Alteplase at 0.6 mg/kg for Acute Ischemic Stroke Within 3 Hours of Onset

Clinical and MRI predictors of no early recanalization within 1 hour after tissue-type plasminogen activator administration

BACKGROUND AND PURPOSE

The aim of the present study was to investigate independent clinical and MRI factors associated with no early recanalization within 1 hour after tissue-type plasminogen activator (tPA) administration.

METHODS

Patients with acute stroke within 3 hours of onset who were treated with tPA were studied prospectively. Patients with internal carotid artery, M1, and M2 occlusion were enrolled, and independent clinical and MRI factors associated with no early recanalization within 1 hour after tPA administration were examined using multivariate logistic regression analysis.

RESULTS

One hundred thirty-two patients (63 men; mean age, 76.4±10.2 years; internal carotid artery occlusion in 37 patients, M1 occlusion in 58, and M2 occlusion in 37) were enrolled. Follow-up MR angiography within 60 minutes after tPA infusion revealed early recanalization in 49 (37.1%) patients (complete in 16 patients, partial in 33) and no recanalization in 83 (62.9%). Using 8 variables (atrial fibrillation, time from stroke onset to treatment ≥140 minutes, use of warfarin, glucose ≥135 mg/dL, large artery diseases, internal carotid artery occlusion, M1 occlusion, and M1 susceptibility vessel sign on T2*) identified on univariate analysis at P<0.2, multivariate logistic regression analysis revealed that M1 susceptibility vessel sign was the only independent factor associated with no early recanalization (OR, 7.157; 95% CI, 1.756 to 29.172; P=0.006). The sensitivity, specificity, positive predictive value, and negative predictive value of M1 susceptibility vessel sign for predicting no early recanalization were 31.3%, 93.9%, 89.7%, and 44.7%, respectively.

CONCLUSIONS

Of clinical and MRI factors before tPA infusion, M1 susceptibility vessel sign on T* is the only independent factor associated with no early recanalization within 1 hour after tPA administration.

[Future neuroprotective strategies in the post-thrombolysis era--neurovascular unit protection and vascular endothelial protection]

From an appearance of recombinant tissue plasminogen activator (rt-PA) in the clinical therapy on 2005 in Japan, the therapeutic strategy of ischemic stroke therapy is now changing dramatically. Many experimental data from animal stroke and clinical trials of neuroprotective agents failed to clinical useful therapeutic strategy. A free radical scavenger, edaravone is the first clinical drug for neuroprotection in the world which has been used in almost all ischemic stroke patients in Japan from 2001. Now, it is especially useful in thrombolytic therapy with rtPA, whereas we still need the newly more effective neuroprotective drugs which can be applied to many ischemic stroke patients. Therefore, we review and describe the future neuroprotective strategies in the post-thrombolysis era.

Early ischemic change on CT versus diffusion-weighted imaging for patients with stroke receiving intravenous recombinant tissue-type plasminogen activator therapy: stroke acute management with urgent risk-factor assessment and improvement (SAMURAI) rt-PA registry

BACKGROUND AND PURPOSE

Alberta Stroke Programme Early CT Score (ASPECTS) is a quantitative topographical score to evaluate early ischemic change in the middle cerebral arterial territory on CT as well as on diffusion-weighted imaging (DWI). The aim of the present study was to elucidate the relationship between CT-ASPECTS and DWI-ASPECTS for patients with hyperacute stroke and their associations with outcomes after recombinant tissue-type plasminogen activator therapy based on a multicenter registry.

METHODS

ASPECTS was assessed on both CT and DWI before intravenous 0.6 mg/kg alteplase in 360 patients with stroke (119 women, 71 ± 11 years old). The outcomes were symptomatic intracerebral hemorrhage within 36 hours and independence at 3 months defined by a modified Rankin Scale score of 0 to 2.

RESULTS

DWI-ASPECTS was positively correlated with CT-ASPECTS (ρ=0.511, P<0.001) and was lower than CT-ASPECTS (median 8 [interquartile range, 6 to 9] versus 9 [8 to 10], P<0.001). Higher baseline National Institutes of Health Stroke Scale score (standardized partial regression coefficient [β] 0.061, P<0.001) and cardioembolic stroke (β 0.35, P<0.001) were related to this discrepancy. The area under the receiver operating characteristic curve for predicting sICH (12 patients) using ASPECTS was 0.673 (95% CI, 0.503 to 0.807) by CT and 0.764 (95% CI, 0.635 to 0.858) by DWI (P=0.275). The area for predicting independence at 3 months (192 patients) was 0.621 (0.564 to 0.674) by CT and 0.639 (0.580 to 0.694) by DWI (P=0.535).

