Thrombolysis With Intravenous rtPA in a Series of 100 Cases of Acute Carotid Territory Stroke

Abstract

Background and Purpose-Although new, large, double-blind, randomized studies are needed to establish the efficiency of intravenous thrombolysis, open trials of sufficient size may also provide novel data concerning specific outcomes after thrombolysis. Methods-An open study of intravenous rtPA in 100 patients with internal carotid artery (ICA) territory strokes between 20 and 81 years of age, with a baseline Scandinavian Stroke Scale (SSS) score of Ͻ48 at entry was conducted. Inclusion time was within 7 hours after stroke onset. rtPA (0.8 mg/kg) was infused for 90 minutes, with an initial 10% bolus. Heparin was given according to 3 consecutive protocols. The SSS evaluation was done on days 0, 1, 7, 30, and 90. CT scan was performed before treatment, on days 1 and 7. Etiological investigations included echocardiography and carotid Doppler sonography and/or angiography. Outcome at 1 year was documented by SSS score, the modified Rankin Scale (mRS) score, and a 10-point invalidity scale. Multivariate logistic regression was used to identify predictors of poor versus good outcome. Results-At day 90, 45 patients (45%) had a good result, defined as complete regression or slight neurological sequelae (mRS score of 0 -1), 18 patients had a moderate outcome (mRS 2-3), and 31 patients had serious neurological sequelae (mRS 4 -5). Six patients died, 2 with intracerebral hematoma after immediate heparin. Five of 11 patients (45.5%) treated between 6 and 7 hours had a good result. The overall intracerebral hematoma rate was 7%. Higher values of fibrin degradation products at 2 hours were observed in the subgroup with intracerebral hematomas. Significant predictors of poor outcome on multivariate logistic regression analysis were baseline SSS score of Ͻ15 (odds ratio [OR], 3.38; 95% confidence interval [CI], 1.07 to 10.74; Pϭ0.04), indistinction between white and gray matter on CT scan (OR, 6.59; 95% CI, 2.19 to 19.79; Pϭ0.0008), and proximal internal carotid thrombosis (OR, 3.29; 95% CI, 0.99 to 10.95; Pϭ0.05). Conclusions-Our study confirms the safety of intravenous rtPA at a dose of 0.8 mg/kg and suggests efficacy for this drug even within 7 hours. Outcome and hematoma rates were at least as favorable as for trials of therapy with a 3-hour time window. Subgroups with a poor prognosis include low baseline neurological score, baseline CT changes, and proximal ICA thrombosis. However, approximately 30% of patients with each of these characteristics show a good outcome, so their inclusion in future routine rtPA protocols is still justified. (Stroke. 1998;29:2529 -2540.)

Heterogeneity in Infarct Patterns and Clinical Outcomes Following Internal Carotid Artery Occlusion

“…2 Patients with internal carotid artery (ICA) occlusion are currently excluded from some thrombolytic trials 3 on the basis of potentially extensive infarction and lack of response to thrombolytic therapy. 4,5 However, it is unknown if all patients with ICA occlusion uniformly have extensive and homogenous infarcts and, if this is not the case, what modifies the extent and pattern of infarction. Researchers have examined the primary and ophthalmic collateral systems without success in explaining the difference in infarct extent.…”

“…Similarly, other investigators found that proximal ICA thrombosis conferred an odds ratio of 3.3 for a poorer outcome but also cautioned that only 30% of the patients had a good response to thrombolytic therapy. 4 It is possible that the patients with ICA occlusion who responded to thrombolytic therapy had recanalization of the MCA but that the therapy had no effect on recanalization of the ICA because of the larger thrombus burden. 16 …”

Evolution of lesion volume in acute stroke treated by intravenous t‐PA

“…Intravenous thrombolysis with a recombinant tissue plasminogen activator (t-PA), alteplase (Actilyse; Boehringer Ingelheim, Biberach, Germany), was given after MRI completion within the first seven hours after stroke onset according to a previously published protocol (11).…”

CT Angiography in an Acute Stroke Protocol: Correlation between Occlusion Site and Outcome of Intravenous Thrombolysis

“…Many studies have been published on the predictive value of factors like time-to-treatment [6][7][8][9] , severity of neurological deficits [10][11][12] and extension of early ischemic lesions on baseline CT scan on admission 11,13,14 , emphasizing how the best results can be obtained when rt-PA is administered within three hours of symptom onset in patients with an NIHSS score ≤ 25 and an ASPECT score > 7.…”