Main Stem Occlusion Research Articles

A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume

In patients with malignant middle cerebral artery infarction (MMI) decompressive surgery within 48 h improves functional outcome. In this respect, early identification of patients at risk of developing MMI is crucial. While the acute diffusion weighted imaging (DWI) lesion volume was found to predict MMI with high predictive values, the potential impact of preexisting brain atrophy on the course of space-occupying middle cerebral artery (MCA) infarction and the development of MMI remains unclear. We tested the hypothesis that the combination of the acute DWI lesion volume with simple measures of brain atrophy improves the early prediction of MMI. Data from a prospective, multicenter, observational study, which included patients with acute middle cerebral artery main stem occlusion studied by MRI within 6 h of symptom onset, was analyzed retrospectively. The development of MMI was defined according to the European randomized controlled trials of decompressive surgery. Acute DWI lesion volume, as well as brain and cerebrospinal fluid volume (CSF) were delineated. The intercaudate distance (ICD) was assessed as a linear brain atrophy marker by measuring the hemi-ICD of the intact hemisphere to account for local brain swelling. Binary logistic regression analysis was used to identify significant predictors of MMI. Cut-off values were determined by Classification and Regression Trees analysis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the resulting models were calculated. Twenty-one (18 %) of 116 patients developed a MMI. Malignant middle cerebral artery infarctions patients had higher National Institutes of Health Stroke Scale scores on admission and presented more often with combined occlusion of the internal carotid artery and MCA. There were no differences in brain and CSF volume between the two groups. Diffusion weighted imaging lesion volume was larger (p < 0.001), while hemi-ICD was smaller (p = 0.029) in MMI patients. Inclusion of hemi-ICD improved the prediction of MMI. Best cut-off values to predict the development of MMI were DWI lesion volume > 87 ml and hemi-ICD ≤ 9.4 mm. The addition of hemi-ICD to the decision tree strongly increased PPV (0.93 vs. 0.70) resulting in a reduction of false positive findings from 7/23 (30 %) to 1/15 (7 %), while there were only slight changes in specificity, sensitivity and NPV. The absolute number of correct classifications increased by 4 (3.4 %). The integration of hemi-ICD as a linear marker of brain atrophy, that can easily be assessed in an emergency setting, may improve the prediction of MMI by lesion volume based predictive models.

A rare indication for surgery in acute myocardial infarction: spontaneous aortic thrombus causing left main stem occlusion

A 52-year old man presented with acute anterolateral ST elevation myocardial infarction. At angiography, the left coronary artery was not found. Aortic root injection revealed a large filling defect (Fig. 1A). Emergency surgery identified an adherent aortic mass extending into the left coronary artery (Fig. 1B and C). The macroscopic appearance suggested a tumour (Fig. 1D); however, histology demonstrated only an organized thrombus, apparently spontaneous.

Evaluation and Management of Massive Endotracheal Hemorrhage in Pediatric Patients: A Case Report and Review of Literature

Massive hemoptysis is a frightening and life-threatening event in children. Prompt, aggressive evaluation and management are necessary. The most common cause of hemoptysis in a pediatric patient is infectious, but other various etiologies including tracheotomy related problems, cystic fibrosis, bronchiectasis, congenital anomalies of the cardiopulmonary vasculature and suction trauma must be considered as well. Presented is a report of a case of acute, massive endotracheal hemorrhage with multiple methods of management including balloon tamponade, highly selective embolization, and mainstem occlusion. This case is an addition to our previously reported case series of nine pediatric patients with massive pulmonary hemorrhage. Various diagnostic and management techniques of hemoptyis in pediatric patients are discussed with an extensive review of the literature.