CONCLUSIONS

For patients with hyperacute stroke, DWI-ASPECTS scored approximately 1 point lower than CT-ASPECTS. Both CT-ASPECTS and DWI-ASPECTS were useful predictors of symptomatic intracerebral hemorrhage and independence at 3 months after recombinant tissue-type plasminogen activator.

Simultaneous combined intravenous recombinant tissue plasminogen activator and endovascular therapy for hyperacute middle cerebral artery m1 occlusion

We investigated the efficacy and safety of combined intravenous (IV) recombinant tissue plasminogen activator (rtPA) and simultaneous endovascular therapy (ET) for hyperacute middle cerebral artery (MCA) M1 occlusion. Between October 2005 and April 2007, in the combined group, 22 patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, were treated with IV rtPA and simultaneous ET was initiated as soon as possible. The other patients were treated with IV rtPA alone (IV group A: n = 11). Between May 2007 and November 2008, all patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, underwent thrombolysis by IV rtPA alone (IV group B: n = 24). The improvement of the National Institutes of Health Stroke Scale score at 24 hours was highest in the combined group (10 ± 4.1). In contrast, it was 5.1 ± 4.7 in the IV group A (P = 0.017) and 5.6 ± 5.6 in IV group B (P = 0.006). In the combined group, successful recanalization was observed in 18 of 22 patients with one symptomatic intracranial hemorrhage. The rate of mRS0-2 at three months was highest in the combined group, 36% in the IV group A and 33% in the IV group B (P = 0.008).Simultaneous treatment with IV rtPA and ET improved the clinical outcome of MCA M1 occlusion without a significant increase of adverse effects in our study.

Using recombinant tissue plasminogen activator to treat acute ischemic stroke in China: analysis of the results from the Chinese National Stroke Registry (CNSR)

BACKGROUND AND PURPOSE

Little is known about intravenous recombinant tissue plasminogen activator (rtPA) use in China. By accessing the Chinese National Stroke Registry (CNSR), the rate of intravenous rtPA use was reviewed. We specifically examined the issues of prehospital and in-emergency department delay and compared them with the published data from developed countries.

METHODS

Funded by Chinese government, CNSR is the only nationwide stroke registry that includes 132 urban hospitals. All patients eligible for intravenous rtPA were included for analysis. We then compared the onset-to-needle time and door-to-needle time in the emergency department in China with those in developed countries.

RESULTS

From September 2007 to August 2008, 14,702 patients with ischemic stroke were entered into CNSR. Among 11,675 patients with known time of stroke onset, 2514 (21.5%) presented to the emergency department within 3 hours, 1469 (12.6%) were eligible for thrombolytic treatment, and 284 (2.4%) were finally treated, 181 (1.6%) of them with intravenous rtPA. The median onset-to-needle time was 180 (interquartile range, 150 to 228) minutes; the median door-to-needle time was 116 (interquartile range, 70 to 150) minutes; the median imaging-to-needle time was 90 (interquartile range, 60 to 129) minutes. Patients who were younger, presented to the emergency department quicker, with higher National Institutes of Health Stroke Scale scores, having higher income, and better education had a better chance of receiving intravenous rtPA.

CONCLUSIONS

Approximately 1 in 5 patients with stroke presenting within 3 hours received thrombolytic therapy. The onset-to-needle time, door-to-needle time, and especially imaging-to-needle time were significantly longer than those in developed countries. Reducing prehospital and in-emergency department response time would help increase intravenous rtPA use in China.

The kurashiki prehospital stroke scale is a prehospital scale that can predict long-term outcome of patients with acute cerebral ischemia

Background and Purpose

Our aim was to confirm the clinical relationship between the Kurashiki Prehospital Stroke Scale (KPSS) scored by paramedics and favorable outcomes in patients with modified Rankin scale (mRS) scores of 0–1 assessed 3 months after symptom onset.

Methods

We enrolled patients with acute stroke and transient ischemic attack showing symptoms on admission. Paramedics transferred patients to our hospital after estimating stroke severity using the KPSS. After categorizing patients into either the mRS 0–1 group (favorable outcome) or the mRS 2–6 group (no favorable outcome), we compared the background data between the two groups. We assessed KPSS scores predictive of a favorable outcome. Multivariate regression modeling was conducted to identify factors independently associated with a favorable outcome.

