Low Rates of Acute Recanalization With Intravenous Recombinant Tissue Plasminogen Activator in Ischemic Stroke

Abstract

Background and Purpose-Acute rates of recanalization after intravenous (IV) recombinant tissue plasminogen activator (rt-PA) in proximal vessel occlusion have been estimated sparingly, typically using transcranial Doppler (TCD). We aimed to study acute recanalization rates of IV rt-PA in CT angiogram-proven proximal (internal carotid artery [ICA], M1 middle cerebral artery [MCA], M2-MCA, and basilar artery) occlusions and their effects on outcome. Materials and Methods-The CT angiogram database of the Calgary stroke program was reviewed for the period 2002 to 2009. All patients with proximal vessel occlusions receiving IV rt-PA who were assessed for recanalization by TCD or angiogram (for acute endovascular treatment) were included for analysis. Rates of acute recanalization as observed on TCD/first run of angiogram and postendovascular therapy recanalization rates were noted. Modified Rankin Scale score Յ2 at 3 months was used as a good outcome. Results-Among 1341 patients in the CT angiogram database, 388 patients with proximal occlusion were identified. Of these, 216 patients had received IV rt-PA; 127 patients underwent further imaging to assess recanalization. Among the patients undergoing TCD (nϭ46) and cerebral angiogram (nϭ103), only 27 (21.25%) patients had acute recanalization. By occlusion subtype, the rates of recanalization were: distal ICA (with or without ICA neck occlusion or stenotic disease) 1 of 24 (4.4%); M1-MCA (with or without ICA neck occlusion or stenotic disease) 21 of 65 (32.3%); M2-MCA 4 of 13 (30.8%); and basilar artery 1 of 25 (4%). Onset to rt-PA time was comparable in patients with and without recanalization. Recanalization (PϽ0.0001; risk ratio, 2.7; 95% confidence interval, 1.5-4.6) was the strongest predictor of outcome (adjusted for age and National Institutes of Health Stroke Scale score). Key Words: intracranial occlusion Ⅲ ischemic stroke Ⅲ recanalization Ⅲ thrombolysis I ntravenous (IV) recombinant tissue plasminogen activator (rt-PA) treatment for acute ischemic stroke 1,2 works by achieving recanalization of intracranial occlusion resulting in restoration of flow and prevention of infarct expansion. 3 Data on recanalization after IV thrombolysis are limited to small angiographic and transcranial Doppler (TCD) monitoring studies. 4 None of the major IV thrombolysis trials has assessed the baseline occlusion status or recanalization rates after treatment. In an era when there is increasing use of endovascular therapies for recanalization, in the absence of robust evidence from randomized controlled trials, there is a desperate need for clear data on the rates of recanalization with IV rt-PA. 5 The present study reports the rates of acute recanalization of proximal intracranial vessel occlusions identified by baseline CT angiography (CTA) among acute ischemic stroke patients treated with IV rt-PA. Conclusions- Patients and MethodsWe identified patients presenting with acute ischemic stroke secondary to major vessel occlusion from the CT Angiography database of the Calgary St...

Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke

“…3,4 The major reason for the limited efficacy of alteplase is the modest rate of early reperfusion among patients with a large-vessel occlusion. 5,6 Local treatment of large-vessel occlusion began with intraarterial delivery of thrombolytic drugs. 7 The Prolyse in Acute Cerebral Thromboembolism (PROACT) II study was the first positive trial of endovascular treatment involving patients with angiographically visualized occlusion of the middle cerebral artery.…”

“…Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis).…”

Mechanical Thrombectomy for Acute Intracranial Internal Carotid Artery Occlusion Compared with Middle Cerebral Artery Occlusion

“…10) Previous studies have shown a recanalization rate after intravenous rt-PA therapy of only 4.4%-12.5% for ICO 11,12) but 51.7% for MCO. 13) To improve the recanalization rate, intra-arterial thrombolytic therapy 5,11,14) and surgical thrombectomy 15) have been performed, but there has been no report that these methods markedly improved the prognosis of ICO, particularly T-occlusion.…”

HERMES: messenger for stroke interventional treatment

“…1 Data from the 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to standard care) allowed more precise estimates of overall treatment effect (adjusted common odds ratio for reduced disability 2·49, 95% CI 1·76-3·53; p<0·0001and absence of heterogeneity strengthened conclusions about the consistency of effects across major subgroups of age and severity. The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin Scale (mRS) for one patient was 2·6, which is extraordinary in itself and a huge advance in care for patients with stroke caused by occlusion of the major intracranial carotidterritory vessels, who often respond poorly to optimal medical care with intravenous thrombolytic drugs 2 and have high risk of mortality or disability. Updates to European and North American guidelines [3][4][5] for acute stroke management have already reflected the findings of these trials by recommending endovascular thrombectomy in suitable patients, conclusions supported by the HERMES analysis.…”