The contribution of transcranial ultrasound to arterial recanalization in acute ischemic stroke patients

Objective To study the effect of transcranial ultrasound (US) on arterial recanalization in acute ischemic stroke patients.Methods Patients with acute middle cerebral artery (MCA) main stem occlusion after 6 h were randomized into a target group receiving low-frequency,pulse-wave mode,transcranial US for 30 min or a control group.All were treated with intravenous urokinase for thrombolysis.Transcranial doppler sonography (TCD) was used to document vascular occlusion and confirm recanalization at 2 h and 24 h after treatment,and the patients were evaluated using the National Institutes of Health Stroke Scale ( NIHSS).Results Recanilization (complete or partial) after 2 hours was significantly higher in the US group (44.4％) compared with the control group ( 10.5％ ).Recanalization had occurred in 50％ of the US group 24 hours after treatment compared with 15.7％ of the controls.At 2 h after treatment,33.3％ of the US group and 5.5％ of the controls had improved at least 4 points on the NIHSS assessment.After 24 hours the figures were 44.4％ and 10.5％.After 3 months,11 subjects from US group (61.1％ ) had a modified Rankin score ≤2 compared with 4 subjects (21％) from the control group.Conclusions In acute ischemic stroke,transcranial US has positive effects on recanalization and neural function. Key words: Transcranial ultrasound ; Ischemic stroke; Thrombolytic therapy ; Stroke

Outcome of MRI-based intravenous thrombolysis in carotid-T occlusion

Low recanalization rates and poor clinical outcome have been reported after intravenous thrombolysis (IV-tPA) in carotid-T occlusion (CTO). We studied clinical outcome and imaging findings of MRI-based intravenous thrombolysis in CTO. Data of patients with acute ischemic stroke and CTO treated with IV-tPA within 6 h of symptom onset based on MRI criteria were retrospectively analyzed. Vessel occlusion was defined based on MR angiography. Acute diffusion and perfusion lesion volumes and final infarct volumes after 3-7 days were delineated. The National Institutes of Health Stroke Scale (NIHSS) was used to assess the neurological deficit on admission. Recanalization was evaluated after 24 h. Clinical outcome was assessed using the modified Rankin Scale (mRS) after 90 days. Clinical and imaging data were compared to patients with middle cerebral artery main stem occlusion (MCAO). A total of 20 patients with CTO and 51 patients with MCAO were studied. Onset to treatment time, NIHSS on admission, initial diffusion and perfusion lesion volumes, and recanalization rates after 24 h were similar between groups. Final infarct volume was larger for CTO (82 vs. 30 ml, p = 0.006). Although overall outcome was not significantly different between groups (p = 0.251), independent outcome (mRS 0-2) tended to be less frequent in CTO (17 vs. 39 %), while poor outcome (mRS 4-6) appeared more common (72 vs. 43 %). The proportion of patients with good clinical outcome after intravenous thrombolysis in CTO is small. Moreover, final infarct volume is larger and clinical outcome appears to be worse compared to MCAO.

AS-131: Left Main Stem Occlusion Carries a Significant Mortality in Patients Presenting with ST-Elevation Myocardial Infarction during Primary Angioplasty

AS-131: Left Main Stem Occlusion Carries a Significant Mortality in Patients Presenting with ST-Elevation Myocardial Infarction during Primary Angioplasty

Transition to Collateral Flow After Arterial Occlusion Predisposes to Cerebral Venous Steal

Stroke-related tissue pressure increase in the core and penumbra determines regional cerebral perfusion pressure (rCPP) defined as a difference between local inflow pressure and venous or tissue pressure, whichever is higher. We previously showed that venous pressure reduction below the pressure in the core causes blood flow diversion-cerebral venous steal. Now we investigated how transition to collateral circulation after complete arterial occlusion affects rCPP distribution. We modified parallel Starling resistor model to simulate transition to collateral inflow after complete main stem occlusion. We decreased venous pressure from the arterial pressure to zero and investigated how arterial and venous pressure elevation augments rCPP. When core pressure exceeded venous, rCPP=inflow pressure in the core. Venous pressure decrease from arterial pressure to pressure in the core caused smaller inflow pressure to drop augmenting rCPP. Further drop of venous pressure decreased rCPP in the core but augmented rCPP in penumbra. After transition to collateral circulation, lowering venous pressure below pressure in the penumbra further decreased rCPP and collaterals themselves became a pathway for steal. Venous pressure level at which rCPP in the core becomes zero we termed the "point of no reflow." Transition from direct to collateral circulation resulted in decreased inflow pressure, decreased rCPP, and a shift of point of no reflow to higher venous loading values. Arterial pressure augmentation increased rCPP, but only after venous pressure exceeded point of no reflow. In the presence of tissue pressure gradients, transition to collateral flow predisposes to venous steal (collateral failure), which may be reversed by venous pressure augmentation.

