Intravenous Tissue Plasminogen Activator Treatment Research Articles

The Massachusetts General Hospital acute stroke imaging algorithm: an experience and evidence based approach

The Massachusetts General Hospital Neuroradiology Division employed an experience and evidence based approach to develop a neuroimaging algorithm to best select patients with severe ischemic strokes caused by anterior circulation...

Preclusion of Ischemic Stroke Patients from Intravenous Tissue Plasminogen Activator Treatment for Mild Symptoms Should Not be Based on Low National Institutes of Health Stroke Scale Scores

Intravenous tissue plasminogen activator (IV tPA) improves neurologic outcome after stroke, but is not recommended for patients with minor neurologic deficits commonly classified by a lower cutoff on the National Institutes of Health Stroke Scale (NIHSS). Because not all stroke signs are captured on the NIHSS, the use of a strict cutoff may exclude functionally impaired stroke patients from IV tPA treatment. We described functional impairment, safety, and clinical outcome in patients derived from our hospital thrombolysis database who had stroke that was considered disabling despite a neurologic deficit that was considered mild. We used 2 cutoffs: NIHSS score ≤ 4 and ≤ 3. Functional impairment was assessed with the modified Rankin Scale (mRS). Between 2008 and 2011, a total of 670 acute ischemic stroke patients received IV tPA in our institution. 107 (16%) of these patients presented with a NIHSS score ≤ 4; 65 (10%) patients presented with a NIHSS score ≤ 3. All of these patients were considered functionally impaired (mRS score ≥ 2). The most frequent symptoms were language impairment (two-thirds), distal (hand) paresis (one-third), and gait disorder in both groups. Symptomatic intracerebral hemorrhage occurred in 1 patient with a NIHSS score of 4 (1%). Despite IV tPA therapy, 26% had a nonfavorable outcome (mRS score 0-1) after 3 months, and 52% had persisting symptoms in both groups. Language impairment, distal (hand) paresis, and gait disorder are common disabling deficits in patients with low NIHSS scores. Judgment of whether a stroke is disabling should not be based on the NIHSS score but on the assessment of the individual neurologic deficits and their impact on functional impairment.

Hemorrhagic Transformation (HT) and Symptomatic Intracerebral Hemorrhage (sICH) Risk Prediction Models for Postthrombolytic Hemorrhage in the Stroke Belt

BackgroundSymptomatic intracerebral hemorrhage (sICH) remains the most feared complication of intravenous tissue plasminogen activator (IV tPA) treatment. We aimed to investigate how previously validated scoring methodologies would perform in treated patients in two US Stroke Belt states.Methods and ResultsWe retrospectively reviewed consecutive patients from two centers in two Stroke Belt states who received IV tPA (2008–2011). We assessed the ability of three models to predict sICH. sICH was defined as a type 2 parenchymal hemorrhage with deterioration in National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points or death. Among 457 IV tPA-treated patients, 19 (4.2%) had sICH (mean age 68, 26.3% Black, 63.2% female). The Cucchiara model was most predictive of sICH in the entire cohort (AUC: 0.6528) and most predictive of sICH among Blacks (OR = 6.03, 95% CI 1.07–34.1, P = 0.0422) when patients were dichotomized by score.ConclusionsIn our small sample from the racially heterogeneous US Stroke Belt, the Cucchiara model outperformed the other models at predicting sICH. While predictive models should not be used to justify nontreatment with thrombolytics, those interested in understanding contributors to sICH may choose to use the Cucchiara model until a Stroke Belt model is developed for this region.

