Clinical deterioration after intravenous recombinant tissue plasminogen activator treatment

A multicenter transcranial Doppler study

Maher Saqqur, Carlos A. Molina, Abdul Salam, Muzaffar Siddiqui, Marc Ribo, Ken Uchino, Sergio Calleja, Zsolt Garami, Khaurshid Khan, Naveed Akhtar, Finton O'Rourke, Ashfaq Shuaib, Andrew M. Demchuk, Andrei Alexandrov

Research output: Contribution to journalArticle

111 Citations (Scopus)

Abstract

BACKGROUND AND PURPOSE - Patients may experience clinical deterioration (CD) after treatment with intravenous recombinant tissue plasminogen activator (rt-PA). We evaluated the ability of flow findings on transcranial Doppler to predict CD and outcomes on modified Rankin Scale. METHODS - Patients with acute stroke received intravenous rt-PA within 3 hours of symptom onset at four academic centers. CD was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by 4 points or more within 24 hours. Poor long-term outcome was defined by modified Rankin Scale ≥2 at 3 months. Transcranial Doppler findings were interpreted using the Thrombolysis in Brain Ischemia flow grading system as persistent arterial occlusion, reocclusion, or complete recanalization. Multiple regression analysis was used to identify transcranial Doppler flow as a predictor for CD after controlling for age, sex, baseline NIHSS, hypertension, and glucose. RESULTS - A total of 374 patients received intravenous rt-PA at 142±60 minutes (median pretreatment NIHSS score 16 points). At the end of intravenous rt-PA infusion, transcranial Doppler showed persistent arterial occlusion in 219 patients (59%), arterial reocclusion in 54 patients (14%), and complete recanalization in 101 patients (27%). CD occurred in 44 patients: 36 had persistent arterial occlusion or reocclusion (82%), 13 symptomatic intracerebral hemorrhage (29%), and both persistent occlusion/reocclusion and symptomatic intracerebral hemorrhage in 10 patients (23%). After adjustment, patient risk for CD with persistent occlusion was OR 1.7 (95% CI: 0.7 to 4) and with arterial reocclusion 4.9 (95% CI: 1.7 to 13) (P=0.002). Patient risk for poor long-term outcomes with persistent occlusion, partial recanalization, or reocclusion was OR 5.2 (95% CI: 2.7 to 9, P=0.001). CONCLUSIONS - Inability to achieve or sustain vessel patency at the end of rt-PA infusion correlates with the likelihood of clinical deterioration and poor long-term outcome. Early arterial reocclusion on transcranial Doppler is highly predictive of CD and poor outcome.

Original languageEnglish (US)
Pages (from-to)69-74
Number of pages6
JournalStroke
Volume38
Issue number1
DOIs
StatePublished - Jan 1 2007

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Tissue Plasminogen Activator
National Institutes of Health (U.S.)
Stroke
Therapeutics
Cerebral Hemorrhage
Brain Ischemia
Regression Analysis
Hypertension
Glucose

All Science Journal Classification (ASJC) codes

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Clinical deterioration after intravenous recombinant tissue plasminogen activator treatment : A multicenter transcranial Doppler study. / Saqqur, Maher; Molina, Carlos A.; Salam, Abdul; Siddiqui, Muzaffar; Ribo, Marc; Uchino, Ken; Calleja, Sergio; Garami, Zsolt; Khan, Khaurshid; Akhtar, Naveed; O'Rourke, Finton; Shuaib, Ashfaq; Demchuk, Andrew M.; Alexandrov, Andrei.

In: Stroke, Vol. 38, No. 1, 01.01.2007, p. 69-74.

Research output: Contribution to journalArticle

Saqqur, M, Molina, CA, Salam, A, Siddiqui, M, Ribo, M, Uchino, K, Calleja, S, Garami, Z, Khan, K, Akhtar, N, O'Rourke, F, Shuaib, A, Demchuk, AM & Alexandrov, A 2007, 'Clinical deterioration after intravenous recombinant tissue plasminogen activator treatment: A multicenter transcranial Doppler study', Stroke, vol. 38, no. 1, pp. 69-74. https://doi.org/10.1161/01.STR.0000251800.01964.f6
Saqqur, Maher ; Molina, Carlos A. ; Salam, Abdul ; Siddiqui, Muzaffar ; Ribo, Marc ; Uchino, Ken ; Calleja, Sergio ; Garami, Zsolt ; Khan, Khaurshid ; Akhtar, Naveed ; O'Rourke, Finton ; Shuaib, Ashfaq ; Demchuk, Andrew M. ; Alexandrov, Andrei. / Clinical deterioration after intravenous recombinant tissue plasminogen activator treatment : A multicenter transcranial Doppler study. In: Stroke. 2007 ; Vol. 38, No. 1. pp. 69-74.
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T2 - A multicenter transcranial Doppler study

AU - Saqqur, Maher

AU - Molina, Carlos A.