Results

The study cohort comprised 147 patients with a premorbid status of mRS 0–1: 69 patients (47%) of them were in the mRS 0–1 group and 78 (53%) in the mRS 2–6 group at the follow-up 3 months after symptom onset. The median KPSS score was lower in the mRS 0–1 group than in the mRS 2–6 group (1 vs. 4, p < 0.001). After classifying the 147 patients into KPSS tertiles with thresholds of 2 and 4, the frequency of mRS 0–1 gradually decreased with increasing KPSS score (lower KPSS, 67.2%; middle KPSS, 47.6%, and higher KPSS, 21.3%; p < 0.001). KPSS score <3 was able to predict a favorable outcome with 67% sensitivity and 71% specificity, and independently associated with mRS 0–1 (odds ratio, 3.0; 95% confidence interval, 1.2–7.3; p = 0.015).

Conclusion

KPSS score <3 apparently presents a reasonable cutoff for predicting a favorable outcome in patients with acute cerebral ischemia.

Large numbers of stroke physicians should be used to treat large numbers of stroke patients with IV rt-PA

PURPOSE

Our aim was to investigate the relationship between number of stroke physicians (SPs) and number of patients treated with intravenous thrombolysis (IV rt-PA) per year.

METHODS

Questionnaires about the infrastructure of acute stroke care including number of SPs and patients given IV rt-PA from October 2008 to September 2009 were sent to 3877 hospitals in Japan. We compared the number of SPs between: 1) hospitals not giving IV rt-PA for a year vs. hospitals giving IV rt-PA for ≥ 1 patient; 2) ≤ 5 vs. >5 patients; 3) ≤ 10 vs. >10 patients; and 4) ≤ 25 vs. >25 patients. We established cut-off numbers of SPs administering IV rt-PA for ≥ 1, >5, >10, and >25 patients/hospital/year using a sensitivity-specificity curve.

RESULTS

Responses were received from 2488 of the 3877 hospitals (64.2%), and 919 hospitals admitted acute stroke patients. Of these, 385 hospitals were not administering IV rt-PA in that year, 250 hospitals gave IV rt-PA for 1-4 patients, 131 hospitals for 5-9 patients, 102 hospitals for 10-25 patients, and 30 hospitals for >25 patients. Cut-off numbers of SPs per hospital were 1 doctor administering IV rt-PA for ≥ 1 patient/year (sensitivity, 83.8%; specificity, 84.5%), 2 doctors for >5 patients (sensitivity, 85.9%; specificity, 74.1%), 3 doctors for >10 patients (sensitivity, 76.3%; specificity, 75.5%), and 4 doctors for >25 patients (sensitivity, 86.2%; specificity, 78.5%). An independent factor for IV rt-PA with >25 patients was ≥ 4 SPs (odds ratio, 3.83; 95% confidence interval, 1.17-12.63; p=0.027).

CONCLUSIONS

Higher numbers of SPs should be associated with higher numbers of patients getting IV rt-PA.

Serial changes in ischemic lesion volume and neurological recovery after t-PA therapy

BACKGROUND AND PURPOSE

The present study investigated the relationship between serial changes in ischemic lesion volume (ILV) and neurological recovery after t-PA therapy.

METHODS

A total of 110 consecutive patients with ICA and MCA occlusion on MRA treated with t-PA within 3 h of onset were prospectively studied. MRI including MRA, DWI, and FLAIR, was performed before, 1 h, 24 h, and 7 days after t-PA infusion to measure serial changes in ILV.

RESULTS

The mean (SD) values of ILV at baseline, 1 h, 24 h, and 7 days after t-PA infusion were 30.2 (61.0), 48.1 (76.3), 98.3 (125.3), and 125.9 (149.8) cm(3), respectively. Recovery at 7 days was remarkable in 46 patients and good in 21 patients. Change in NIHSS score (baseline NIHSS minus NIHSS at 7 days) correlated with ΔILV (ILV at 7 days minus baseline ILV) (r=0.611, P<0.0001). Sensitivity and specificity curve analysis demonstrated that a cutoff value for ΔILV of 40 cm(3) (sensitivity, 80.0%; specificity, 79.3%) indicated remarkable recovery, and that 80 cm(3) (78.8% and 76.3%) indicated good recovery.

CONCLUSION

The thresholds of ΔILV enlargement for remarkable and good recovery after t-PA therapy were 40 and 80 cm(3), respectively.

Fibrinolysis and Beyond: Bridging the Gap between Local and Systemic Clot Removal

Recanalization methods in ischemic stroke have been progressively expanded over the past years. In addition the continuous development of specialized mechanical devices for thrombectomy a broad spectrum of new drugs has been tested: Both options, novel drugs as well as new devices, can be employed independently of each other, but in most cases a combination of the two with the standard treatment of intravenous fibrinolysis is applied. Until recently, a large number of case series have been performed to investigate the effects of various drugs and interventions, but only a few trials have been conducted to determine the optimal conditions for combining both procedures. This review surveys the different systemic and endovascular vessel reopening practices and their major bridging techniques.

