doi: 10.1161/01.STR.0000021001.18101.A5
(Stroke. 2002;33:2066.)
© 2002 American Heart Association, Inc.
Original Contributions |
Clinical and Vascular Outcome in Internal Carotid Artery Versus Middle Cerebral Artery Occlusions After Intravenous Tissue Plasminogen Activator
From the Department of Neurology (I.L., R.H.L., C.C., S.K., L.R.C., G.S.) and Biometrics Center (R.A.P.), Beth Israel Deaconess Medical Center, Boston, Mass.
Correspondence to Italo Linfante, MD, Department of Neurology, Division of Cerebrovascular Diseases, Beth Israel Deaconess Medical Center, East Campus DA 779, 330 Brookline Ave, Boston, MA 02115. E-mail ilinfant{at}caregroup.harvard.edu
Background and Purpose— Early reperfusion is a predictor of good outcome in acute ischemic stroke. We investigated whether middle cerebral artery (MCA) occlusions have a better clinical outcome and proportion of recanalization compared with internal carotid artery (ICA) occlusion after standard treatment with intravenous (IV) tissue plasminogen activator (tPA).
Patients— In a retrospective analysis of our prospective stroke database between January 7, 1998, and January 30, 2002, we identified 36 consecutive patients who were treated with IV tPA within 3 hours after symptom onset of a stroke in the distribution of a documented ICA or MCA occlusion. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before tPA, at 24 hours, 3 days, and 3 months after stroke. Three-month outcome was recorded by modified Rankin scale. Magnetic resonance angiography or computed tomographic angiography was obtained before tPA. The presence of recanalization was assessed by transcranial Doppler and/or magnetic resonance angiography within 3 days after stroke onset.
Results— Nineteen patients had MCA occlusion, and 17 had ICA-plus-MCA occlusion before tPA. Although there was no difference in age and NIHSS at day 0 between the 2 groups, the MCA group had a lower day 3 NIHSS score compared with the ICA group (P=0.006) in an ANCOVA. In addition, patients who had a MCA occlusion had lower day 1 and 3 NIHSS scores compared with the ICA group (P=0.04 and P=0.03, respectively; Wilcoxon rank sum). Similarly, NIHSS was significantly lower in patients who recanalized on days 1 and 3 (P=0.004 and P=0.003 respectively, Wilcoxon rank sum). When we adjusted for NIHSS score at day 0 in an ANCOVA, the adjusted mean was lower in the group that recanalized compared with the group that did not recanalize (P<0.001). There was a significant difference between the proportion of recanalization in the MCA group (15 of 17 recanalized, 88%) at 3 days after tPA compared with that of the ICA group (5 of 16 recanalized, 31%; P=0.001, Fisher exact test). The 3-month modified Rankin scale was not different between the 2 groups.
Conclusions— Despite comparable age and NIHSS scores before IV tPA, MCA occlusions have lower day 1 and 3 NIHSS scores and higher proportion of recanalization compared with ICA occlusions. A combined IV/intra-arterial or mechanical thrombolysis may be needed to achieve early recanalization in ICA occlusions.
Key Words: carotid artery, internal • computed tomography • magnetic resonance imaging • middle cerebral artery • stroke • thrombolysis • tissue plasminogen activator
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