Prediction of Malignant Middle Cerebral Artery Infarction Using Computed Tomography-Based Intracranial Volume Reserve Measurements

Early decompressive surgery in patients with malignant middle cerebral artery (MCA) infarction improves outcome. Elevation of intracranial pressure depends on both the space occupying brain edema and the intracranial volume reserve (cerebrospinal fluid [CSF]). However, CSF volume was not investigated as a predictor of malignant infarction so far. We hypothesize that assessment of CSF volume in addition to admission infarct size improves early prediction of malignant MCA infarction. Stroke patients with carotid-T or MCA main stem occlusion and ischemic lesion (reduced cerebral blood volume [CBV]) on perfusion CT were considered for the analysis. The end point malignant MCA infarction was defined by clinical signs of herniation. Volumes of CSF and CBV lesion were determined on admission. Receiver-operator characteristics analysis was used to calculate predictive values for radiological and clinical measurements. Of 52 patients included, 26 (50%) developed malignant MCA infarction. Age, a decreased level of consciousness on admission, CBV lesion volume, CSF volume, and the ratio of CBV lesion volume to CSF volume were significantly different between malignant and nonmalignant groups. The best predictor of a malignant course was the ratio of CBV lesion volume to CSF volume with a cut-off value of 0.92 (96.2% sensitivity, 96.2% specificity, 96.2% positive predictive value, and 96.2% negative predictive value). Based on admission native CT and perfusion CT measurements, the ratio of ischemic lesion volume to CSF volume predicts the development of malignant MCA infarction with higher accuracy than other known predictors, including ischemic lesion volume or clinical characteristics.

Identification of critical coronary artery disease

Sir, Although stigmata such as the occurence of ST-segment elevation (STE) in lead aVR, with concurrent ST-segment depression in leads II, III, aVF, and V3–V6, are highly suggestive of left main stem (LMS) occlusion,1 and were indeed present, in part, in the recently reported case,2 they also occur in left anterior descending (LAD) coronary artery occlusion,3,4 and, to a lesser extent, also in left circumflex artery occlusion,4 thereby justifying urgent triage for percutaneous intervention in virtually all patients with acute coronary syndrome characterized, as …

Stenting of Acute Left Main Coronary Artery Occlusion Using Balloon Anchoring Technique after Transcatheter Aortic Valve Implantation

We describe a case of acute left main stem occlusion complicating a transcatheter transfemoral aortic valve implantation. We treated this emergency using the balloon anchoring technique to insert and implant a stent in the left main stem. Transcatheter transfemoral or transapical aortic valve implantation (TAVI) is a promising treatment in patients with severe, symptomatic surgically nonamenable patients. Registries have reported 3-month mortality rates between 10 and 20%. (1) Most of the fatalities have been caused by the general poor patient condition because of advanced age or severe co-morbidities. However, TAVI has also been associated with new types of procedure-related complications such as valve embolization and cardiac perforation. Here, we describe a case of acute occlusion of the left coronary main stem following transfemoral TAVI. We treated this emergency using the balloon anchoring technique to insert and implant a stent in the left main stem.

Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: A prospective multicenter observational study

Early identification of patients at risk of space-occupying "malignant" middle cerebral artery (MCA) infarction (MMI) is needed to enable timely decision for potentially life-saving treatment such as decompressive hemicraniectomy. We tested the hypothesis that acute stroke magnetic resonance imaging (MRI) predicts MMI within 6 hours of stroke onset. In a prospective, multicenter, observational cohort study patients with acute ischemic stroke and MCA main stem occlusion were studied by MRI including diffusion-weighted imaging (DWI), perfusion imaging (PI), and MR-angiography within 6 hours of symptom onset. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI. Of 140 patients included, 27 (19.3%) developed MMI. The following parameters were identified as independent predictors of MMI: larger acute DWI lesion volume (per 1 ml odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.06; p < 0.001), combined MCA + internal carotid artery occlusion (5.38, 1.55-18.68; p = 0.008), and severity of neurological deficit on admission assessed by the National Institutes of Health Stroke Scale score (per 1 point 1.16, 1.00-1.35; p = 0.053). The prespecified threshold of a DWI lesion volume >82 ml predicted MMI with high specificity (0.98, 95% CI 0.94-1.00), negative predictive value (0.90, 0.83-0.94), and positive predictive value (0.88, 0.62-0.98), but sensitivity was low (0.52, 0.32-0.71). Stroke MRI on admission predicts malignant course in severe MCA stroke with high positive and negative predictive value and may help in guiding treatment decisions, such as decompressive surgery. In a subset of patients with small initial DWI lesion volumes, repeated diagnostic tests are required.

Transcranial Duplex Sonography and CT Angiography in Acute Stroke Patients

Acute occlusion of cervical or intracranial arteries is the most common cause of ischemic stroke (IS). The aims of the current study were to compare the occurrence of acute pathologic findings in intracranial arteries using transcranial color-coded sonography (TCCS) and computed tomographic angiography (CTA) performed within 3 hours of IS onset and to assess the correlation between the vascular findings on admission and the patient's clinical state on admission and 3 months after the IS. Forty-five consecutive patients with an acute IS were included in the prospective study during an 18-month period. All patients underwent CTA and TCCS within the first 3 hours of symptom onset. A high rate of pathologic findings in the intracranial circulation was found (70.9% in CTA and 77.4% in TCCS examinations). The CTA and TCCS findings with respect to the intracranial arteries were consistent in 87.1% of cases (Cohen's kappa, .797). The sensitivity, specificity, and positive and negative predictive values achieved with TCCS in patients with middle cerebral artery main stem occlusion were 92.3%, 94.4%, and 92.3% and 94.4%, respectively. There was no correlation between the patient's clinical status on admission and 3 months after the onset of the IS and the CTA or the TCCS findings (P > .1 in all cases). A substantial agreement was found between TCCS and CTA in the detection of pathologic findings in intracranial vessels in acute stroke patients. Both methods can be used for this purpose.

Late presentation of left main stem occlusion after blunt chest trauma

Blunt chest trauma is a rare but known cause of acute coronary lesions. Commonly, the left anterior descending artery is involved which results in an anterior myocardial infarction, diagnosed within a variable time span of 24 hours to 6 months. We report on an unusual case of left main stem occlusion young adult patient presenting with evolving angina 5 years after an apparently minor chest trauma.