Intravenous thrombolysis based on diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch in acute stroke patients with unknown onset time

BACKGROUND AND PURPOSE

Patients with unknown onset time would be able to receive intravenous thrombolysis when showing diffusion-weighted imaging (DWI)/fluid-attenuated inversion recovery (FLAIR) mismatch.

METHODS

Consecutive acute stroke patients with unknown onset time were prospectively enrolled. We defined patients as having unknown onset time when the last known normal time (LNT) was not consistent with the first found abnormal time (FAT). Only patients with anterior-circulation stroke and presence of arterial lesion were enrolled. Intravenous thrombolysis was conducted within 3 h from FAT if the patient showed DWI/FLAIR mismatch.

RESULTS

From June 2009 to May 2010, 10 patients [median age, 84 years (interquartile range, IQR, 64-90); National Institutes of Health Stroke Scale (NIHSS) score, 14 (IQR, 9-19)] were enrolled. Subjects included 4 patients who developed stroke during sleep, 5 with disturbance of consciousness, and 1 with aphasia. Median interval between LNT and thrombolysis was 5.6 h (IQR, 4.5-9.8) and median interval between FAT and thrombolysis was 2.5 h (IQR, 2.1-2.8). Three patients had internal carotid artery occlusion, 5 had M1 occlusion, and 2 had M2 occlusion. Early recanalization within 24 h was seen in 7 patients (complete recanalization, n = 4; partial recanalization, n = 3). No patients experienced symptomatic cerebral hemorrhage within 48 h. At day 7, 5 patients showed dramatic recovery (defined as ≥ 10-point reduction in total NIHSS score or score of 0 or 1). At 3 months, favorable outcome (modified Rankin scale score, 0-2) was seen in 4 patients.

CONCLUSION

Acute stroke patients with DWI/FLAIR mismatch may be able to safely receive intravenous thrombolysis.

MR imaging-based localized intra-arterial thrombolysis assisted by mechanical clot disruption for acute ischemic stroke due to middle cerebral artery occlusion

BACKGROUND AND PURPOSE

LIT-MCD is used in our institution for acute stroke due to MCA occlusion, with the goal of reducing symptomatic intracranial hemorrhage by maintaining recanalization of the occluded vessels. The purpose of the study was to investigate the safety and efficacy of LIT-MCD and to identify factors associated with a poor outcome in patients undergoing this procedure.

MATERIALS AND METHODS

LIT-MCD for MCA occlusion was performed in 90 of 1907 consecutive patients with acute stroke admitted to our institution. Radiographic data and clinical outcome were evaluated in the 90 patients, and factors predictive of a poor outcome (3-month mRS score, 3-6) were investigated by multivariate analysis.

RESULTS

Recanalization was achieved in 73 of the 90 patients (81%); symptomatic intracranial hemorrhage occurred in 7 (8%); procedure-related complications, in 9 (10%); and a favorable clinical outcome (3-month mRS score, 0-2), in 48 (53%). A high baseline NIHSS score (≥20), a low preprocedural ASPECTS on MR imaging (≤7), proximal M1 occlusion (in the horizontal segment of the MCA at or proximal to the lenticulostriate arteries), and no recanalization were significant predictors of a poor clinical outcome.

CONCLUSIONS

LIT-MCD is a safe and effective treatment for acute stroke due to MCA occlusion. However, further intervention is needed to improve the outcome of patients with proximal M1 occlusion.

Effective intravenous thrombolytic therapy in a patient with cerebral infarction associated with left atrial myxoma

A 70-year-old man presented with sudden onset of global aphasia and right hemiplegia. Brain MRI revealed occlusion of the left middle cerebral artery. He was diagnosed as having a hyperacute cerebral infarction. Intravenous thrombolytic therapy was started, and the neurological symptoms were resolved after 11 h. Echocardiography showed a mobile mass in the left atrium, suspicious of a myxoma. The tumor was resected and pathologically diagnosed as a myxoma. In this patient, intravenous thrombolytic therapy was effective, and no adverse effects were observed. This suggests that, even with complications of myxoma, thrombolytic therapy can be considered if there are no contraindications.

