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(Stroke. 2007;38:192.)
© 2007 American Heart Association, Inc.
Research Reports |
From the Department of Neurology, National Core Research Center for Nanomedical Technology (K.-Y.L., S.W.H., S.H.K., H.S.N., S.W.A., J.H.H.) and Diagnostic Radiology (D.J.K., D.I.K., S.H.S.), Yonsei University College of Medicine, Seoul, Korea.
Correspondence to Ji Hoe Heo, MD, PhD, Department of Neurology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemoon-ku, 120-752, Seoul, Korea. E-mail jhheo{at}yumc.yonsei.ac.kr
| Abstract |
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Methods— CT angiography was performed before IV rt-PA in all patients and digital subtraction angiography was undertaken for intra-arterial thrombolysis in cases of no improvement after rt-PA infusion.
Results— Forty-five patients were treated with IV rt-PA. Initial CT angiography showed relevant arterial occlusions in 35 patients. Recanalization after rt-PA therapy was demonstrated by digital subtraction angiography in 7 of the 31 patients with the occlusion on initial CT angiography: 2/16 in the internal carotid or proximal middle cerebral artery, 3/11 in the distal middle cerebral artery and 2/4 in the basilar artery occlusion.
Conclusions— The early recanalization rate after IV rt-PA use was very low in cases with large proximal arterial occlusions. CT angiography before IV rt-PA may be useful for the prediction of its efficacy.
Key Words: CT angiography thrombolysis tissue plasminogen activator
| Introduction |
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| Subjects and Methods |
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Recanalization status was classified according to the Thrombolysis in Cerebral Infarction (TICI) classification5 (Grade 0, no perfusion; Grade 1, penetration with minimal perfusion; Grade 2a, partial filling
of the entire vascular territory; Grade 2b, complete filling, but the filling is slower than normal; Grade 3, complete perfusion).
| Results |
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2) was achieved in 7 of the 31 patients (22.6%) whose arterial occlusion had been found on initial CTAs. The early recanalization was least common in the occlusion of the internal carotid artery (ICA) or proximal middle cerebral artery (MCA; M1, 2/16, 12.5%). The recanalization rate was 27.3% (3/11) in patients with the distal MCA (M2 and distal) and 50% (2/4) in those with basilar artery occlusion. After IA thrombolysis, the final recanalization was achieved in 20 of 31 patients (Table). The median time from onset to successful recanalization among those treated with IA thrombolysis was 325 minutes (range 195 to 380 minutes, 13 patients). All of the 7 patients with initially normal CTAs exhibited acute cerebral infarctions on follow-up MRIs. Infarctions were in the perforating arterial territory in 3, and multiple and small in the MCA territory in 3 patients. There were multiple and bilateral cerebral and cerebellar infarctions in 1. Atrial fibrillation was diagnosed in 3 of those 4 patients with multiple infarctions.
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The median baseline NIHSS score was 13 for 45 patients. At 30 days, it was 2 (assessed in 36 patients). Fifty percent (21 of 42 patients assessed) had a good functional outcome at 90 days, defined as modified Rankin Scale score
1. Eighteen of 39 patients with ICA territory infarction showed early ischemic changes (Alberta Stroke Program Early CT Score [ASPECTS] <10) on initial brain CT.6 Although good functional outcomes were frequent in high ASPECTS, it was not statistically significant (ASPECTS >7 in 17/33 and ASPECTS
7 in 1/6,
2 test, P=0.19). Two of 7 patients who showed recanalization after IV rt-PA and 8 of 20 patients who showed recanalization after combined IV and IA thrombolysis had good functional outcomes. The mortality rate after 90 days was 13.3% (6 patients) attributable to an intracranial hemorrhage (1), massive cerebral infarctions (4) or an undefined cause after discharge (1). Symptomatic hemorrhage occurred in 3 patients (2 in the IV rt-PA group) and 1 of them who had distal ICA occlusion and treated with IV rt-PA died 3 days after thrombolysis.
| Discussion |
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The present study indicates that CTA at the time of initial evaluation might predict some of the patients who will respond poorly to IV rt-PA, and this information may be helpful in the decision of immediate individualized therapeutic planning. For example, in cases with occlusion at the distal ICA or proximal MCA segment on the initial CTA, additional treatment with IA thrombolysis or mechanical clot removal may be considered from the beginning. However, further studies are necessary because the number of patients in the present study was too small to provide conclusive data regarding recanalization rates in each arterial segment.
| Acknowledgments |
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This work was supported by Korea Science and Engineering Foundation (KOSEF) through the National Core Research Center for Nanomedical Technology (R15-2004 to 024-00000-0) and by a grant of the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (A060171).
Disclosures
None.
Received July 11, 2006; revision received August 3, 2006; accepted September 6, 2006.
| References |
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2. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke. 2005; 36: 869–871.
3. Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR, Alvarez-Sabin J, Montaner J, Saqqur M, Demchuk AM, Moye LA, Hill MD, Wojner AW. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004; 351: 2170–2178.
4. Lee KY, Kim DI, Kim SH, Lee SI, Chung HW, Shim YW, Kim SM, Heo JH. Sequential combination of intravenous recombinant tissue plasminogen activator and intra-arterial urokinase in acute ischemic stroke. AJNR Am J Neuroradiol. 2004; 25: 1470–1475.
5. Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, Dillon W, Warach S, Broderick J, Tilley B, Sacks D; Technology Assessment Committee of the American Society of Interventional and Therapeutic Neuroradiology; Technology Assessment Committee of the Society of Interventional Radiology. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke. 2003; 34: e109–e137.[Medline] [Order article via Infotrieve]
6. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000; 355: 1670–1674.[CrossRef][Medline] [Order article via Infotrieve]
7. del Zoppo GJ, Poeck K, Pessin MS, Wolpert SM, Furlan AJ, Ferbert A, Alberts MJ, Zivin JA, Wechsler L, Busse O, Greenlee R, Brass L, Mohr JP, Feldmann E, Hacke W, Kase CS, Biller J, Gress D, Otis SM. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992; 32: 78–86.[CrossRef][Medline] [Order article via Infotrieve]
8. von Kummer R, Hacke W. Safety and efficacy of intravenous tissue plasminogen activator and heparin in acute middle cerebral artery stroke. Stroke. 1992; 23: 646–652.
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