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Yeo LLL, Kong WY, Paliwal P, Teoh HL, Seet RC, Soon D, Rathakrishnan R, Ong V, Lee TH, Wong HF, Chan BPL, Leow WK, Yuan C, Ting E, Gopinathan A, Tan BYQ, Sharma VK. Intravenous Thrombolysis for Acute Ischemic Stroke due to Cervical Internal Carotid Artery Occlusion. J Stroke Cerebrovasc Dis 2016; 25:2423-9. [PMID: 27344361 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/15/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Internal carotid artery (ICA) occlusions are poorly responsive to intravenous thrombolysis with tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). Most study populations have combined intracranial and extracranial ICA occlusions for analysis; few have studied purely cervical ICA occlusions. We evaluated AIS patients with acute cervical ICA occlusion treated with IV-tPA to identify predictors of outcomes. METHODS We studied 550 consecutive patients with AIS who received IV-tPA and identified 100 with pure acute cervical ICA occlusion. We evaluated the associations of vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and leptomeningeal collateral vessel status via 3 different grading systems, with functional recovery at 90 days, mortality, recanalization of the primary occlusion, and symptomatic intracranial hemorrhage (SICH). Modified Rankin Scale score 0-1 was defined as an excellent outcome. RESULTS The 100 patients had mean age of 67.8 (range 32-96) and median NIHSS score of 19 (range 4-33). Excellent outcomes were observed in 27% of the patients, SICH in 8%, and mortality in 21%. Up to 54% of the patients achieved recanalization at 24 hours. On ordinal regression, good collaterals showed a significant shift in favorable outcomes by Maas, Tan, or ASPECTS collateral grading systems. On multivariate analysis, good collaterals also showed reduced mortality (OR .721, 95% CI .588-.888, P = .002) and a trend to less SICH (OR .81, 95% CI .65-1.007, P = .058). Interestingly, faster treatment was also associated with favorable functional recovery (OR 1.028 per minute, 95% CI 1.010-1.047, P = .001). CONCLUSIONS Improved outcomes are seen in patients with early acute cervical ICA occlusion and better collateral circulation. This could be a valuable biomarker for decision making.
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Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore.
| | - Wan Yee Kong
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Prakash Paliwal
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Hock L Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Raymond C Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Derek Soon
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Rahul Rathakrishnan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Venetia Ong
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine and School of Medical Technology, Chang Gung University, Taoyuan, Taiwan
| | - Ho-Fai Wong
- College of Medicine and School of Medical Technology, Chang Gung University, Taoyuan, Taiwan; Division of Neuroradiology, Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Wee Kheng Leow
- Department of Computer Science, National University of Singapore, Singapore
| | - Cheng Yuan
- Department of Computer Science, National University of Singapore, Singapore
| | - Eric Ting
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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