Stroke fast track reduces time delay to neuroimaging and increases use of thrombolysis in an academic medical center in Thailand

Delays between hospital arrival and neuroimaging prevented patients from receiving thrombolysis. We report impact of Stroke Fast Track (SFT) on time to imaging, and rates of recombinant tissue plasminogen activator (rt-PA) in eligible patients. Characteristics, time intervals, and rates of rt-PA were evaluated in 464 patients with suspected acute stroke within 7 days (2005-2006). Complete time intervals were available on 380. Median times between emergency room arrival, brain computerized tomography (CT), and CT results were 25 and 45 minutes, respectively, for patients arriving <3 hours from onset, 40, and 65 minutes for those arriving >3 hours, and 35 and 60 minutes for all patients, which is significantly shorter than 2.5 hours to CT in 2004, prior to SFT (P < .0001). Although not different in time to first physician, patients arriving >3 hours had longer times to CT and CT results (P < .001). Overall, 5.5% of ischemic stroke patients received intravenous rt-PA, including 27.1% of those arriving within 3 hours, which represented 100% of all eligible patients, compared with 0% in 2004. SFT reduced time delay in neuroimaging and increased use of rt-PA in Thailand. Continuous quality improvement is needed to achieve best results in each setting, and to insure optimal care for acute stroke patients.

Residual vessel length on magnetic resonance angiography identifies poor responders to alteplase in acute middle cerebral artery occlusion patients: exploratory analysis of the Japan Alteplase Clinical Trial II

BACKGROUND AND PURPOSE

It remains unknown whether the effects of 0.6 mg/kg alteplase differ with occlusion site of the middle cerebral artery (MCA). We therefore evaluated the effects of 0.6 mg/kg intravenous alteplase in patients with different sites of MCA occlusion.

METHODS

An exploratory analysis was made of 57 patients enrolled in the Japan Alteplase Clinical Trial II (J-ACT II), originally designed to evaluate 0.6 mg/kg alteplase in Japanese patients with unilateral occlusion of the MCA (M1 or M2 portion). The residual vessel length (in mm), determined by pretreatment magnetic resonance angiography, was used to reflect the occluded site. The proportions of patients with valid recanalization (modified Mori grade 2 to 3) at 6 and 24 hours and a modified Rankin Scale (mRS) score of 0 to 1 and of 0 to 2 at 3 months were compared between the groups dichotomized according to length of the residual vessel. Multiple logistic-regression models were generated to elucidate the predictors of valid recanalization, mRS 0 to 1, and mRS 0 to 2.

RESULTS

Receiver operating characteristics analysis revealed that 5 mm was the practical cutoff length for dichotomization. In patients with an M1 length < 5 mm (n = 12), the frequencies of valid recanalization at 6 and 24 hours (16.7% and 25.0%) were significantly lower compared with those (62.1% and 82.8%, respectively) of the 45 patients with a residual M1 length ≥ 5 mm and an M2 occlusion (P = 0.008 for 6 hours, P < 0.001 for 24 hours). The proportions of patients who achieved an mRS of 0 to 1 and an mRS of 0 to 2 were also lower for those with an M1 length < 5 mm (8.3% and 16.7%, respectively) compared with the other group (57.8% and 68.9%, respectively; P = 0.003 for mRS 0 to 1, P = 0.002 for mRS 0 to 2). In logistic-regression models, the site of MCA occlusion (< 5 mm) was a significant predictor of valid recanalization at 6 and 24 hours and of an mRS of 0 to 1 and of mRS of 0 to 2.

CONCLUSIONS

In patients with acute MCA occlusion, a residual vessel length < 5 mm on magnetic resonance angiography can identify poor responders to 0.6 mg/kg alteplase. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412867.

Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry

Background— Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. The Taiwan Stroke Registry, with 30 599 stroke admissions between 2006 and 2008, was used to assess the applicability of GWTG-Stroke in Taiwan, which spends ≈1/10 of what the United States does in medical costs per new or recurrent stroke.

Methods and Results— Taiwan Stroke Registry, sponsored by the Taiwan Department of Health, engages 39 academic and community hospitals and covers the entire country with 4 steps of quality control to ensure the reliability of entered data. Five GWTG-Stroke performance measures and 1 safety indicator are applicable to assess Taiwan Stroke Registry quality of stroke care. Demographic and outcome figures are comparable between GWTG-Stroke and Taiwan Stroke Registry. Two indicators (early and discharge antithrombotics) are close to GWTG-Stroke standards, while 3 other indicators (intravenous tissue plasminogen activator, anticoagulation for atrial fibrillation, lipid-lowering medication) and 1 safety indicator fall behind. Preliminary analysis shows that compliance with selected GWTG-Stroke guidelines is associated with better outcomes.

Conclusions— Results suggest that GWTG-Stroke performance measures, with modification for ethnic factors, can become global standards across national and economic boundaries for assessing and improving quality of stroke care and outcomes. GWTG-Stroke can be incorporated into ongoing stroke registries across nations.

