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Abstract

Background

Intravenous administration of recombinant tissue plasminogen activator (rtPA) is approved treatment for acute ischemic stroke <3 h of symptom onset.

Purpose

To determine the impact of the timing and degree of recanalization on clinical outcome after rtPA infusion in patients.

Material and Methods

Seventy-five patients with ischemic stroke in the middle cerebral artery territory treated with intravenous rtPA within 3 h were studied consecutively. Magnetic resonance imaging (MRI), including magnetic resonance angiography (MRA), before, 6 h, and 24 h after thrombolytic therapy was undertaken. Depending on the MRA results acquired 6 h after rtPA infusion, recanalization was graded as: early recanalization (ER), delayed recanalization (DR), and no recanalization (NR). Clinical outcome was assessed using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS).

Results

Of patients in the ER, DR and NR groups, 71.4% (15/21), 13.3% (2/15), and 30.7% (12/39), respectively, showed dramatic improvement in NIHSS score 7 days after rtPA administration compared with those scores upon hospital admission. The 6-h and 24-h NIHSS scores and 3-month mRS scores of ER patients were significantly lower than those of the other two groups (P < 0.05). The 24-h, 7-d NHISS and mRS scores of DR patients were significantly higher than NR patients (P = 0.001, 0.002, 0.049, respectively). Three patients in the DR group died during follow-up.

Conclusion

These data suggest that DR is associated with clinical deterioration. Patients treated with rtPA thrombolysis should be under close observation for 6–24 h. Corresponding treatment should be considered once DR appears.

Keywords

Ischemic stroke modified Rankin Scale National Institutes of Health Stroke Scale recanalization timing recombinant tissue plasminogen activator

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References

Zangerle

Kiechl

Spiegel

. Recanalization after thrombolysis in stroke patients: predictors and prognostic implications. Neurology 2007; 68: 39–44.

del Zoppo

Poeck

Pessin

. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol 1992; 32: 78–86.

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333: 1581–1587.

Neumann-Haefelin

du Mesnil de Rochemont

Fiebach

. Effect of incomplete (spontaneous and postthrombolytic) recanalization after middle cerebral artery occlusion: a magnetic resonance imaging study. Stroke 2004; 35: 109–114.

Pfefferkorn

Rosenberg

. Closure of the blood-brain barrier by matrix metalloproteinase inhibition reduces rtPA-mediated mortality in cerebral ischemia with delayed reperfusion. Stroke 2003; 34: 2025–2030.

Adams

Jr Davis

Leira

. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53: 126–131.

Kimura

Iguchi

Shibazaki

. Hemorrhagic transformation of ischemic brain tissue after t-PA thrombolysis as detected by MRI may be asymptomatic, but impair neurological recovery. J Neurol Sci 2008; 272: 136–142.

Wang

Wei

. An investigation of age-related iron deposition using susceptibility weighted imaging. PLoS One 2012; 7: e50706–e50706.

Nambiar

Sohn

Almekhlafi

. CTA collateral status and response to recanalization in patients with acute ischemic stroke. Am J Neuroradiol 2014; 35: 884–890.

10.

Molina

Montaner

Abilleira

. Timing of spontaneous recanalization and risk of hemorrhagic transformation in acute cardioembolic stroke. Stroke 2001; 32: 1079–1084.

11.

Yamaguchi

Mori

Minematsu

. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan alteplase clinical trial (J-ACT). Stroke 2006; 37: 1810–1815.

12.

Molina

Montaner

Abilleira

. Time course of tissue plasminogen activator-induced recanalization in acute cardioembolic stroke: a case-control study. Stroke 2001; 32: 2821–2827.

13.

Humpich

Singer

du Mesnil de Rochemont

. Effect of early and delayed recanalization on infarct pattern in proximal middle cerebral artery occlusion. Cerebrovasc Dis 2006; 22: 51–56.

14.

Wunderlich

Goertler

Postert

. Recanalization after intravenous thrombolysis: does a recanalization time window exist? Neurology 2007; 68: 1364–1368.

15.

Gralla

Burkhardt

Schroth

. Occlusion length is a crucial determinant of efficiency and complication rate in thrombectomy for acute ischemic stroke. AJNR Am J Neuroradiol 2008; 29: 247–252.

16.

Röther

Schellinger

Gass

. Effect of intravenous thrombolysis on MRI parameters and functional outcome in acute stroke <6 hours. Stroke 2002; 33: 2438–2445.

17.

Kassem-Moussa

Graffagnino

. Nonocclusion and spontaneous recanalization rates in acute ischemic stroke: a review of cerebral angiography studies. Arch Neurol 2002; 59: 1870–1873.

18.

Fassbender

Dempfle

Mielke

. Changes in coagulation and fibrinolysis markers in acute ischemic stroke treated with recombinant tissue plasminogen activator. Stroke 1999; 30: 2101–2104.

19.

Benchenane

Berezowski

Fernandez-Monreal

. Oxygen glucose deprivation switches the transport of tPA across the blood brain barrier from an LRP-dependent to an increased LRP-independent process. Stroke 2005; 36: 1065–1070.

20.

Sumii

. Involvement of matrix metalloproteinase in thrombolysis-associated hemorrhagic transformation after embolic focal ischemia in rats. Stroke 2002; 33: 831–836.

21.

Hallenbeck

Dutka

. Background review and current concepts of reperfusion injury. Arch Neurol 1990; 47: 1245–1254.

22.

Latour

Kang

Ezzeddine

. Early blood-brain barrier disruption in human focal brain ischemia. Ann Neurol 2004; 56: 468–477.

23.

Kaur

Zhao

Klein

. The neurotoxicity of tissue plasminogen activator? J Cereb Blood Flow Metab 2004; 24: 945–963.

24.