Ultrasound-Enhanced Thrombolysis: From Bedside to Bench

HomeStrokeVol. 39, No. 12Ultrasound-Enhanced Thrombolysis: From Bedside to Bench Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBUltrasound-Enhanced Thrombolysis: From Bedside to Bench Jürgen Eggers, MD Jürgen EggersJürgen Eggers Stroke Unit, Department of Neurology, Asklepios Hospital North, Hamburg, Germany Search for more papers by this author Originally published23 Oct 2008https://doi.org/10.1161/STROKEAHA.108.531848Stroke. 2008;39:e193Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 23, 2008: Previous Version 1 To the Editor:We highly appreciate Tsivgoulis and Alexandrov’s1 comment regarding our article about sonothrombolysis with transcranial color-coded sonography (TCCS) and recombinant tissue plasminogen activator.2 However, several conclusions made by these colleagues require a response. The assumption that the multibeam configuration of TCCS causes an increased rate of symptomatic intracranial hemorrhage in the target group is not justified. The overwhelming part of insonation was performed by using the pulsed wave Doppler mode as it was also used by Alexandrov and coworkers in the CLOTBUST trial.3 As we described in the Methods section, multibeam color-coded mode was only used for the identification of the vessel occlusion before starting the continuous insonation.2 Additionally, the exact location of the Doppler sample volume at the targeted occlusion site was recurrently proved by intermitted switching from the Doppler mode to the color-coded mode. This interval of switching depends on the examiner’s choice, either using the so called “refreshing-mode” of the device for an ultrashort period (every 7 seconds during continuous insonation for enhancing thrombolysis in our study) or individually when used for diagnostic purpose. This frequent visualization of the Doppler sample volume location allows optimal targeting of the occlusion site by the ultrasound beam. Because the position of transducer at the acoustic window of the temporal bone did not change, the insonation angle did not vary remarkably.This ability of switching from Doppler mode to color-coded mode by using the same device and transducer makes TCCS such an advanced and useful tool for identifying (and treating) acute intracranial vessel occlusion.2,4 As the pulsed wave Doppler mode enables to measure blood flow velocities at a defined location, the color-coded mode displays the flow of the major part of the Circle of Willis at one glance. Also, the modality of brightness-mode is helpful to identify landmarks which allow locating the site of an occluded middle cerebral artery without any residual flow (like in our study) in Doppler or color-coded mode.The statement by Tsivgoulis that there was only a trend toward a better functional outcome after 90 days as determined by both the modified Rankin Scale and the Barthel Index does not reflect the results of our study correctly. The modified Rankin Scale showed only a trend, but the Barthel Index measurement revealed a highly significant improvement of the target group. However, the Barthel Index is no longer accepted as an end point for stroke trials, so we did not regard this result as valid.Both transcranial Doppler ultrasound and TCCS enhance thrombolysis by the same high-frequency low-energy “diagnostic” transcranial pulsed wave ultrasound. However, in our opinion TCCS is the more advanced tool offering many advantages compared to transcranial Doppler ultrasound.DisclosuresNone.1 Tsivgoulis G, Alexandrov AV. Ultrasound-enhanced thrombolysis from bedside to bench. Stroke. 2008; 39: 1404–1405.LinkGoogle Scholar2 Eggers J, König IR, Koch B, Händler G, Seidel G. Sonothrombolysis with transcranial color-coded sonography and recombinant tissue-type plasminogen activator in acute middle cerebral artery main stem occlusion: results from a randomized study. Stroke. 2008; 39: 1470–1475.LinkGoogle Scholar3 Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR, Alvarez-Sabin J, Montaner J, Saqqur M, Demchuk AM, Moye LA, Hill MD, Wojner AW; CLOTBUST Investigators. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004; 351: 2170–2178.CrossrefMedlineGoogle Scholar4 Gerriets T, Postert T, Goertler M, Stolz E, Schlachetzki F, Sliwka U, Seidel G, Weber S, Kaps M. DIAS I: duplex-sonographic assessment of the cerebrovascular status in acute stroke: a useful tool for future stroke trials. Stroke. 2000; 31: 2342–2345.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails December 2008Vol 39, Issue 12 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.108.531848PMID: 18948600 Originally publishedOctober 23, 2008 PDF download Advertisement

Minimally Invasive Off-Pump Aortic Valve Implantation: The Surgical Safety Net

Minimally invasive techniques for transcatheter aortic valve implantation are rapidly developing. Feasibility of off-pump, sternal-sparing aortic valve implantation has already been demonstrated, initial clinical results are promising, and there will be further technical improvements. However, any complication, some even unknown thus far, can occur at any time during transcatheter aortic valve implantation requiring conversion to cardiopulmonary bypass and conventional surgery. We present a case of left mainstem occlusion during minimally invasive off-pump transapical aortic valve implantation focusing on bail-out strategies. Due to the "surgical safety-net," cardiopulmonary bypass was immediately established, and after coronary bypass grafting, the patient recovered and was discharged from the hospital.

