CT Angiography Use in Acute Stroke Patients Undergoing i.v. TPA
Background: IV rt-PA has been demonstrated to be an effective treatment for selected cases of acute ischemic stroke. Unfortunately, there is a substantial risk of cerebral hemorrhage when thrombolytic agents are used in the setting of cerebral ischemia. Because of this risk it would be useful to identify a subgroup of patients with increased likelihood to benefit from rt-PA. . The NINDS rt-PA Stroke Study Group failed to identify such a subgroup. We postulated that patients without occlusive lesions of a major intracranial artery (e.g., MCA stem, ICA, Basilar) may be better candidates for IV rt-PA because of decreased hemorrhage risk and increased recanalization rates. Methods: We analyzed prospective data in all acute stroke patients from 10/97 -3/00 treated with IV rt-PA. All patients had urgent Helical CT angiography (CTA) at 3 mm slices from skull base to vertex. Patients eligible for rt-PA by NINDS criteria received drug if CTA did not show a major vessel occlusion, as assessed by raw data viewed on the scanner by the Stroke Team within 5 minutes post acquisition. Results: 14 patients (mean age 62; 58% male) were treated according to this protocol. Strokes were classified by TOAST criteria as 8 embolic, 5 cryptogenic, 1 small vessel. Mean time to drug was 125 min (range; 30–180 min). The initial head CT scan was without hypodensity in 12/14 patients. The mean initial NIHSS score improved from 12.1 to 4.2 ( at 24 hrs) and to 1.8 (at 7 d). The NIHSS at 24 hours improved by ≥4 points in 12 patients and did not deteriorate in any. At day 7 the NIHSS had improved by ≥4 points in all patients and was back to 0 in 6. The modified Rankin index at day seven was 0 in 7 patients, 1–2 in 6 patients, and 3 in one patient. All strokes but one were located in the anterior circulation. There were no symptomatic or asymptomatic intracranial hemorrhages or systemic complications. Conclusions: IV rt-PA may be most useful in patients with small distal emboli and/or lacunar stroke. The smaller size clot and smaller area of ischemia in these patients may reduce risk of hemorrhage, and patent proximal arteries may increase chances of recanalization.