Stroke Statistics in Korea: Part II Stroke Awareness and Acute Stroke Care, A Report from the Korean Stroke Society and Clinical Research Center For Stroke

The aim of the current Part II of Stroke Statistics in Korea is to summarize nationally representative data on public awareness, pre-hospital delay, thrombolysis, and quality of acute stroke care in a single document. The public's knowledge of stroke definition, risk factors, warning signs, and act on stroke generally remains low. According to studies using open-ended questions, the correct definition of stroke was recognized in less than 50%, hypertension as a stroke risk factor in less than 50%, and other well-defined risk factors in less than 20%. Among stroke warning signs, sudden paresis or numbness was best appreciated, with recognition rates ranging in 36.9-73.7%, but other warning signs including speech disturbance were underappreciated. In addition, less than one third of subjects in a representative population survey were aware of thrombolysis and had knowledge of the appropriate act on stroke, calling emergency medical services (EMS). Despite EMS being an essential element in the stroke chain of survival and outcome improvement, EMS protocols for field stroke diagnosis and prehospital notification for potential stroke patients are not well established. According to the Assessment for Quality of Acute Stroke Care, the median onset-to-door time for patients arriving at the emergency room was 4 hours (mean, 17.3 hours) in 2010, which was not reduced compared to 2005. In contrast, the median door-to-needle time for intravenous tissue plasminogen activator (IV-TPA) treatment was 55.5 minutes (mean, 79.5 minutes) in 2010, shorter than the median time of 60.0 minutes (mean, 102.8 minutes) in 2008. Of patients with acute ischemic stroke, 7.9% were treated with IV-TPA in 2010, an increase from the 4.6% in 2005. Particularly, IV-TPA use for eligible patients substantially increased, from 21.7% in 2005 to 74.0% in 2010. The proportion of hospitals equipped with a stroke unit has increased from 1.1% in 2005 to 19.4% in 2010. Performance, as measured by quality indicators, has steadily improved since 2005, and the performance rates for most indicators were greater than 90% in 2010 except for early rehabilitation consideration (89.4%) and IV-TPA use for eligible patients (74.0%). In summary, the current report indicates a substantial improvement in in-hospital acute stroke care, but also emphasizes the need for enhancing public awareness and integrating the prehospital EMS system into acute stroke management. This report would be a valuable resource for understanding the current status and implementing initiatives to further improve public awareness of stroke and acute stroke care in Korea.

Validity of a computerised five-level emergency triage system for patients with acute ischaemic stroke

ObjectivesAn ideal triage system used in the emergency department (ED) should identify patients who need urgent medical care. The purpose of this study was to validate the Taiwan Triage and...

Analysis of DWI ASPECTS and recanalization outcomes of patients with acute-phase cerebral infarction.

In order to rapidly judge the response to intravenous tissue plasminogen activator (Ⅳ tPA) treatment, we retrospectively analyzed clinical data, such as MRI diffusion-weighted images (DWI), and treatment outcomes in 73 patients who developed anterior circulation disorders. The patients with favorable outcomes (modified Rankin Scale [mRS]: 2 or less) at discharge accounted for 32.9%. In these patients, the National Institutes of Health Stroke Scale (NIHSS) value, DWI Alberta Stroke Programme Early CT Score (ASPECTS), and the incidence of large artery (internal carotid artery [ICA]/sphenoidal segment of the middle cerebral artery [M1]) occlusion at their hospital visit were lower, higher, and lower, respectively (all P < 0.05 in univariate analysis). Multivariate analysis showed significant differences in DWI ASPECTS and the incidence of large artery occlusion. A DWI ASPECTS of at least 8 was found to be predictive of favorable outcomes. However, subclass analysis in the group with a DWI ASPECTS of 8 or higher predicting favorable outcome revealed 13 patients (41.9%) with unfavorable (mRS, 3-6) outcome. The factor associated with unfavorable outcomes is ICA occlusion. The combination of DWI ASPECTS and MRA appeared to be useful for predicting outcomes of Ⅳ tPA.