Strokes with minor symptoms: an exploratory analysis of the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials

BACKGROUND AND PURPOSE

The pivotal National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator trials excluded patients with ischemic stroke with specific minor presentations or rapidly improving symptoms. The recombinant tissue plasminogen activator product label notes that its use for minor neurological deficit or rapidly improving stroke symptoms has not been evaluated. As a result, patients with low National Institutes of Health Stroke Scale scores are not commonly treated in clinical practice. We sought to further characterize the patients with minor stroke who were included in the National Institute of Neurological Disorders and Stroke trials.

METHODS

Minor strokes were defined as National Institutes of Health Stroke Scale score ≤ 5 at baseline for this retrospective analysis, because this subgroup is most commonly excluded from treatment in clinical practice and trials. Clinical stroke syndromes were defined based on prespecified National Institutes of Health Stroke Scale item score clusters. Clinical outcomes were reviewed generally and within these cluster subgroups.

RESULTS

Only 58 cases had National Institutes of Health Stroke Scale scores of 0 to 5 in the National Institute of Neurological Disorders and Stroke trials (42 recombinant tissue plasminogen activator and 16 placebo), and 2971 patients were excluded from the trials due to "rapidly improving" or "minor symptoms" as the primary reason. No patients were enrolled with isolated motor symptoms, isolated facial droop, isolated ataxia, dysarthria, isolated sensory symptoms, or with only symptoms/signs not captured by the National Institutes of Health Stroke Scale score (ie, National Institutes of Health Stroke Scale=0). There were ≤ 3 patients with each of the other isolated deficits enrolled in the trial.

CONCLUSIONS

The National Institute of Neurological Disorders and Stroke trials excluded a substantial number of strokes with minor presentations, those that were included were small in number, and conclusions about outcomes based on specific syndromes cannot be drawn. Further prospective, systematic study of this subgroup is needed.

[TCD monitoring during intravenous administration of recombinant tissue plasminogen activator]

Our aim is to investigate the utility of transcranial Doppler (TCD) monitoring during intravenous administration of 0.6 mg/kg recombinant tissue plasminogen activator (IV rt-PA) which is governmental approved in Japan. Acute ischemic stroke patients with M1 portion of the middle cerebral artery (M1) occlusion treated with IV rt-PA were prospectively enrolled. M1 occlusion was diagnosed before IV rt-PA using magnetic resonance angiography (MRA). Patients without sufficient temporal window of TCD were excluded. TCD monitoring was conducted for 1 hour (h) during IV rt-PA. Recanalization on TCD was defined using thrombolysis in brain ischemia (TIBI) flow grades. After all patients were classified into two groups according to the presence of TCD recanalization (TCD recanalization and TCD non-recanalization group), three-month patients outcome, recanalization rate on MRA 1 h of IV rt-PA, and symptomatic cerebral hemorrhage within 24 h were compared between two groups. We enrolled 16 patients. Eight patients (50%, 7 men [88%]; age, 70 years [interquartile range. 55-81]; NIHSS score, 18 [12-22]) were in the TCD recanalization group and 8 (50%, 6 men [75%]; age, 72 years [62-79]; NIHSS score 19 [15-23] were in the TCD non-recanalization group. Symptomatic cerebral hemorrhage was not seen in both groups at all. MRA 1 h of IV rt-PA revealed recanalization in all 8 (100%) patients with TCD recanalization group and 2 (25%) with TCD non-recanalization group (agreement, 88%; and kappa value, 0.75, P = 0.002). At three months, 5 (63%) of 8 patients in the TCD recanalization group had favorable outcome, and 0 (0%) of 8 in the TCD non-recanalization group (P = 0.026). TCD monitoring for 1 h during IV rt-PA can diagnose the recanalization based on MRA. TCD monitoring should predict good clinical outcome at three months.

Thrombolysis with 0.6 mg/kg intravenous alteplase for acute ischemic stroke in routine clinical practice: the Japan post-Marketing Alteplase Registration Study (J-MARS)

BACKGROUND AND PURPOSE

In Japan, alteplase at 0.6 mg/kg was approved in October 2005 for use within 3 hours of stroke onset by the Ministry of Health, Labor and Welfare (MHLW). The aim of the Japan post-Marketing Alteplase Registration Study (J-MARS), which was requested by MHLW at the time of approval, was to assess the safety and efficacy of 0.6 mg/kg alteplase in routine clinical practice for the Japanese.

METHODS

A total of 7492 patients from 942 centers were enrolled in the J-MARS, an open-label, nonrandomized, observational study, from October 2005 to October 2007. Primary outcome measures were symptomatic intracranial hemorrhage (a deterioration in NIHSS score >or=4 from baseline) and favorable outcome (modified Rankin Scale score, 0-1) at 3 months after stroke onset.

