Abstract
Background and Purpose: The benefit of thrombolysis in ischemic stroke patients without a visible vessel occlusion still requires investigation. This study tested the hypothesis that non-lacunar stroke patients with no visible vessel occlusion on baseline imaging would have a favorable outcome regardless of treatment with alteplase.Methods: We utilized a prospectively collected registry of ischemic stroke patients [the International Stroke Perfusion Imaging Registry (INSPIRE)] who had baseline computed tomographic perfusion and computed tomographic angiography. The rates of patients achieving modified Rankin Scale (mRS) 0–1 were compared between alteplase treated and untreated patients using logistic regression to generate odds ratios.Results: Of 1569 patients in the INSPIRE registry, 1,277 were eligible for inclusion. Of these, 306 (24%) had no identifiable occlusion and were eligible for alteplase, with 141 (46%) of these patients receiving thrombolysis. The treated and untreated groups had significantly different median baseline National Institutes of Health Stroke Scale (NIHSS) [alteplase 8, interquartile range (IQR) 5–10, untreated 6, IQR 4–8, P < 0.001] and median volume of baseline perfusion lesion [alteplase 5.6 mL, IQR 1.3–17.7 mL, untreated 2.6 mL, IQR 0–6.7 mL, P < 0.001]. After propensity analysis, alteplase treated patients without a vessel occlusion were less likely to have an excellent outcome (mRS 0–1; 56%) than untreated (78.8%, OR, 0.42, 95% confidence interval, 0.24–0.75, P = 0.003).Conclusions: In this non-randomized comparison, alteplase treatment in patients without an identifiable vessel occlusion did not result in higher rates of favorable outcome compared to untreated. However, treated patients displayed less favorable baseline prognostic factors than the untreated group. Further studies may be required to confirm this data.
Highlights
Alteplase has been shown to be an effective therapy for ischemic stroke patients when administered within 4.5 h of symptom onset [1,2,3,4]
Patients without a vessel occlusion at baseline who were treated with alteplase had reduced odds of achieving an excellent or good 90-day clinical outcome than patients who were not treated [modified Rankin Scale (mRS) 0–1, alteplase 56%, untreated 79%, odds ratio (OR) 0.36, 95% confidence interval (CI) 0.22–0.59, P < 0.001; mRS 0–2, alteplase 68%, untreated 88%, OR 0.31, 95% CI 0.17– 0.56, P < 0.001, Table 2, Figure 1] even following propensity matching
Alteplase treated patients with no vessel occlusion had an increased odd of poor clinical outcome than untreated patients, this was no longer significant following propensity matching
Summary
Alteplase has been shown to be an effective therapy for ischemic stroke patients when administered within 4.5 h of symptom onset [1,2,3,4]. There are several possible reasons which may result in patients presenting to hospital with the clinical symptoms suggestive of a stroke but with no identifiable vessel occlusion on CTA. Patients without a baseline occlusion or a perfusion lesion are often excluded from trials of reperfusion therapy, as identifying a reperfusion therapy “target” improves the likelihood of detecting clinical changes between study groups [13, 14]. This is due, in part, to the poor natural history of stroke in patients with an identifiable large vessel occlusion who do not undergo recanalization. This study tested the hypothesis that non-lacunar stroke patients with no visible vessel occlusion on baseline imaging would have a favorable outcome regardless of treatment with alteplase
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