Thromobolysis for Acute Ischemic Stroke: Is Intra-arterial Better than Intravenous? A Treatment Effects Model

Three randomized trials of intra-arterial thrombolysis (IAT) for acute ischemic stroke ≤ 6 hours were conducted without intravenous tissue plasminogen activator (IV-tPA) treatment of patients in the control groups now known to benefit. The effect of IV-tPA treatment on 130 control subjects in the Prolyse in Acute Cerebral Thromboembolism (PROACT), PROACT II, and Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) studies was modeled using linearly weighted time-dependent odds ratios (ORs) from pooled IV-tPA trials. In the PROACT trials, the model assumed that 50% (36/73) were treated at 4.5 hours, the median time to arteriography. For MELT, the model assumed treatment at arrival plus 90 minutes based on hospital arrival times obtained from the principal investigator. The OR of 1.31 for all 130 controls (91 presumed treated ≤ 4.5 hours; OR 1.44) was applied to the original control data to derive the adjusted control outcome, and this was compared to the IAT group. Sensitivity analyses were performed. Meta-analysis of the original data revealed a statistically significant benefit for IAT (P = .03). After adjustment for the effect of IV-tPA in controls, there was no longer a significant treatment benefit for IAT (P = .26). Loss of significant IAT treatment benefit persisted if either the OR for benefit of IV-tPA or the number of treated controls was more than halved. These 3 randomized trials of IAT for acute ischemic stroke ≤ 6 hours would not likely have shown a benefit if eligible controls had been treated with IV-tPA. Whether IAT is superior to IV-tPA in IV-tPA-eligible patients or better than placebo in IV-tPA-ineligible patients remains to be determined.

Abstract 62: Thrombolysis with Intravenous Recombinant Tissue Plasminogen Activator 3 to 4.5 h After Acute Ischemic Stroke In China

Background and Purpose_ Extending the time window is an important strategy in maximizing thrombolytic therapy in stroke patients. ECASS III had examined a 3 to 4.5h time window and showed a benefit to treated patients. However, little is known about safety and efficacy of intravenous recombinant tissue plasminogen activator(rtPA) treatment in the 3 to 4.5 h time window of acute ischemic stroke in chinese people. Methods_ We analyzed data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China(TIMS-China)- a prospective, multicentric cohort study of intravenous alteplase treatment with patient enrollment from 67 centres across China. Patients who were fully compliant with Chinese product characteristics criteria of alteplase except for the time window and within 4.5 h after symptom onset were included. The symptomatic intracranial hemorrhage, mortality and 90-day outcome of patients treated between 3 and 4.5 h and within 3 h of symptom onset were compared. Results_ A total of 574 patients were included. 165 patients received alteplase between 3 and 4.5 h of symptom onset and 409 patients received altepase within 3 h. In the 3-4.5h cohort, treatment was started at a median of 80 min later after symptom onset (220 min versus 140 min, p&lt;0.0001). After adjustment for the baseline variables including age, sex, past history, aspirin treatment at stroke onset, baseline NIHSS, et al, there were no significant differences between the 3-4.5h cohort and the within 3h cohort for any outcome measure-rate of symptomatic intracranial haemorrhage(2.42% versus 1.47%, p=0.70); mortality(5.70% versus 6.33%, p=0.52); and independence(70.25% versus 64.56%, p=0.15). Conclusion_ Our study suggests that intravenous rtPA treatment also remains safe and effective for chinese people between 3 and 4.5 h of symptom onset after acute ischemic stroke.

Abstract 156: Impact Of Obesity And Metabolic Syndrome In Stroke Patients Undergoing Intravenous Thrombolysis