RESULTS

The proportion of patients with symptomatic intracranial hemorrhage in 7492 patients (safety analysis) was 3.5% (95% confidence interval [CI], 3.1%-3.9%) within 36 hours and 4.4% (95% CI, 3.9%-4.9%) at 3 months. The overall mortality rate was 13.1% (95% CI, 12.4%-13.9%) and the proportion of patients with fatal symptomatic intracranial hemorrhage was 0.9% (95% CI, 0.7%-1.2%). The outcomes at 3 months were available for 4944 patients and the proportion of favorable outcome (efficacy analysis) was 33.1% (95% CI, 31.8%-34.4%). The subgroup analysis in patients between 18 and 80 years with a baseline NIHSS score <25 demonstrated that favorable outcome at 3 months was 39.0% (95% CI, 37.4%-40.6%).

CONCLUSIONS

These data suggest that 0.6 mg/kg intravenous alteplase within 3 hours of stroke onset could be safe and effective in routine clinical practice for the Japanese.

Early stroke treatment with IV t-PA associated with early recanalization

PURPOSE

Time from stroke onset to treatment (OTT) is potentially an important factor affecting subsequent outcome in patients treated with t-PA. The aim of the study was to assess the correlation between OTT and early recanalization rate after IV-t-PA therapy.

METHODS

Consecutive stroke patients treated with t-PA within 3h of onset were prospectively studied. Patients with major brain artery occlusion on MRA before t-PA infusion were enrolled. The correlation between OTT and the early recanalization rate within 1h after t-PA infusion was determined.

RESULTS

102 patients (M1 occlusion, 41 patients; M2, 19; ICA, 31; BA, 8; and PCA, 3) were enrolled. Follow-up MRA within 1h after t-PA infusion showed early recanalization in 42 (41.2%) patients (complete in 13 patients, partial in 29). The early recanalization rate was 53.8% with OTT <or=100 min, 57.1% in 101-110 min, 50.0% in 111-120 min, 63.6% in 121-130 min, 33.3% in 131-140 min, 30.0% in 141-150 min, 36.4% in 151-160 min, 18.2% in 161-170 min, and 32.0% in 171-180 min. OTT was negatively correlated with the early recanalization rate (r=-0.767, P=0.0301). After adjusting the presence of age (>74), ICA occlusion, baseline NIHSS score (<10), and glucose (>150 mg/dl), adjusted OR for early recanalization of OTT <or=130 min against OTT >130-180 min was 2.97 (95% CI 1.27-6.96, P=0.012).

CONCLUSION

Early recanalization depended on time from stroke onset to IV-t-PA administration. Thus, t-PA should be given to acute stroke patients as soon as possible.

Outcomes of thrombolytic therapy for acute ischemic stroke in Chinese patients: the Taiwan Thrombolytic Therapy for Acute Ischemic Stroke (TTT-AIS) study

BACKGROUND AND PURPOSE

The safety and efficacy of alteplase for ischemic stroke has not been examined in Chinese patients. We assessed the safety and efficacy of alteplase for acute ischemic stroke in daily clinical practice in Taiwan.

METHODS

A prospective, multicenter, observational study was conducted in Taiwan from December 2004 to July 2008. Eligible patients (241) receiving alteplase were recruited and divided into 2 groups: standard dose (0.90 + or - 0.02 mg/kg, n=125) and lower dose (0.72 + or - 0.07 mg/kg, n=116). Primary outcome measures were safety: symptomatic intracerebral hemorrhage and death within 3 months. The secondary outcome measure was efficacy a modified Rankin scale of 0 to 2 after 3 months.

RESULTS

The standard-dose group had higher rates of symptomatic intracerebral hemorrhage using National Institute of Neurological Diseases and Stroke, European Cooperative Acute Stroke Study, and Safe Implementation of Thrombolysis in Stroke-Monitoring Study definitions (10.4% versus 5.2%, 8.0% versus 2.6%, and 5.6% versus 1.7%, respectively) and mortality within 3 months (12.8% versus 6.9%), twice that of the lower-dose group. This pattern was more prominent in older patients. Significantly higher rates of symptomatic intracerebral hemorrhage per European Cooperative Acute Stroke Study (15.4% versus 3.3%, P=0.0257) and mortality (21.1% versus 5.0%, P=0.0099) and significantly lower independence rate (32.6% versus 53.6%, P=0.0311) were observed among patients > or = 70 years old receiving the standard dose than those receiving the lower dose.

CONCLUSIONS

This study suggests that the standard dose of 0.9 mg/kg alteplase may not be optimal for treating aged Chinese patients. However, the dose of recombinant tissue plasminogen activator for ischemic stroke in Chinese patients should be based on more broad and convincing evidences and randomized trials of lower versus higher doses are needed.

