Importance of Cerebral Artery Recanalization in Patients With Stroke With and Without Neurological Improvement After Intravenous Thrombolysis

Abstract

P atients with major cerebral artery occlusion represent the most severe cases of ischemic stroke, 1 for whom prompt recanalization would offer an alternative to a very unfavorable outcome. 2 We have previously demonstrated that hyperdense middle cerebral artery sign, which indicates proximal middle cerebral artery occlusion, disappears after intravenous thrombolysis (IVT) in approximately half of cases, and this disappearance, implying vessel recanalization (although not verified as its marker), is associated with lower mortality and better functional outcome.3 Nevertheless, a large proportion of patients (45% in our previous study) 3 does not achieve vessel recanalization by IVT only. The need for additional recanalizing interventions in this group has been discussed 4-8 because their 3-month survival and independence are unsatisfactory with IVT only. 3,9,10 Several newer combined methods have been suggested for rescue reperfusion in patients with stroke with large vessel occlusion after unsuccessful IVT treatment, such as intra-arterial thrombolysis and mechanical retrieval of the clot.11-15 Combination of IVT and endovascular treatment of major vessel occlusion (intra-arterial thrombolysis and Background and Purpose-Recanalization status after intravenous thrombolysis (IVT) in patients with ischemic stroke is a reference point to proceed with a rescue reperfusion intervention, although early neurological improvement (NI) may preclude endovascular procedures. We aimed to evaluate the importance of restoration of blood flow at the arterial occlusion site in subgroups of patients with stroke stratified by early NI after IVT. Methods-The following patients were recruited from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register: (1) with baseline vessel occlusion documented by computed tomographic (CT) or magnetic resonance (MR) angiography and follow-up angioimaging between 22 and 36 hours after IVT available; and (2) with dense cerebral artery sign on admission CT scan and results of follow-up CT reported. Recanalization at 24 hours was defined as absence of vessel occlusion or as resolution of dense cerebral artery sign on follow-up 22-to 36-hour imaging. NI was assessed at 2 hours and 24 hours after IVT and was defined as improvement by 20% from baseline National Institute of Health Stroke scale score. Primary outcome measure was independence, defined as modified Rankin scale score 0 to 2 after 3 months. Results-Of 28136 cases registered between December 2003 and November 2009, 5324 cases (19%) met the inclusion criteria. Patients with both NI at 2 hours post-treatment and vessel recanalization had the best chances to achieve independence at 3 months (adjusted odds ratio, 15.8; 95% confidence interval, 12.5-20.0), followed by those who had NI despite persistent occlusion (adjusted odds ratio, 4.7; 95% confidence interval, 3.6-6.1); and those without NI despite recanalization (adjusted odds ratio, 2.7; 95% confidence interval, 2.2-3.3). Conclusions-Recanalization of an occ...

Postcontrast CT to Estimate Arteriosclerotic Stenosis at the Site of Occlusion before Emergency Endovascular Treatment for Vertebral–Basilar Artery Occlusion

“…7,15,16) Important factors for the favorable prognosis of patients with posterior circulation cerebral infarction included a favorable collateral pathway, narrow extent of occlusion, early reperfusion, and successful state of reperfusion. 7,[17][18][19][20] In patients with posterior circulation cerebral infarction, atherosclerosis was more frequent than in those with anterior circulation cerebral infarction. 21) In particular, this tendency was more marked in Asians.…”

Worse Outcome in Stroke Patients Treated with rt-PA Without Early Reperfusion: Associated Factors

“…However, in the absence of angiographic or ultrasonographic confirmation, the clinical criteria to define effective reperfusion are both unanimous and possibly vary in relation to the sample studied. An improvement of ≥ 10 points or ≥ 20% between baseline and at 24 h has nevertheless shown a good relationship [ 37 – 40 ]. Here, we used the cutoff point ≥ 8 because the sensitivity and specificity were higher (with a cutoff point ≥ 10, the sensitivity was 84.3%, but the specificity was 86.1%).…”

Tissue plasminogen activator followed by antioxidant-loaded nanoparticle delivery promotes activation/mobilization of progenitor cells in infarcted rat brain

“…Limiting the size of the infarcted area after ischemic stroke by promoting reperfusion is the first step in counteracting the detrimental effects of a stroke; however, the timing of reperfusion after stroke is critical, since early reperfusion results in better recovery [22]. The next step in recovery is to protect the brain from reperfusion injury to prevent further loss of neurons and glia [23].…”