Sonothrombolysis With Transcranial Color-Coded Sonography and Recombinant Tissue-Type Plasminogen Activator in Acute Middle Cerebral Artery Main Stem Occlusion

Sonothrombolysis is a new treatment approach in acute ischemic stroke. The results of a monocenter, randomized clinical study are presented. Subjects with acute middle cerebral artery main stem occlusion were randomized into a target group receiving 1-hour transcranial continuous insonation using a 1.8-MHz Doppler ultrasound (US) probe or a control group. All underwent standard thrombolysis with intravenous recombinant tissue-type plasminogen activator. Thirty-seven subjects were included; 19 subjects were treated in the target (US) group and 18 in the control (no-US) group, all with no residual flow in the middle cerebral artery main stem occlusion (Thrombolysis in Brain Ischemia recanalization grade 0). Compared with the no-US group, the US group showed greater improvement in National Institutes of Health Stroke Scale values at days 1 and 4 and a higher median Thrombolysis in Brain Ischemia grade 1 hour after recombinant tissue-type plasminogen activator initiation. Recanalization (complete or partial) after 1 hour occurred in 57.9% of the US group and 22.2% of the no-US group (P=0.045). After 90 days, 4 subjects from the US group had a modified Rankin Score <or=1 (none from the no-US group) and 8 had a Barthel Index >or=95 (none from the no US group; P=0.106 and P=0.003, respectively). Three subjects from the US group (15.8%) developed a symptomatic intracranial hemorrhage as did one (5.6%) in the no-US group (P=0.60). This small randomized study indicates a beneficial impact of transcranial ultrasound on recanalization and short-term outcome in subjects with middle cerebral artery main stem occlusion and recombinant tissue-type plasminogen activator treatment.

RECANALIZATION AFTER INTRAVENOUS THROMBOLYSIS: DOES A RECANALIZATION TIME WINDOW EXIST?

Background: To evaluate the time course of major vessel recanalization under IV thrombolysis in relation to functional outcome in acute ischemic stroke. Methods: A total of 99 patients with an acute anterior circulation vessel occlusion who underwent IV thrombolysis were included. All patients had a standardized admission and follow-up procedure. Color-coded duplex sonography was performed on admission, 30 minutes after thrombolysis, and at 6 and 24 hours after onset of symptoms. Recanalization was classified as complete, partial, and absent. Functional outcome was rated with the modified Rankin Scale on day 30. Results: Complete recanalization occurred significantly more frequently in patients with multiple branch occlusions compared to those with mainstem occlusion (OR 5.33; 95% CI, 2.18 to 13.05; p p p = 0.002) was significantly associated with a favorable outcome. Multivariate analysis revealed recanalization at any time within 24 hours and NIHSS scores on days 1 and 7 together explaining 75% of the functional outcome variance 30 days after stroke. Conclusions: Complete recanalization up to 24 hours after stroke onset is significantly associated with the short-term clinical course and functional outcome 30 days after acute stroke.

