. Delgado-Mederos, J. Alvarez-Sabin, A. V. Alexandrov, et al. Accuracy of Serial National Institutes of Health Stroke Scale Scores to Identify Artery Status in Acute Ischemic Stroke Circulation, May 22, 2007; 115(20): 2660 - 2665. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Holscher, J.A. Sattin, R. Raman, W. Wilkening, C.V. Fanale, S.E. Olson, R.F. Mattrey, and P.D. Lyden Real-Time Cerebral Angiography: Sensitivity of a New Contrast-Specific Ultrasound Technique AJNR Am. J. Neuroradiol., April 1, 2007; 28(4): 635 - 639. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Saqqur, C. A. Molina, A. Salam, M. Siddiqui, M. Ribo, K. Uchino, S. Calleja, Z. Garami, K. Khan, N. Akhtar, et al. Clinical Deterioration After Intravenous Recombinant Tissue Plasminogen Activator Treatment: A Multicenter Transcranial Doppler Study Stroke, January 1, 2007; 38(1): 69 - 74. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Schneider, T. Gerriets, M. Walberer, C. Mueller, R. Rolke, B. M. Eicke, J. Bohl, O. Kempski, M. Kaps, G. Bachmann, et al. Brain Edema and Intracerebral Necrosis Caused by Transcranial Low-Frequency 20-kHz Ultrasound: A Safety Study in Rats Stroke, May 1, 2006; 37(5): 1301 - 1306. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R.M. Sugg, E.A. Noser, H.M. Shaltoni, N.R. Gonzales, M.S. Campbell, R. Weir, E.D. Cacayorin, and J.C. Grotta Intra-arterial reteplase compared to urokinase for thrombolytic recanalization in acute ischemic stroke. AJNR Am. J. Neuroradiol., April 1, 2006; 27(4): 769 - 773. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Saposnik, S. Di Legge, F. Webster, and V. Hachinski Predictors of major neurologic improvement after thrombolysis in acute stroke Neurology, October 25, 2005; 65(8): 1169 - 1174. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Daffertshofer, A. Gass, P. Ringleb, M. Sitzer, U. Sliwka, T. Els, O. Sedlaczek, W. J. Koroshetz, and M. G. Hennerici Transcranial Low-Frequency Ultrasound-Mediated Thrombolysis in Brain Ischemia: Increased Risk of Hemorrhage With Combined Ultrasound and Tissue Plasminogen Activator: Results of a Phase II Clinical Trial Stroke, July 1, 2005; 36(7): 1441 - 1446. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Saqqur, A. Shuaib, A. V. Alexandrov, M. D. Hill, S. Calleja, T. Tomsick, J. Broderick, and A. M. Demchuk Derivation of Transcranial Doppler Criteria for Rescue Intra-arterial Thrombolysis: Multicenter Experience From the Interventional Management of Stroke Study Stroke, April 1, 2005; 36(4): 865 - 868. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. A. Noser, H. M. Shaltoni, C. E. Hall, A. V. Alexandrov, Z. Garami, E. D. Cacayorin, J. K. Song, J. C. Grotta, and M. S. Campbell III Aggressive Mechanical Clot Disruption: A Safe Adjunct to Thrombolytic Therapy in Acute Stroke? Stroke, February 1, 2005; 36(2): 292 - 296. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Pfaffenberger, B. Devcic-Kuhar, C. Kollmann, S. P. Kastl, C. Kaun, W. S. Speidl, T. W. Weiss, S. Demyanets, R. Ullrich, H. Sochor, et al. Can a Commercial Diagnostic Ultrasound Device Accelerate Thrombolysis?: An In Vitro Skull Model Stroke, January 1, 2005; 36(1): 124 - 128. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. V. Alexandrov, C. A. Molina, J. C. Grotta, Z. Garami, S. R. Ford, J. Alvarez-Sabin, J. Montaner, M. Saqqur, A. M. Demchuk, L. A. Moye, et al. Ultrasound-Enhanced Systemic Thrombolysis for Acute Ischemic Stroke N. Engl. J. Med., November 18, 2004; 351(21): 2170 - 2178. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. V. Alexandrov Ultrasound Identification and Lysis of Clots Stroke, November 1, 2004; 35(11_suppl_1): 2722 - 2725. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Berlis, H. Lutsep, S. Barnwell, A. Norbash, L. Wechsler, C. A. Jungreis, A. Woolfenden, G. Redekop, M. Hartmann, and M. Schumacher Mechanical Thrombolysis in Acute Ischemic Stroke With Endovascular Photoacoustic Recanalization Stroke, May 1, 2004; 35(5): 1112 - 1116. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Brown, K. C. Johnston, D. P. Wagner, and E. C. Haley Jr Predicting Major Neurological Improvement With Intravenous Recombinant Tissue Plasminogen Activator Treatment of Stroke Stroke, January 1, 2004; 35(1): 147 - 150. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Neumann-Haefelin, R. du Mesnil de Rochemont, J.B. Fiebach, A. Gass, C. Nolte, T. Kucinski, J. Rother, M. Siebler, O.C. Singer, K. Szabo, et al. Effect of Incomplete (Spontaneous and Postthrombolytic) Recanalization After Middle Cerebral Artery Occlusion: A Magnetic Resonance Imaging Study Stroke, January 1, 2004; 35(1): 109 - 114. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. M. Hardig, H. W. Persson, G. Gido, and S. B. Olsson Does Low-Energy Ultrasound, Known to Enhance Thrombolysis, Affect the Size of Ischemic Brain Damage? J. Ultrasound Med., December 1, 2003; 22(12): 1301 - 1308. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C Foerch, R Du Mesnil de Rochemont, O Singer, T Neumann-Haefelin, M Buchkremer, F E Zanella, H Steinmetz, and M Sitzer S100B as a surrogate marker for successful clot lysis in hyperacute middle cerebral artery occlusion J. Neurol. Neurosurg. Psychiatry, March 1, 2003; 74(3): 322 - 325. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Labiche, F. Al-Senani, A. W. Wojner, J. C. Grotta, M. Malkoff, and A. V. Alexandrov Is the Benefit of Early Recanalization Sustained at 3 Months?: A Prospective Cohort Study Stroke, March 1, 2003; 34(3): 695 - 698. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Rother, P.D. Schellinger, A. Gass, M. Siebler, A. Villringer, J.B. Fiebach, J. Fiehler, O. Jansen, T. Kucinski, V. Schoder, et al. Effect of Intravenous Thrombolysis on MRI Parameters and Functional Outcome in Acute Stroke <6 Hours Stroke, October 1, 2002; 33(10): 2438 - 2445. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. V. Alexandrov and J. C. Grotta Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator Neurology, September 24, 2002; 59(6): 862 - 867. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Nedelmann, B. M. Eicke, E. G. Lierke, A. Heimann, O. Kempski, and H. C. Hopf Low-Frequency Ultrasound Induces Nonenzymatic Thrombolysis In Vitro J. Ultrasound Med., June 1, 2002; 21(6): 649 - 656. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. A. Felberg, N. J. Okon, A. El-Mitwalli, W. S. Burgin, J. C. Grotta, and A. V. Alexandrov Early Dramatic Recovery During Intravenous Tissue Plasminogen Activator Infusion: Clinical Pattern and Outcome in Acute Middle Cerebral Artery Stroke Stroke, May 1, 2002; 33(5): 1301 - 1307. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Ishibashi, M. Akiyama, H. Onoue, T. Abe, and H. Furuhata Can Transcranial Ultrasonication Increase Recanalization Flow With Tissue Plasminogen Activator? Stroke, May 1, 2002; 33(5): 1399 - 1404. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. A. Taylor, G. D. Hughes, and R. J. Garrison Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges Am J Public Health, April 1, 2002; 92(4): 548 - 551. [Abstract] [Full Text]
|
|
|
|
|
|
F. Schlachetzki, T. Holscher, H. J. Koch, B. Draganski, A. May, G. Schuierer, and U. Bogdahn Observation on the Integrity of the Blood-Brain Barrier After Microbubble Destruction by Diagnostic Transcranial Color-Coded Sonography J. Ultrasound Med., April 1, 2002; 21(4): 419 - 429. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Cintas, A. P. Le Traon, and V. Larrue High Rate of Recanalization of Middle Cerebral Artery Occlusion During 2-MHz Transcranial Color-Coded Doppler Continuous Monitoring Without Thrombolytic Drug Stroke, February 1, 2002; 33(2): 626 - 628. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. A. Molina, J. Montaner, S. Abilleira, J. F. Arenillas, M. Ribo, R. Huertas, F. Romero, and J. Alvarez-Sabin Time Course of Tissue Plasminogen Activator-Induced Recanalization in Acute Cardioembolic Stroke: A Case-Control Study Stroke, December 1, 2001; 32(12): 2821 - 2827. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. V. Alexandrov, W. S. Burgin, A. M. Demchuk, A. El-Mitwalli, and J. C. Grotta Speed of Intracranial Clot Lysis With Intravenous Tissue Plasminogen Activator Therapy : Sonographic Classification and Short-Term Improvement Circulation, June 19, 2001; 103(24): 2897 - 2902. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. Scott Burgin and A. V. Alexandrov Deterioration following improvement with tPA therapy: Carotid thrombosis and reocclusion Neurology, February 27, 2001; 56(4): 568 - 570. [Full Text] [PDF]
|
|
|
|
|
|
A. M. Demchuk, W. S. Burgin, I. Christou, R. A. Felberg, P. A. Barber, M. D. Hill, and A. V. Alexandrov Thrombolysis in Brain Ischemia (TIBI) Transcranial Doppler Flow Grades Predict Clinical Severity, Early Recovery, and Mortality in Patients Treated With Intravenous Tissue Plasminogen Activator Stroke, January 1, 2001; 32(1): 89 - 93. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. D. Blacker and A. V. Alexandrov High Rate of Complete Recanalization and Dramatic Clinical Recovery During tPA Infusion When Continuously Monitored With 2-MHz Transcranial Doppler Monitoring Response Stroke, December 1, 2000; 31 (12): 3079 - 3083. [Full Text]
|
|
|
|
 |
|
 TCD Monitors, Perhaps Aids Recovery During t-PA Infusion Journal Watch Neurology, August 9, 2000; 2000(809): 4 - 4. [Full Text]
|
|
|
|
|
|
L. Robinson, A. V. Alexandrov, and J. C. Grotta Clototripsy? Response Stroke, August 1, 2000; 31(8): 2024 - 2025. [Full Text] [PDF]
|
|
|
|
|
|
W. S. Burgin, M. Malkoff, R. A. Felberg, A. M. Demchuk, I. Christou, J. C. Grotta, and A. V. Alexandrov Transcranial Doppler Ultrasound Criteria for Recanalization After Thrombolysis for Middle Cerebral Artery Stroke Stroke, May 1, 2000; 31(5): 1128 - 1132. [Abstract] [Full Text] [PDF]
|
|