Background: The influence of high body mass index (BMI) in acute stroke patients treated with intravenous thrombolysis has not been extensively studied. Previous studies have observed an “obesity paradox” among stroke patients, where better outcomes were observed among overweight and obese patients. The purpose of this study is to determine the influence of obesity and risk components of metabolic syndrome to stroke recovery in patients undergoing intravenous recombinant tissue plasminogen activator (rtPA) treatment. Methods: Patients with acute ischemic stroke who received intravenous rtPA within three-hour from symptom onset at St. Marys Hospital, Mayo Clinic, Rochester, between April 2006 and January 2011, were included in this study. Information on vascular risk factors, stroke severity, and baseline hemodynamic and laboratory indices, were collected. Study outcomes, consisting symptomatic intracerebral hemorrhage (sICH) and poor functional recovery (modified Rankin scale &gt;2), were compared between obese (body mass index, BMI &gt;30 kg/m 2 ), overweight (BMI 25-30 kg/m 2 ) and normal weight (BMI &lt;25 kg/m 2 ) patients. The association between BMI, risk components of the metabolic syndrome and dose of rtPA per kg body weight to stroke outcomes were assessed in a multivariable model. Results: A total of 158 patients (mean age, 75 years; baseline NIHSS, 11), frequency-matched by age and baseline stroke severity, were included in this study. No differences in the frequency of SICH and poor functional recovery were observed among obese, overweight and normal weight patients, before and after adjusting for their baseline characteristics. A linear trend towards worse stroke recovery was observed in patients with a greater number of metabolic risk components (p-trend=0.043). By contrast, there were no significant associations between the number of risk components of metabolic syndrome with respect to sICH. Using stepwise regression analyses, age, baseline stroke severity and the number of risk components of the metabolic syndrome accounted for 52% variation in functional recovery following rtPA treatment. Conclusions: Acute stroke outcomes do not differ between obese and overweight patients. The presence of metabolic risk factors contributes significantly to functional outcomes following rtPA treatment. These results suggest that decreasing the prevalence of metabolic syndrome in the community could reduce the societal burden of stroke-related disability.

Intravenous tissue plasminogen activator treatment for ischemic stroke in dabigatran-treated patients

Vergouwen et al. reported that intravenous tissue plasmin-ogen activator (IV tPA) treatment was not associated withan increased risk of secondary intracerebral hemorrhage orgastrointestinal hemorrhage in patients with acute ischemicstroke taking warfarin with an international normalizedratio (INR) <1.7 [6]. These results mean that IV tPAtreatment should not be discouraged in patients takingwarfarin with INR <1.7.Recently, dabigatran, a new oral anticoagulant, wasapproved by the FDA. In the Randomized Evaluation ofLong-Term Anticoagulant Therapy trial, dabigatran wasshown to be as effective as warfarin in prevention of systemicembolism and future stroke, with lower risk of majorhemorrhage [2]. Additionally, dabigatran does not needmonitoring (differently from warfarin). Therefore, the numberof dabigatran-treated patients presenting with ischemic strokemay increase in the future. However, there is no guidelinewhether dabigatran-treated patients presenting with ischemicstroke can be considered eligible for IV tPA treatment or not.Only two case reports demonstrated the safety of IV tPAtreatment for acute ischemic stroke in dabigatran-treatedpatient [3, 5]. On the other hand, Ammollo et al. reportedthat dabigatran enhanced the susceptibility of plasma clots totPA-induced lysis in in vitro study [ 1]. Based on Ammollo’sresults, we can hypothesize that dabigatran may also enhancethebleedingriskcausedbytPA.Although we recognize the lack of data on IV tPAtreatment for acute ischemic stroke in dabigatran-treatedpatients, we need provisional guidelines of the topic, asearly as possible, in order to avoid confusion. Some tests,such as activated partial thrombin time and ecarin clottingtime, which have been reported as correlated with dabiga-tran concentrations, can be helpful for clinicians todetermine the indication of IV tPA for such patients [4].

Outcome of Acute Ischemic Stroke in Very Elderly Patients: Is Intravenous Thrombolysis Beneficial?

Background/Aims: Intravenous tissue plasminogen activator (tPA) treatment is recommended in acute stroke within 3 h of onset; however, the benefit of its use in the elderly remains uncertain. We assessed the safety and efficacy of tPA treatment in elderly patients. Methods: We recruited 97 elderly Chinese patients aged ≧80 years with cerebral ischemia presenting within 3 h of onset. Favorable outcomes were defined as discharge to home and modified Rankin Scale (mRS) ≤2 at discharge. Results: For moderate to severe patients (NIHSS ≧6), the baseline characteristics between the tPA (n = 30) and non-tPA (n = 41) group were not different. The proportion of patients discharged home was 56.7 and 61%, respectively (p = 0.72). For patients with baseline mRS ≤2, the frequency of discharged mRS ≤2 was not different (27.3% of the tPA group and 26.9% of the non-tPA group; p = 1.00). Symptomatic intracranial hemorrhage was 6.7 and 2.4%, respectively (p = 0.31). For minor stroke patients (NIHSS ≤5), tPA was not considered and the outcome of those discharged home and mRS ≤2 was 73 and 88%, respectively. Conclusion: Elderly patients can be treated safely with intravenous tPA, whereas our data did not support routine thrombolysis. Further randomized trials in the elderly are encouraged.

