Original Research Intravenous Thrombolysis Outcomes in Patients Presenting with Large Vessel Acute Ischemic Strokes—CT Angiography-Based Prognosis Ansaar Rai, MD, Brendan Cline, MS, Eric Williams, MS, Jeffrey Carpenter, MD, Thomas Roberts, MD From the Radiology & Neurology, West Virginia University, Morgantown, WV (AR); and Neuroradiology, West Virginia University, Morgantown, WV (BC, EW, JC, TR).

ABSTRACT BACKGROUND AND PURPOSE

Keywords: Stroke, thrombolysis, CTA.

To establish outcome rates for patients receiving intravenous thrombolysis based on vascular occlusion site. METHODS

This is a retrospective analysis of 225 patients who had received intravenous-rt-PA for anterior circulation strokes. The occlusion-site was prospectively determined on the admission computed tomographic angiography (CTA) and divided into: large vessel occlusion (LVO) including patients with an internal carotid artery terminus or middle cerebral artery (M1/proximal M2) occlusions and no large vessel occlusion (No-LVO; distal M2/M3/ACA) including patients with either distal or no occlusions. The primary outcome was the modified Rankin score (mRS) at 90-days with a good outcome defined by mRS of 0-2.000. RESULTS

There were 114 (50.7%) patients in the LVO and 111 (49.3%) in the No-LVO group. A good outcome was seen in 28 (24.6%) patients in the LVO and 77 (69.4%) patients in the No-LVO group (OR .14; 95% CI: .08-.26; P < .0001). Mortality was observed in 13 (11.7%) patients in the No-LVO group and 48 (42.1%) patients in the LVO group (OR .18; 95% CI: .09-.36; P < .0001). Significant hemorrhage was seen in 14 (12.5%) patients in the LVO and 0 (0%) patients in the No-LVO group (P < .0001). Older age (OR .96; 95% CI: .93-.98; P = .002) and presence of LVO (OR .29; 95% CI: .12-.68; P = .004) were significant independent predictors of poor outcome.

Acceptance: Received October 17, 2013, and in revised form January 29, 2014. Accepted for publication March 2, 2014. Correspondence: Address correspondence to Ansaar Rai, Radiology & Neurology, West Virginia University, Morgantown, WV. E-mail: ansaar.rai@ gmail.com. Conflicts of Interest: The authors report no conflicts of interest. J Neuroimaging 2015;25:238-242. DOI: 10.1111/jon.12126

CONCLUSION

CTA identification of proximal occlusions is associated with significantly poor outcomes in patients receiving intravenous stroke thrombolysis.

Introduction IV rt-PA constitutes the mainstay of therapy for patients presenting with acute ischemic stroke (AIS). A benefit of intravenous (IV) thrombolysis has already been demonstrated in clinical trials.1,2 The randomized clinical trials however did not evaluate the efficacy of rt-PA based on the site of cerebral vascular occlusion. Large vessel strokes constitute almost half of the AIS cases3 and are a significant source of morbidity and mortality.3–6 A higher clot burden associated with these large vessel occlusions (LVO) portends a poor outcome7 and as such the more proximal the intracranial vascular occlusion, the lower the efficacy of IV thrombolysis.4,7–10 Before contemplating a prospective comparison between IV rt-PA and endovascular therapy, establishing baseline outcomes for IV rt-PA based on vessel occlusion site is important.

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Methodology Patient Selection The institutional review board’s approval was obtained for this retrospective analysis. Patients who had received IV thrombolysis for AIS were identified from a prospectively maintained database. A total of 310 patients received IV rt-PA, Alteplase R , Genentech Inc., San Francisco, CA) over a 10(Activase year period. Patients had undergone a baseline computed tomographic angiography (CTA) study as part of their workup in addition to the standard noncontrast head CT. The decision to administer IV rt-PA was not based on the CTA. The occlusion site was determined on the baseline CTA as described in the next section. Patients who had undergone endovascular therapy in addition to the IV rt-PA (n = 25) and/or had a vertebro-basilar occlusion (n = 24) were excluded. There were

◦ 2014 by the American Society of Neuroimaging C

Table 1. Comparison of Age, NIHSS, and Comorbidities between the Two Groups

Age NIHSS DM HTN AFIB Smoking HPL

LVO

No-LVO

P

75.2 ± 13.2 15.9 ± 7.5 23 (25%) 78 (84.8%) 40 (43.5%) 25(36.2%) 40 (25.5%)

64.2 ± 17 7.3 ± 5 18 (28.1%) 47 (73.4%) 8 (12.5%) 15(23.8%) 25 (39.1%)

Intravenous thrombolysis outcomes in patients presenting with large vessel acute ischemic strokes--CT angiography-based prognosis.

To establish outcome rates for patients receiving intravenous thrombolysis based on vascular occlusion site...
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