AU - Salam, Abdul

AU - Siddiqui, Muzaffar

AU - Ribo, Marc

AU - Uchino, Ken

AU - Calleja, Sergio

AU - Garami, Zsolt

AU - Khan, Khaurshid

AU - Akhtar, Naveed

AU - O'Rourke, Finton

AU - Shuaib, Ashfaq

AU - Demchuk, Andrew M.

AU - Alexandrov, Andrei

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N2 - BACKGROUND AND PURPOSE - Patients may experience clinical deterioration (CD) after treatment with intravenous recombinant tissue plasminogen activator (rt-PA). We evaluated the ability of flow findings on transcranial Doppler to predict CD and outcomes on modified Rankin Scale. METHODS - Patients with acute stroke received intravenous rt-PA within 3 hours of symptom onset at four academic centers. CD was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by 4 points or more within 24 hours. Poor long-term outcome was defined by modified Rankin Scale ≥2 at 3 months. Transcranial Doppler findings were interpreted using the Thrombolysis in Brain Ischemia flow grading system as persistent arterial occlusion, reocclusion, or complete recanalization. Multiple regression analysis was used to identify transcranial Doppler flow as a predictor for CD after controlling for age, sex, baseline NIHSS, hypertension, and glucose. RESULTS - A total of 374 patients received intravenous rt-PA at 142±60 minutes (median pretreatment NIHSS score 16 points). At the end of intravenous rt-PA infusion, transcranial Doppler showed persistent arterial occlusion in 219 patients (59%), arterial reocclusion in 54 patients (14%), and complete recanalization in 101 patients (27%). CD occurred in 44 patients: 36 had persistent arterial occlusion or reocclusion (82%), 13 symptomatic intracerebral hemorrhage (29%), and both persistent occlusion/reocclusion and symptomatic intracerebral hemorrhage in 10 patients (23%). After adjustment, patient risk for CD with persistent occlusion was OR 1.7 (95% CI: 0.7 to 4) and with arterial reocclusion 4.9 (95% CI: 1.7 to 13) (P=0.002). Patient risk for poor long-term outcomes with persistent occlusion, partial recanalization, or reocclusion was OR 5.2 (95% CI: 2.7 to 9, P=0.001). CONCLUSIONS - Inability to achieve or sustain vessel patency at the end of rt-PA infusion correlates with the likelihood of clinical deterioration and poor long-term outcome. Early arterial reocclusion on transcranial Doppler is highly predictive of CD and poor outcome.

AB - BACKGROUND AND PURPOSE - Patients may experience clinical deterioration (CD) after treatment with intravenous recombinant tissue plasminogen activator (rt-PA). We evaluated the ability of flow findings on transcranial Doppler to predict CD and outcomes on modified Rankin Scale. METHODS - Patients with acute stroke received intravenous rt-PA within 3 hours of symptom onset at four academic centers. CD was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by 4 points or more within 24 hours. Poor long-term outcome was defined by modified Rankin Scale ≥2 at 3 months. Transcranial Doppler findings were interpreted using the Thrombolysis in Brain Ischemia flow grading system as persistent arterial occlusion, reocclusion, or complete recanalization. Multiple regression analysis was used to identify transcranial Doppler flow as a predictor for CD after controlling for age, sex, baseline NIHSS, hypertension, and glucose. RESULTS - A total of 374 patients received intravenous rt-PA at 142±60 minutes (median pretreatment NIHSS score 16 points). At the end of intravenous rt-PA infusion, transcranial Doppler showed persistent arterial occlusion in 219 patients (59%), arterial reocclusion in 54 patients (14%), and complete recanalization in 101 patients (27%). CD occurred in 44 patients: 36 had persistent arterial occlusion or reocclusion (82%), 13 symptomatic intracerebral hemorrhage (29%), and both persistent occlusion/reocclusion and symptomatic intracerebral hemorrhage in 10 patients (23%). After adjustment, patient risk for CD with persistent occlusion was OR 1.7 (95% CI: 0.7 to 4) and with arterial reocclusion 4.9 (95% CI: 1.7 to 13) (P=0.002). Patient risk for poor long-term outcomes with persistent occlusion, partial recanalization, or reocclusion was OR 5.2 (95% CI: 2.7 to 9, P=0.001). CONCLUSIONS - Inability to achieve or sustain vessel patency at the end of rt-PA infusion correlates with the likelihood of clinical deterioration and poor long-term outcome. Early arterial reocclusion on transcranial Doppler is highly predictive of CD and poor outcome.

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