Rapid revascularization reverses cerebral and myocardial ischemia arising from aortic dissection

Thrombolytic therapy is relatively contraindicated in aortic dissection (AD)–related cerebral and myocardial ischemia for high risk of bleeding. We report a 52-year-old woman experiencing acute cerebral and myocardial ischemia arising from AD. Intravenous recombinant tissue plasminogen activator treatment was held immediately when carotid duplex revealed common carotid artery dissection and chest computed tomography confirmed the existence of type A AD. Emergent surgery completely reversed her neurologic deficit and myocardial injury. We suggest that carotid duplex could be a useful tool to detect AD-related stroke before thrombolytic therapy and would not delay the timing for treatment.

Magnetic Resonance Imaging-Guided Thrombolysis in Minor Stroke

We thought your readers would like to know that mild or improving stroke symptoms remain a common cause for exclusion from intravenous tissue plasminogen activator (tPA) treatment. Still, up to 30% of these patients are at risk of death and dependence (1, 2). Clinical criteria are poorly predictive of proximal intracranial occlusion, and may thus underestimate the risk of subsequent neurological deterioration (3). Acute stroke magnetic resonance imaging (MRI) was shown to increase the safety of intravenous thrombolysis (4). We assessed the safety of MRI-guided thrombolysis in patients with minor deficits. Consecutive patients with baseline National Institutes of Health Stroke Scale (NIHSS) r4 and pretreatment MRI, including diffusion and perfusion sequences, were identified from a prospective database that included all patients treated with intravenous tPA between January 2008 and April 2010 (n5302). Twenty-eight patients had a baseline NIHSSr4; among these, three patients were managed with CT. Twentyfive patients were eventually included with a median NIHSS score of 4 (range, 0–4). Persistent occlusion and/or hypoperfusion were confirmed in all patients. All patients had limited diffusion lesions (median volume and range: 0 8, 0– 16 0 ml). Five patients had no visible lesion on diffusion MRI, while a perfusion defect and/or arterial occlusion were confirmed. All patients with perfusion MRI (n5 21) showed significant hypoperfusion volumes (median volume and range: 88 2, 0 9–206 2 ml) with a diffusion–perfusion mismatch. No symptomatic intracranial haemorrhage was observed. All patients were independent at three-months (modified Rankin scale: 0–2) (Fig. 1). These results are in line with a recent series of minor stroke patients (5) and confirm the safety of MRI-based thrombolysis in patients with minor stroke. A proximal occlusion was found in 68% of our patients, emphasising the necessity of a complete neurovascular assessment. The effectiveness of MRI-guided thrombolysis in minor stroke patients needs to be confirmed in randomised trials.

Local Intra-Arterial Thrombolysis With Urokinase for Acute Ischemic Stroke Before and After the Approval of Intravenous Tissue Plasminogen Activator Treatment in Taiwan

