Clinical and Vascular Outcome in Internal Carotid Artery Versus Middle Cerebral Artery Occlusions After Intravenous Tissue Plasminogen Activator

Abstract

Background and Purpose — Early reperfusion is a predictor of good outcome in acute ischemic stroke. We investigated whether middle cerebral artery (MCA) occlusions have a better clinical outcome and proportion of recanalization compared with internal carotid artery (ICA) occlusion after standard treatment with intravenous (IV) tissue plasminogen activator (tPA). Patients — In a retrospective analysis of our prospective stroke database between January 7, 1998, and January 30, 2002, we identified 36 consecutive patients who were treated with IV tPA within 3 hours after symptom onset of a stroke in the distribution of a documented ICA or MCA occlusion. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before tPA, at 24 hours, 3 days, and 3 months after stroke. Three-month outcome was recorded by modified Rankin scale. Magnetic resonance angiography or computed tomographic angiography was obtained before tPA. The presence of recanalization was assessed by transcranial Doppler and/or magnetic resonance angiography within 3 days after stroke onset. Results — Nineteen patients had MCA occlusion, and 17 had ICA-plus-MCA occlusion before tPA. Although there was no difference in age and NIHSS at day 0 between the 2 groups, the MCA group had a lower day 3 NIHSS score compared with the ICA group ( P =0.006) in an ANCOVA. In addition, patients who had a MCA occlusion had lower day 1 and 3 NIHSS scores compared with the ICA group ( P =0.04 and P =0.03, respectively; Wilcoxon rank sum). Similarly, NIHSS was significantly lower in patients who recanalized on days 1 and 3 ( P =0.004 and P =0.003 respectively, Wilcoxon rank sum). When we adjusted for NIHSS score at day 0 in an ANCOVA, the adjusted mean was lower in the group that recanalized compared with the group that did not recanalize ( P <0.001). There was a significant difference between the proportion of recanalization in the MCA group (15 of 17 recanalized, 88%) at 3 days after tPA compared with that of the ICA group (5 of 16 recanalized, 31%; P =0.001, Fisher exact test). The 3-month modified Rankin scale was not different between the 2 groups. Conclusions — Despite comparable age and NIHSS scores before IV tPA, MCA occlusions have lower day 1 and 3 NIHSS scores and higher proportion of recanalization compared with ICA occlusions. A combined IV/intra-arterial or mechanical thrombolysis may be needed to achieve early recanalization in ICA occlusions.

CT Angiography Clot Burden Score and Collateral Score: Correlation with Clinical and Radiologic Outcomes in Acute Middle Cerebral Artery Infarct

“…29 Proximal clot location is increasingly appreciated as an important determinant in outcome. 3,[30][31][32] Patients with a larger clot burden have been shown to have larger infarction volumes at baseline and poorer clinical outcomes. 33,34 The CBS is designed to be weighted to vessel location, assigning higher points to the terminal ICA and proximal MCA locations.…”

Penumbra System: A Novel Mechanical Thrombectomy Device for Large-Vessel Occlusions in Acute Stroke

“…[18][19][20][21] It was also demonstrated that early revascularization correlated very well with good clinical outcome. 6,7,17 The PROACT and PROACT II trials have shown revascularization rates of 58% and 66%, respectively, with good clinical outcomes of mRS 0 -1 at 3 months in 31% in the PROACT subjects and of mRS of 0 -2 in 40% of the PROACT II subjects.…”

Late Endovascular Revascularization in Acute Ischemic Stroke Based on Clinical-Diffusion Mismatch

“…[20][21][22] However, it is likely that in certain patients, should the site of occlusion a priori be known to exist in a small branch, CDM may also help triage candidates who might benefit from systemic thrombolysis alone.…”