Timing of Recanalization After Intravenous Thrombolysis and Functional Outcomes After Acute Ischemic Stroke

Yeo, Leonard L.L.; Paliwal, Prakash; Teoh, Hock Luen; Seet, Raymond C.S.; Chan, Bernard P.L.; Shen, Liang; Venketasubramanian, Narayanaswamy; Rathakrishnan, Rahul; Ahmad, Aftab; Ng, Kim Tien; Loh, Pei K; Ong, Jonathan; Wakerley, Benjamin R; Chong, Vincent; Bathla, Girish; Sharma, Vijay K.

doi:10.1001/2013.jamaneurol.547

Cited by 90 publications

(59 citation statements)

References 27 publications

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“…A positive relation between distal thrombus location and recanalization has been found in multiple studies. 7,[31][32][33] In contrast, Lemmens et al 34 found no relation between distal occlusion and recanalization, though they did find a better clinical response with increased reperfusion. Moreover, none of our patients with an intracranial carotid occlusion showed complete reperfusion (despite complete recanalization in 15% and 54% receiving IV-rtPA in this patient group of 13 patients).…”

Section: Predictors Of Reperfusionmentioning

confidence: 92%

Predictors of Reperfusion in Patients with Acute Ischemic Stroke

Horsch¹,

Dankbaar²,

Niesten³

et al. 2015

AJNR Am J Neuroradiol

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Section: Predictors Of Reperfusionmentioning

confidence: 92%

Predictors of Reperfusion in Patients with Acute Ischemic Stroke

Horsch¹,

Dankbaar²,

Niesten³

et al. 2015

AJNR Am J Neuroradiol

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“…After the initiation of intravenous r-tPA, some patients will experience successful recanalization, obviating the need to pursue follow-on endovascular therapy. 28 However, because recanalization occurs in only a minority of patients with large-vessel occlusion receiving intravenous r-tPA alone (eg, 37.3% in the ESCAPE trial), noninvasive intracranial vascular imaging should proceed without delay before or immediately after initiation of r-tPA to identify the majority of patients who will benefit from follow-on endovascular therapy and to expedite its performance. This approach was explicitly taken by investigators in the ESCAPE trial, helping them achieve a median CT-to-groin puncture time of only 51 minutes.…”

Section: Analysis and Conclusionmentioning

confidence: 99%

2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Powers¹,

Derdeyn²,

Biller³

et al. 2015

Stroke

1,968

1,205

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3020Purpose-The aim of this guideline is to provide a focused update of the current recommendations for the endovascular treatment of acute ischemic stroke. When there is overlap, the recommendations made here supersede those of previous guidelines. Methods-This focused update analyzes results from 8 randomized, clinical trials of endovascular treatment and other relevant data published since 2013. It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations. Members of the writing committee were appointed

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“…However, as the clinical outcome is significantly better in patients who show recanalization on late follow-up compared to patients with persistent occlusion at the same time, our findings are clinically important [29]. …”

Section: Discussionmentioning

confidence: 99%

Predictive Value of Thrombus Attenuation on Thin-Slice Non-Contrast CT for Persistent Occlusion after Intravenous Thrombolysis

Niesten¹,

Schaaf²,

Graaf³

et al. 2014

Cerebrovasc Dis

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Background: In stroke erythrocyte-rich thrombi are more sensitive to intravenous thrombolysis with recombinant tissue plasminogen activator (IV-rtPA) and have higher density on non-contrast CT (NCCT). We investigated the relationship between thrombus density and recanalization and whether persistent occlusions can be predicted by Hounsfield unit (HU) measurements. Methods: In 88 IV-rtPA-treated patients with intracranial ICA or MCA occluding thrombus and follow-up imaging, thrombus and contralateral vessel attenuation measurements were performed on thin-slice NCCT. Mean absolute and relative HU were compared between patients with persistent occlusion (modified Thrombolysis in Cerebral Infarction system, grade 0/1/2a) and recanalization (grade 2b/3). Univariate and multivariate (adjusted for stroke subtype, clot burden score, occlusion site and time to thrombolysis) odds ratios for persistent occlusion were calculated. Additional prognostic value for persistent occlusion was estimated by adding HU measurements to the area under the curve (AUC) of known determinants and calculating optimal cut-off values. Results: Patients with persistent occlusion (n = 19) had significant lower mean HU (absolute 52.2 ± 9.5, relative 1.29 ± 0.20) compared to recanalization (absolute 63.1 ± 10.7, relative 1.54 ± 0.23, both p < 0.0001). Odds ratios for persistent occlusion were 3.1 (95% confidence interval, CI 1.6-6.0) univariate and 3.1 (95% CI 1.7-5.7) multivariate per 10 absolute HU decrease and 3.2 (95% CI 1.6-6.5) univariate and 4.1 (95% CI 1.8-9.1) multivariate per 0.20 relative HU decrease. Attenuation measurements significantly increased the AUC (0.67) of the known determinants to 0.84 (absolute HU) and 0.86 (relative HU). Cut-off values of <56.5 absolute HU and <1.38 relative HU showed optimal predictive values for persistent occlusion. Conclusions: Thrombus density is related to recanalization rate. Lower absolute and relative HU are independently related to persistent occlusion and HU measurements significantly increase discriminative performances of known recanalization determinants.

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Timing of Recanalization After Intravenous Thrombolysis and Functional Outcomes After Acute Ischemic Stroke

Cited by 90 publications

References 27 publications

Predictors of Reperfusion in Patients with Acute Ischemic Stroke

Predictors of Reperfusion in Patients with Acute Ischemic Stroke

2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Predictive Value of Thrombus Attenuation on Thin-Slice Non-Contrast CT for Persistent Occlusion after Intravenous Thrombolysis

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