Local intra-arterial thrombolysis (LIT) has been previously suggested as an effective therapy for acute ischemic stroke. In this study, we describe our experience of using LIT for the treatment of Taiwanese patients with ischemic stroke at different vascular locations, before and after Alteplase was approved as a first-line treatment in Taiwan. The criteria required for the initiation of LIT have become more stringent after the approval of Alteplase (AA). A retrospective analysis of medical records was conducted for 20 ischemic stroke patients treated with LIT; including 10 patients treated before and 10 patients treated after AA (we did not treat any of the patients in this study with AA). Urokinase was used for LIT treatment. Outcome measures included patient demographics, clinical characteristics, and clinical outcomes before and after LIT. Clinical outcomes were evaluated using four different stroke scales. The median National Institutes of Health stroke scale score (NIHSS) before treatment was reported to be 19.2 (range: 8-30). After AA, only one patient who had an occluded internal carotid artery (ICA) was treated with LIT. Among the 20 patients, 11 (55%) (five before AA and six after AA) reported having favorable or good clinical outcomes within 3 months of treatment, whereas five reported having poor outcomes (three before AA and two after AA), and the rest four patients died following treatment (two before AA and two after AA). Arterial recanalization was reported as complete in 10 patients (50%; seven middle cerebral artery [MCA] and three basilar artery; six before AA and four after AA), as incomplete in four patients (20%; one MCA and three basilar artery; one before AA and three after AA), and it failed in the remaining six patients (30%; two MCA and four ICA; three before AA and three after AA). Five patients (one MCA and four ICA) in whom recanalization had failed reported having poor outcomes, including one ICA patient who subsequently succumbed to the illness. Intracranial hemorrhagic and intraventricular hemorrhage transformation occurred in three and two patients, respectively. A case of intraventricular hemorrhage transformation after AA was also reported. On the basis of our experience, we found that LIT was of limited value in patients with ICA occlusion before AA approval. After AA, the outcomes in acute stroke patients, who were receiving urokinase therapy and who were carefully selected on the basis of the site of occlusion, were improved.

Clot Busting Appropriate in Octogenarians

Clot Busting Appropriate in Octogenarians

Quality of Care and Outcomes in Patients With Diabetes Hospitalized With Ischemic Stroke

Diabetes is a common comorbid disease in stroke patients and has a strong influence on stroke-related outcomes, including stroke recurrence. We sought to examine the quality of care and in-hospital outcomes in patients with diabetes in the Get With the Guidelines-Stroke (GWTG-Stroke) program. Data were obtained from 415 926 ischemic stroke patients from 1070 United States hospitals that participated in GWTG-Stroke between 2003 and 2008. We analyzed the relationships between diabetes and quality of care, in-hospital mortality, and discharge home using multivariable logistic regression. There were 130 817 (31%) ischemic stroke patients with diabetes. Quality of care received by patients with and without diabetes was similar except for intravenous recombinant tissue plasminogen activator (rt-PA) and cholesterol treatment. Fifty-four percent of patients with diabetes who arrived within 2 hours of onset received rt-PA compared to 60.8% of patients without diabetes (adjusted odds ratio [aOR], 0.83; 95% CI, 0.79-0.88). Almost 80% of patients with diabetes were discharged on cholesterol treatment compared to 71% of patients without diabetes (aOR, 1.40; 95% CI, 1.37-1.44). Diabetes patients were less likely to be discharged home (aOR, 0.80; 95% CI, 0.78-0.81) and had a higher risk of in-hospital death (aOR, 1.12; 95% CI, 1.08-1.15). Quality of care among patients with and without diabetes was similar except for rt-PA and cholesterol treatment. Diabetes was associated with worse stroke-related outcomes. Greater quality-improvement efforts to increase the use of rt-PA and other secondary prevention treatments in patients with diabetes are warranted.

Cost-Effectiveness of Patient Selection Using Penumbral-Based MRI for Intravenous Thrombolysis

Better selection of patients for intravenous recombinant tissue plasminogen activator (IV tPA) treatment may improve clinical outcomes. We examined the cost-effectiveness of adding penumbral-based MRI to usual computed tomography (CT)-based methods to identify patients for IV tPA treatment. A decision-analytic model estimated the lifetime costs and outcomes associated with penumbral-based MRI selection in a patient population similar to that enrolled in the IV tPA clinical trials. Inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. Outcomes included cost per life-year saved and cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Sensitivity analyses were conducted. The addition of penumbral-based MRI selection increased total cost by $103 over the patient's remaining lifetime. Penumbral-based MRI selection resulted in favorable outcomes (modified Rankin Scale <or=1) more often than CT-based selection (36.66% versus 35.06%) with an incremental cost per life year of $1840 and an incremental cost per QALY of $1004. Multivariate sensitivity analysis predicted cost-effectiveness (<or=$50,000 per QALY) in 99.7% of simulation runs. Selecting ischemic stroke patients for IV tPA treatment using penumbral-based MRI after routine CT may increase overall acute care costs, but the benefit is large enough to make this highly cost-effective. This economic analysis lends further support to the consideration of a paradigm shift in acute stroke evaluation.

