Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion

Ioannis Christou, Robert A. Felberg, Andrew M. Demchuk, W. Scott Burgin, Marc Malkoff, James C. Grotta, Andrei Alexandrov

Research output: Contribution to journalArticle

118 Citations (Scopus)

Abstract

Background and Purpose. It has been suggested that intravenous tissue plasminogen activator (TPA) would not lyse the large thrombus associated with internal carotid artery (ICA) occlusion and, therefore, would be ineffective in this setting. Vascular imaging, safety, and outcome of TPA therapy for ICA occlusion is not well described. Our goal was to determine the site of occlusion, early recanalization after TPA infusion, and its relationship to outcome. Methods. We reviewed our database of all stroke patients treated with IV TPA between July 1997 and July 1999. We identified all cases with carotid occlusion suggested by transcranial Doppler (TCD) and angiography. Occlusion and recanalization were assessed by site including proximal ICA (prICA), terminal ICA (tICA), and middle cerebral artery (MCA). Baseline National Institutes of Health Stroke Scale (NIHSS) scores and follow-up Rankin scores were obtained. Results. We treated 20 patients with carotid occlusion (age 63.9 ± 10.8 years, 11 males, 9 females). Time to TPA infusion after stroke onset was 128 ± 66 minutes. Baseline NIHSS scores were 16.4 ± 5.4. Time to follow-up was 3.5 ± 4.9 months (2 patients were lost to follow-up). Occlusion sites were prICA 40%, tICA 70%, and concurrent MCA 45%. Multiple sites were involved in 10/20 patients (50%). Among patients with pretreatment and posttreatment vascular imaging studies (n = 18), recanalization in the prICA and tICA was complete in 10%, partial in 16%, and none in 74%. MCA recanalization was complete in 35%, partial in 24%, and none in 41 %. At follow-up, Rankin 0-1 was found in 8 patients (44%), Rankin 2-3 in 3 (17%), and Rankin 4-5 in 3 (17%). Mortality was 22% (n = 4) including 1 fatal intracerebral hemorrhage. Improvement was closely related to resumption of MCA flow (P < .01). Conclusions. Most patients did not recanalize their ICA occlusion after intravenous TPA therapy. However, recanalization of associated proximal MCA clot, found in 45% of our patients, or improved MCA collateral flow was strongly associated with good outcome.

Original languageEnglish (US)
Pages (from-to)119-123
Number of pages5
JournalJournal of Neuroimaging
Volume12
Issue number2
DOIs
StatePublished - Jan 1 2002
Externally publishedYes

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Internal Carotid Artery
Tissue Plasminogen Activator
Middle Cerebral Artery
Stroke
National Institutes of Health (U.S.)
Blood Vessels
Lost to Follow-Up
Cerebral Hemorrhage
Angiography
Thrombosis
Databases
Safety
Mortality
Therapeutics

All Science Journal Classification (ASJC) codes

  • Radiology Nuclear Medicine and imaging
  • Clinical Neurology

Cite this

Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. / Christou, Ioannis; Felberg, Robert A.; Demchuk, Andrew M.; Scott Burgin, W.; Malkoff, Marc; Grotta, James C.; Alexandrov, Andrei.

In: Journal of Neuroimaging, Vol. 12, No. 2, 01.01.2002, p. 119-123.

Research output: Contribution to journalArticle

Christou, Ioannis ; Felberg, Robert A. ; Demchuk, Andrew M. ; Scott Burgin, W. ; Malkoff, Marc ; Grotta, James C. ; Alexandrov, Andrei. / Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. In: Journal of Neuroimaging. 2002 ; Vol. 12, No. 2. pp. 119-123.
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abstract = "Background and Purpose. It has been suggested that intravenous tissue plasminogen activator (TPA) would not lyse the large thrombus associated with internal carotid artery (ICA) occlusion and, therefore, would be ineffective in this setting. Vascular imaging, safety, and outcome of TPA therapy for ICA occlusion is not well described. Our goal was to determine the site of occlusion, early recanalization after TPA infusion, and its relationship to outcome. Methods. We reviewed our database of all stroke patients treated with IV TPA between July 1997 and July 1999. We identified all cases with carotid occlusion suggested by transcranial Doppler (TCD) and angiography. Occlusion and recanalization were assessed by site including proximal ICA (prICA), terminal ICA (tICA), and middle cerebral artery (MCA). Baseline National Institutes of Health Stroke Scale (NIHSS) scores and follow-up Rankin scores were obtained. Results. We treated 20 patients with carotid occlusion (age 63.9 ± 10.8 years, 11 males, 9 females). Time to TPA infusion after stroke onset was 128 ± 66 minutes. Baseline NIHSS scores were 16.4 ± 5.4. Time to follow-up was 3.5 ± 4.9 months (2 patients were lost to follow-up). Occlusion sites were prICA 40{\%}, tICA 70{\%}, and concurrent MCA 45{\%}. Multiple sites were involved in 10/20 patients (50{\%}). Among patients with pretreatment and posttreatment vascular imaging studies (n = 18), recanalization in the prICA and tICA was complete in 10{\%}, partial in 16{\%}, and none in 74{\%}. MCA recanalization was complete in 35{\%}, partial in 24{\%}, and none in 41 {\%}. At follow-up, Rankin 0-1 was found in 8 patients (44{\%}), Rankin 2-3 in 3 (17{\%}), and Rankin 4-5 in 3 (17{\%}). Mortality was 22{\%} (n = 4) including 1 fatal intracerebral hemorrhage. Improvement was closely related to resumption of MCA flow (P < .01). Conclusions. Most patients did not recanalize their ICA occlusion after intravenous TPA therapy. However, recanalization of associated proximal MCA clot, found in 45{\%} of our patients, or improved MCA collateral flow was strongly associated with good outcome.",
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AU - Felberg, Robert A.