Extended superciliary approach for middle cerebral artery embolectomy after unsuccessful endovascular recanalization therapy: technical note

OBJECTIVE

Although an intra-arterial mechanical embolectomy extends the therapeutic time window for restoration of the cerebral blood flow, its suboptimal recanalization rate also necessitates a salvage procedure if the patient is still within the therapeutic time window. As such, a surgical embolectomy can be performed in a rapid and less invasive manner for an acute middle cerebral artery (MCA) occlusion. The technical details of this procedure are discussed and demonstrated.

METHODS

Four patients with an acute MCA occlusion were treated using a novel surgical embolectomy technique after unsuccessful intra-arterial mechanical recanalization therapy. Unique to the proposed surgical technique are a laterally extended superciliary approach, small (3-mm) arteriotomy, and closure of the arteriotomy using an aneurysm clip after removal of the intravascular embolus.

RESULTS

Occluded MCAs were successfully recanalized using the present technique, and the operative time from skin incision to recanalization was 1 to 1.5 hours in each patient. One to 3 arteriotomies were made in each patient. Six of the 8 arteriotomies in the present series were closed using an aneurysm clip, whereas the other 2 arteriotomies were repaired using microsutures. Postoperative angiograms demonstrated patent MCAs without remarkable clip-induced stenosis. The successful recanalization provided considerable neurological improvement in all patients without procedural complications, except for 1 patient with a fatal putaminal hemorrhage resulting from a reperfusion injury.

CONCLUSION

A laterally extended superciliary approach and clip application for arteriotomy closure enable a surgical embolectomy to become a rapid and less invasive procedure.

Effects of 0.6 mg/kg intravenous alteplase on vascular and clinical outcomes in middle cerebral artery occlusion: Japan Alteplase Clinical Trial II (J-ACT II)

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate further the efficacy of 0.6 mg/kg intravenous alteplase on vascular and clinical outcomes in patients with middle cerebral artery occlusion in a postmarketing Phase IV trial of prospective cohort study design.

METHODS

Alteplase was given intravenously at 0.6 mg/kg to patients with ischemic stroke within 3 hours of onset with MR angiography-documented middle cerebral artery occlusion. Vascular outcome was evaluated by MR angiography at 6 and 24 hours after symptom onset based on the modified Mori grade. The primary end points also included a favorable outcome (modified Rankin Scale 0 to 1 at 3 months after onset) and incidence of symptomatic intracranial hemorrhage within 36 hours after treatment. The impact of recanalization on clinical outcome was assessed by stepwise logistic regression analysis.

RESULTS

Fifty-eight patients were enrolled. Recanalization was noted in 51.7% on 6-hour MR angiography and 69.0% on 24-hour MR angiography. A favorable clinical outcome was achieved in 46.6%. None had symptomatic intracranial hemorrhage. In logistic regression models, recanalization on either 6-hour or 24-hour MR angiography was an independent predictor for clinical outcome as well as the baseline National Institutes of Health Stroke Scale score.

CONCLUSIONS

Early recanalization of an occluded middle cerebral artery can be provoked by 0.6 mg/kg intravenous alteplase and may induce a favorable clinical outcome. The rates of recanalization and favorable outcome are comparable to that previously reported with the 0.9-mg/kg dose.

Hyper-acute stroke patients associated with aortic dissection

BACKGROUND AND PURPOSE

Intravenous thrombolysis using tissue plasminogen activator (tPA) can improve patient outcomes in acute stroke if administered within 3 hours of onset. However, patients with aortic dissection should avoid tPA therapy due to the possibility of tPA administration inducing rupture of the aortic dissection. We studied the frequency and clinical characteristics of stroke patients presenting with aortic dissection within 3 hours of onset.

METHODS

Among stroke patients admitted to our hospital within 3 hours of onset, we examined the frequency of patients presenting with aortic dissection. Next, we examined the clinical characteristics of such patients, including cases published on PubMed.

RESULTS

Among 208 stroke patients presenting within 3 hours of onset, 2 patients (1%) displayed aortic dissection. Carotid duplex ultrasonography could exclude them from tPA therapy. For 19 patients, including 17 published cases from PubMed, median age was 61.0 years, 47% were women, right pulse weakness was seen in 70%, chest pain in 22%, and lone left hemiparesis in 72%. In 6 patients, carotid ultrasonography showed arterial dissection due to aortic dissection.

CONCLUSION

Aortic dissection may not be a rare complication in acute stroke within 3 hours of onset. Right pulse weakness and left hemiparesis are often present. Carotid ultrasonography may be useful in diagnosing aortic dissection before tPA infusion.