Abstract 2466: Transapical Aortic Valve Implantation At One Year

Objective: To evaluate the results of minimally invasive transapical aortic valve implantation (TAP-AVI) at one year follow-up. Methods: 61 high risk patients with symptomatic aortic valve stenosis received TAP-AVI at our institution since 02/2006. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Edwards SAPIEN™ THV, Edwards Lifesciences, Irvine, CA, USA) was used. All valves were implanted in a hybrid operative theatre under fluoroscopic and echocardiographic guidance. Patient age was 82.7 ±4.5 years, 79% were female, NYHA class was 3.4 ±0.5, previous cardiac surgery had been performed in eight patients, logistic EuroSCORE risk for mortality was 28.1 ±11.9% and STS score risk for mortality was 15.9 ±8.6%. Results: TAP-AVI was performed successfully in 58 (95.1%) of the patients; three patients required early conversion due to proximal dislocation, secondary dissection of the aortic root and main stem occlusion. Two of the converted patients were discharged alive. A total of 73.7% of the patients were treated completely off-pump, secondary use of cardiopulmonary bypass was required in 3/39 (7.8%). 82% of the patients were extubated early after 80 ±17min. Echocardiography revealed good valve function; trivial to mild (1°), paravalvular incompetence was present in 41%. At thirty days four (6.6%) patients and during follow-up eight patients (15.3%) died, all with good valve function at most recent echo. Thirty day survival was 93 ±3.4%, six months survival 74.4 ±6.6% and one year survival 70.5 ±7.3%, respectively. There were no neurological events. Conclusions: Transapical aortic valve implantation is a safe, minimally invasive and off-pump technique to treat high risk patients with aortic stenosis. One year results are good, especially when considering the overall risk profile of these patients.

Intravenous or Intra-Arterial Thrombolysis?

See related article, pages 2191–2195. Intravenous recombinant tissue plasminogen activator (rt-PA) given within 3 hours of stroke onset is considered the standard treatment of stroke and is approved by the health authorities of most countries. It increases the rate of favorable outcomes from the range of 20% to 38% to 31% to 50%.1 Patients with mild or moderate strokes, persons younger than 75 years, and patients treated very early have the best chance for a favorable outcome to treatment.2,3 Nevertheless, more than half of stroke victims face a bleak outlook. Therefore, better means to treat stroke are needed. Intra-arterial thrombolysis (IAT) with pro-urokinase and a small dose of heparin has been tested in a phase III trial to treat stroke patients of <6 hours duration because of middle cerebral artery (MCA) main stem (M1 segment) and main branch (M2 segment) occlusion.4 Recanalization rates were 66% when treated with pro-urokinase and 18% with placebo ( P <0.001). At 90 days, 40% of patients treated with pro-urokinase but only 25% assigned to placebo had regained independency (modified Rankin scale of 0, 1, or 2; P =0.04). The FDA has not approved pro-urokinase for stroke treatment. Nevertheless, IAT mostly with rt-PA or urokinase is used increasingly at stroke centers by interventionalists. Since the FDA granted approval of the MERCI retriever for arterial embolectomy, mechanical recanalization has gained popularity as well.5 Forty-five percent of occluded MCAs and 53% of occluded intracranial internal carotid arteries were recanalized successfully with the MERCI retriever. Vessel recanalization rose to …

Recanalization after intravenous thrombolysis

To evaluate the time course of major vessel recanalization under IV thrombolysis in relation to functional outcome in acute ischemic stroke. A total of 99 patients with an acute anterior circulation vessel occlusion who underwent IV thrombolysis were included. All patients had a standardized admission and follow-up procedure. Color-coded duplex sonography was performed on admission, 30 minutes after thrombolysis, and at 6 and 24 hours after onset of symptoms. Recanalization was classified as complete, partial, and absent. Functional outcome was rated with the modified Rankin Scale on day 30. Complete recanalization occurred significantly more frequently in patients with multiple branch occlusions compared to those with mainstem occlusion (OR 5.33; 95% CI, 2.18 to 13.05; p < 0.0001) and was associated with lower NIH Stroke Scale (NIHSS) scores (p < 0.001). Not the specific time point of recanalization at 6 or 24 hours after stroke onset, but recanalization per se within 24 hours (OR 7.8; 95% CI 2.2 to 28.2; p = 0.002) was significantly associated with a favorable outcome. Multivariate analysis revealed recanalization at any time within 24 hours and NIHSS scores on days 1 and 7 together explaining 75% of the functional outcome variance 30 days after stroke. Complete recanalization up to 24 hours after stroke onset is significantly associated with the short-term clinical course and functional outcome 30 days after acute stroke.