AU - Demchuk, Andrew M.

AU - Scott Burgin, W.

AU - Malkoff, Marc

AU - Grotta, James C.

AU - Alexandrov, Andrei

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N2 - Background and Purpose. It has been suggested that intravenous tissue plasminogen activator (TPA) would not lyse the large thrombus associated with internal carotid artery (ICA) occlusion and, therefore, would be ineffective in this setting. Vascular imaging, safety, and outcome of TPA therapy for ICA occlusion is not well described. Our goal was to determine the site of occlusion, early recanalization after TPA infusion, and its relationship to outcome. Methods. We reviewed our database of all stroke patients treated with IV TPA between July 1997 and July 1999. We identified all cases with carotid occlusion suggested by transcranial Doppler (TCD) and angiography. Occlusion and recanalization were assessed by site including proximal ICA (prICA), terminal ICA (tICA), and middle cerebral artery (MCA). Baseline National Institutes of Health Stroke Scale (NIHSS) scores and follow-up Rankin scores were obtained. Results. We treated 20 patients with carotid occlusion (age 63.9 ± 10.8 years, 11 males, 9 females). Time to TPA infusion after stroke onset was 128 ± 66 minutes. Baseline NIHSS scores were 16.4 ± 5.4. Time to follow-up was 3.5 ± 4.9 months (2 patients were lost to follow-up). Occlusion sites were prICA 40%, tICA 70%, and concurrent MCA 45%. Multiple sites were involved in 10/20 patients (50%). Among patients with pretreatment and posttreatment vascular imaging studies (n = 18), recanalization in the prICA and tICA was complete in 10%, partial in 16%, and none in 74%. MCA recanalization was complete in 35%, partial in 24%, and none in 41 %. At follow-up, Rankin 0-1 was found in 8 patients (44%), Rankin 2-3 in 3 (17%), and Rankin 4-5 in 3 (17%). Mortality was 22% (n = 4) including 1 fatal intracerebral hemorrhage. Improvement was closely related to resumption of MCA flow (P < .01). Conclusions. Most patients did not recanalize their ICA occlusion after intravenous TPA therapy. However, recanalization of associated proximal MCA clot, found in 45% of our patients, or improved MCA collateral flow was strongly associated with good outcome.

AB - Background and Purpose. It has been suggested that intravenous tissue plasminogen activator (TPA) would not lyse the large thrombus associated with internal carotid artery (ICA) occlusion and, therefore, would be ineffective in this setting. Vascular imaging, safety, and outcome of TPA therapy for ICA occlusion is not well described. Our goal was to determine the site of occlusion, early recanalization after TPA infusion, and its relationship to outcome. Methods. We reviewed our database of all stroke patients treated with IV TPA between July 1997 and July 1999. We identified all cases with carotid occlusion suggested by transcranial Doppler (TCD) and angiography. Occlusion and recanalization were assessed by site including proximal ICA (prICA), terminal ICA (tICA), and middle cerebral artery (MCA). Baseline National Institutes of Health Stroke Scale (NIHSS) scores and follow-up Rankin scores were obtained. Results. We treated 20 patients with carotid occlusion (age 63.9 ± 10.8 years, 11 males, 9 females). Time to TPA infusion after stroke onset was 128 ± 66 minutes. Baseline NIHSS scores were 16.4 ± 5.4. Time to follow-up was 3.5 ± 4.9 months (2 patients were lost to follow-up). Occlusion sites were prICA 40%, tICA 70%, and concurrent MCA 45%. Multiple sites were involved in 10/20 patients (50%). Among patients with pretreatment and posttreatment vascular imaging studies (n = 18), recanalization in the prICA and tICA was complete in 10%, partial in 16%, and none in 74%. MCA recanalization was complete in 35%, partial in 24%, and none in 41 %. At follow-up, Rankin 0-1 was found in 8 patients (44%), Rankin 2-3 in 3 (17%), and Rankin 4-5 in 3 (17%). Mortality was 22% (n = 4) including 1 fatal intracerebral hemorrhage. Improvement was closely related to resumption of MCA flow (P < .01). Conclusions. Most patients did not recanalize their ICA occlusion after intravenous TPA therapy. However, recanalization of associated proximal MCA clot, found in 45% of our patients, or improved MCA collateral flow was strongly associated with good outcome.

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