Intravenous Thrombolysis in Stroke Attributable to Cervical Artery Dissection

Abstract

Background and Purpose-Intravenous thrombolysis (IVT) for stroke seems to be beneficial independent of the underlying etiology. Whether this is also true for cervical artery dissection (CAD) is addressed in this study. Methods-We used the Swiss IVT databank to compare outcome and complications of IVT-treated patients with CAD with IVT-treated patients with other etiologies (non-CAD patients). Main outcome and complication measures were favorable 3-month outcome, intracranial cerebral hemorrhage, and recurrent ischemic stroke. Modified Rankin Scale score Յ1 at 3 months was considered favorable. Results-Fifty-five (5.2%) of 1062 IVT-treated patients had CAD. Patients with CAD were younger (median age 50 versus 70 years) but had similar median National Institutes of Health Stroke Scale scores (14 versus 13) and time to treatment (152.5 versus 156 minutes) as non-CAD patients. In the CAD group, 36% (20 of 55) had a favorable 3-month outcome compared with 44% (447 of 1007) non-CAD patients (OR, 0.72; 95% CI, 0.41 to 1.26), which was less favorable after adjustment for age, gender, and National Institutes of Health Stroke Scale score (OR, 0.50; 95% CI, 0.27 to 0.95; Pϭ0.03). Intracranial cerebral hemorrhages (asymptomatic, symptomatic, fatal) were equally frequent in CAD (14% [7%, 7%, 2%]) and non-CAD patients (14% [9%, 5%, 2%]; Pϭ0.99). Recurrent ischemic stroke occurred in 1.8% of patients with CAD and in 3.7% of non-CAD-patients (Pϭ0.71). Conclusion-IVT-treated patients with CAD do not recover as well as IVT-treated non-CAD patients. However, intracranial bleedings and recurrent ischemic strokes were equally frequent in both groups. Key Words: carotid artery Ⅲ cervical artery dissection Ⅲ complications Ⅲ dissection Ⅲ outcome Ⅲ thrombolysis I ntravenous thrombolysis (IVT) for acute ischemic stroke using recombinant tissue plasminogen activator has been shown to be safe and efficacious. 1,2 Treatment response seems to be independent of the underlying stroke mechanism. 3 However, whether this observation includes patients with strokes attributable to cervical artery dissection (CAD) has not been studied. CAD is characterized by intramural accumulation of blood. Theoretically, IVT might promote and increase the intramural bleeding in CAD and cause progressive hemodynamic worsening and infarct growth. In patients with stroke with aortic dissection extending to the cervical arteries, IVT might be dangerous as it is in patients with IVT for myocardial infarction. 4 -6 According to recent pilot data, the outcome of 7 IVT-treated patients with CAD tended to be worse than that of 7 patients with CAD not treated with IVT. 7 In turn, patients with CAD have not been excluded from randomized, placebo-controlled trials 1,8,9 of IVT in stroke. Treatment guidelines 10 do not advise against IVT in such patients, but randomized, placebo-controlled trial-based data about IVT versus placebo in patients with CAD are not available. Only information of case series without control groups and small sample sizes (ie, 30, 11 11, 12 6, 13 a...

IV thrombolysis and renal function

“…13,14 Local study investigators completed the forms systematically using prospectively ascertained in-hospital IV ischemic stroke thrombolysis registries. Completed forms from all centers were compiled in the coordinating center Basel, where the analysis of the pooled data was performed, as described previously.…”

Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study

“…It represents up to 20%-25% of stroke etiology in young adults 1 and is the most common cause in patients younger than 55 years of age. ICD is the consequence of a mural hematoma in the arterial wall, with separation of the intima from the media.…”

“…3,4 Intravenous thrombolysis (IVT) 5 is associated with poor recanalization rates and poor clinical outcomes. 1,3 Several published series have reported very low recanalization rates in tandem occlusions, from 8% to 9% during the first 2 hours 6,7 after thrombolytic drug infusion to 31% in the next 24 -72 hours. 4 Endovascular treatment is now increasingly considered and performed, especially following the results from randomized controlled trials ( [8][9][10][11][12] which demonstrated the superiority of combined strategies versus stand-alone intravenous treatments in large-vessel occlusion stroke.…”

Diagnosis and treatment of cervikal arteries dissection

“…Trombolitik tedavinin mural hematomun büyümesine veya yalancı lumen içindeki trombüsün kopması ile emboliye neden olabilme risklerine karşın bu tedavinin seçilmiş vakalarda, güvenle kullanılabileceği de vurgulanmaktadır (40,41). Disseksiyon vakalarında görülen psödoanevrizmaların çoğunlukla benign seyirli olduğu kabul edilmektedir.…”