Factors Associated with Early Recanalization Failure following Intravenous rt-PA Therapy for Ischemic Stroke

Abstract

Background: Although intravenous recombinant tissue-type plasminogen activator (rt-PA) therapy can be effective for ischemic stroke, a considerable percentage of patients do not receive any benefit as a result of early recanalization failure. We aimed to investigate the factors associated with early recanalization failure following intravenous rt-PA therapy. Methods: Patients with acute ischemic stroke and internal carotid artery (ICA) or middle cerebral artery occlusion on initial magnetic resonance angiography (MRA) who received intravenous rt-PA therapy within 3 h of stroke onset and underwent follow-up MRA within 8 h after treatment were enrolled. Baseline characteristics, stroke features, onset to treatment time, initial National Institutes of Health Stroke Scale (NIHSS) score, initial Alberta Stroke Programme Early CT Score on diffusion-weighted imaging-ASPECTS (Alberta Stroke Program Early Computed Tomography Score), the presence of ICA or M1 origin (the residual length <5 mm) (ICA/M1 origin occlusion), initial vital signs, and laboratory findings were recorded. Early recanalization on the follow-up MRA within 8 h was evaluated by modified Mori grade: grade 0, no reperfusion; grade 1, movement of thrombus; grade 2, partial recanalization, and grade 3, complete recanalization. Results: Seventy subjects (35 women, 77 ± 12 years) were enrolled. The median (interquartile range: IQR)NIHSS score was 18 (12.5-24), and the mean onset to treatment time was 141 ± 54 min. ICA was occluded in 29%, M1 origin in 17%, M1 middle in 13%, M1 distal in 26% and M2 in 15%. The median (IQR) pretreatment diffusion weighted imaging-ASPECTS was 8 (6-9), and follow-up time of MRA was 65 min (59-70) after rt-PA therapy. Thirty-two subjects (46%) showed modified Mori grade 0; 10 (14%), grade 1; 9 (13%), grade 2, and 19 (27%), grade 3. Multivariate analyses revealed ICA/M1 origin occlusion (OR 3.71, 95% CI 1.03-14.87, p = 0.044), and C-reactive protein (per 0.1-mg/dl increment, OR 1.19, 95% CI 1.03-1.44, p = 0.013) were independently associated with subjects with no recanalization (grade 0-1), whereas age (per years old, OR 0.93, 95% CI 0.86-0.99, p = 0.014) and high-density lipoprotein cholesterol (per 1-mg/dl increment, OR 0.94, 95% CI 0.89-0.98, p = 0.004) were inversely associated with those. Conclusion: ICA/M1 origin occlusion and C-reactive protein were positively and high-density lipoprotein cholesterol was negatively associated with early recanalization failure.

Simple clinical predictors of stroke outcome based on National Institutes of Health Stroke Scale score during 1‐h recombinant tissue‐type plasminogen activator infusion

“…If these patients with milder stroke were also included, three patients in group P and eight in group D would be added. After approval of the MERCI Retriever for clinical use in Japan in 2010, the patients in our registry principally underwent follow-up MRA at around 1 h [40]. Thirdly, our indicator is not simple because of separating patients into two groups based on the arterial occlusion site.…”

“…Although follow-up MRA was performed in 91 of 108 patients, most of these were done on the second day or later. After approval of the MERCI Retriever for clinical use in Japan in 2010, the patients in our registry principally underwent follow-up MRA at around 1 h [40]. ICA/M1 origin occlusion (i.e.…”

Age‐specific clinical characteristics and outcome in patients over 60 years old with large hemispheric infarction

“…Although previous systematic review about predictors of brain edema in LHI indicated that the mean age of patients with life‐threatening edema was 3.2 years lower than those patients without (Hofmeijer, Algra, & Kappelle, ), more than half of patients suffered from brain edema were over 60 years of age in our cohort. This might be partly explained by the higher rate of atrial fibrillation (53.57% vs. 31.03%) and higher proportion of cardio‐embolism (55.71% vs.38.79%) in the older age group, and those patients are more likely to exhibit internal carotid artery or the proximal MCA occlusion which was associated with early recanalization failure，developing severe ischemic stroke and brain edema (Koga et al, ; Sakamoto et al, ). Although DHC within 48 hr after symptom onset has been proven to benefit highly selected patients with LHI (Huttner & Schwab, ), only 0.3% of all ischemic stroke patients would be eligible for DHC on the basis of the strict eligibility criteria in the European hemicraniectomy trials and age >60 years was the most common reason for ineligibility of hemicraniectomy (Rahme, Curry, et al, ).…”

From “Time is Brain” to “Imaging is Brain”: A Paradigm Shift in the Management of Acute Ischemic Stroke

“…4 However, alteplase is less effective in patients with the most disabling strokes due to large-vessel occlusion than in those with distal occlusions. [5][6][7] To overcome this issue, after the publication of seven pivotal randomized clinical trials (RCTs) [8][9][10][11][12][13][14] between 2014 and 2015, endovascular thrombectomy (EVT) within 6 hours of symptoms onset became the standard of care for patients with large-vessel occlusion in the anterior circulation. 15 While these studies were underway, various authors noted that individuals vary widely in the rate in which ischemic penumbra evolves into infarct core and in the rate of progression of irreversible injury.…”