Early Recanalization Rates and Clinical Outcomes in Patients With Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion and Isolated Middle Cerebral Artery Occlusion

Abstract

Patients and MethodsThis is a retrospective analysis of the CLOTBUST collaboration databank that includes patients with acute MCA occlusions treated with intravenous tissue plasminogen activator (tPA). 3 A sonographer performed transcranial Doppler (TCD) with a 2-MHz device (Ez-Dop, DWL; PMD 100, Spencer Technologies; Multigon, 500 mol/L, Multigon Industries). MCA occlusion and recanalization were identified using previously validated criteria before and during the first 2 hours after tPA bolus. 3 Before tPA bolus, we also performed carotid duplex (Sonosite 180 Plus), and previously validated diagnostic criteria for ICA occlusion were applied. 4 Tandem ICA/MCA lesions (tandem group) were defined as hemodynamically significant ICA obstruction (70% to 100% obstruction) with MCA occlusion, and isolated MCA occlusion was diagnosed when patients had abnormal TIBI (Thrombolysis In Brain Ischemia) flow grades without evidence of significant ICA obstruction on carotid duplex ultrasound and TCD.Neurological deficit was measured with the National Institutes of Health Stroke Scale (NIHSS) before, 30, 60, 90, and 120 minutes, and 24 hours after bolus. Modified Rankin scale (mRS) scores were obtained at 90 days after onset by a stroke neurologist blind to TCD findings. Early neurological improvement (ENI) was defined as reduction of NIHSS by Ն10 or decrease of total NIHSS to Յ4 within 24 hours after bolus. 5 Good outcome was defined by mRS Յ2. ResultsA total of 104 patients were included in our study. Seventytwo (69%) patients had isolated MCA occlusion and 32 (31%) patients had tandem lesions. Their demographic data and clinical parameters are summarized in the Table. Stroke subtypes in the isolated MCA group were: LVA 8.5%; CE 5.3%; LA 1%; and UE 37% of patients. In patients with tandem lesion, stroke subtypes were: LVA 62%; CE 22%; OE 6%; and UE 9% of patients.Complete recanalization rate increased with time after bolus in the isolated lesion group. It occurred in 26.4% of the isolated lesion group and 9.4% of the tandem group at 90 minutes after bolus (Pϭ0.05) and at 2 hours in 38.9% and 9.4%, respectively (Pϭ0.002; Figure 1). Complete recanalization rate was different according to the stroke subtype: LVA 14.4% and CE 39.1% (Pϭ0.02).ENI was achieved in 46% of the isolated lesion group and in 25% of the tandem group (Pϭ0.045; Table), and the median NIHSS score reduction was different between the 2 groups at 2 hours and 24 hours after bolus (Pϭ0.002 and Pϭ0.05, respectively; Figure 2). Good outcomes were similar in the 2 groups. DiscussionOur results showed that early complete recanalization and ENI are more common with the isolated lesion group compared with the tandem group despite similar baseline characteristics. MCA recanalization rate was lower with tandem than with isolated lesions in other studies at Ͼ24 hours after onset. 2,7 In our study, the isolated lesion group had faster and higher complete recanalization rate than the tandem group during the first 2 hours. Recanalization rate increased with time in the iso...

Emergent Stenting of Extracranial Internal Carotid Artery Occlusion in Acute Stroke Has a High Revascularization Rate

“…For patients presenting within the time frame for intravenous tPA treatment, this approach was considered in conjunction with intravenous tPA because tPA alone has a low probability of recanalizing ICA occlusions and tandem occlusions. 9,10 The lack of serious complications encountered in the 8 patients who received systemic tPA and acute ICA stenting indicates that this procedure may be performed safely.…”

Early Recanalization After Intravenous Administration of Recombinant Tissue Plasminogen Activator as Assessed by Pre- and Post-Thrombolytic Angiography in Acute Ischemic Stroke Patients

“…Rates were reported as being between 16.8% and 38%. [1][2][3] However, in the Interventional Management of Stroke study, 1 the dose of rt-PA used was two-thirds of that used for conventional therapy, the duration of the infusion was reduced by a half, and the arterial occlusion before IV rt-PA was not determined. TCD itself may augment the thrombolytic effect of rt-PA. 3 Therefore, the exact recanalization rate by conventional IV rt-PA has remained uncertain.…”

Ultrasound-Enhanced Thrombolysis in Acute Ischemic Stroke: Potential, Failures, and Safety

“…28 Finally, real-time flow findings during TCD-monitoring are predictive of the long-term functional outcome in ischemic stroke. 29,30 Once abnormal residual flow signals are identified, an ultrasound beam can be steadily focused at the presumed intracranial thrombus location, and arterial recanalization can be monitored in real time. 26 In work at our institution, intravenous TPA infusion was continuously monitored with 2-MHz TCD 26 and early recanalization and dramatic recovery rates higher than expected were observed.…”