Safety and Efficacy of MRI-Based Selection for Recombinant Tissue Plasminogen Activator Treatment: Responder Analysis of Outcome in the 3-Hour Time Window

Introduction: The use of MRI may alter the target population for intravenous recombinant tissue plasminogen activator (rtPA) treatment relative to conventional CT. If selection changes, it remains crucial to demonstrate safety and efficacy of rtPA for the overall population, as well as in subpopulations hypothesized to benefit from MRI. Materials and Methods: Clinical outcome and incidence of symptomatic intracerebral hemorrhage (ICH) was recorded in 112 consecutive patients treated with intravenous rtPA (0–3 h) with MRI as first-choice imaging modality. According to the responder analysis, favorable outcome was separately defined for mild (NIHSS <8; n = 51), moderate (NIHSS 8–14; n = 30) and severe (NIHSS >14; n = 31) stroke. Results: Eighty-three patients were treated with rtPA after MRI, and 29 after CT. Adjusted for baseline severity, 42% of all patients had a favorable outcome, compared to 37% in NINDS. Among patients with severe stroke, MR-selected patients showed a good outcome in 52% of patients compared to 29% in NINDS (p < 0.05). Symptomatic ICH occurred in 2 patients (1.9 %), and 7 patients died during hospitalization (6.3%). Conclusion: MRI-based rtPA is safe and time-efficient. Outcome data compares well with NINDS data. Diagnostic information obtained from multimodal MRI may affect the target group. Our data support the hypothesized benefit of MRI in patients with severe stroke.

Clinical and Tissue Response to Intravenous Thrombolysis in Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion

The benefit of intravenous thrombolysis in tandem internal carotid artery (ICA)/middle cerebral artery (MCA) occlusion remains unclear. We studied clinical and imaging outcome of intravenous thrombolysis in MRI-selected patients with tandem ICA/MCA occlusion as compared to isolated MCA occlusion. We analyzed data of MRI-selected acute ischemic stroke patients treated with intravenous tissue plasminogen activator within 6 hours. Initial perfusion and diffusion lesion volumes were calculated. Final infarct volume was assessed on follow-up imaging after 5 to 8 days. Recanalization/reperfusion was assessed after 24 hours using MRA. Favorable outcome was defined as a modified Rankin scale score of 0 to 1 after 90 days. Of 38 patients with proximal MCA occlusion, 14 (37%) had a tandem ICA/MCA occlusion. Median NIHSS on admission (15 vs 15), initial perfusion (246 vs 246 mL), and diffusion lesion volume (22 vs 21 mL), final infarct volume (30 vs 39 mL), and the proportion of patients with a favorable outcome after 3 months (50% vs 46%) were similar in tandem ICA/MCA occlusion versus isolated MCA occlusion. The presence of tissue at risk appears to play a key role for the likelihood of clinical recovery after intravenous tissue plasminogen activator treatment in acute stroke patients with tandem ICA/MCA occlusion. There appears to be no evidence to exclude patients with tandem ICA/MCA occlusion from intravenous thrombolysis.

Is Thrombolysis Safe in Patients Taking Antiplatelet Agents

Appropriate selection of patients with acute stroke for intravenous tissue plasminogen activator (t-PA) treatment is essential to maximize the probability of good outcome and to minimize treatment complications, particularly intracerebral hemorrhage. Guidelines specify withholding antiplatelet therapy for 24 hours after intravenous (IV) t-PA administration, but whether prior use of antiplatelet agents raises the risk for hemorrhage is uncertain. In this study, …