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rtPA intravenous thrombolysis in anterior choroidal artery territory stroke

From the Cerebrovascular Unit and Ataxia Research Center (Drs. Trouillas, Derex, Nighoghossian, Honnorat, Riche, Neuschwander, Getenet, and Li) and the Department of Neuroradiology (Drs. Berthezene, Turjman, and Froment), Hôpital Neurologique, Lyon, France.

Address correspondence and reprint requests to Dr. Paul Trouillas, Unité Cérébrovasculaire et Centre de Recherches sur l’Ataxie, Hôpital Neurologique, 59 Boulevard Pinel, 69003 Lyon, France.

OBJECTIVE: To study the possible specific response to recombinant tissue plasminogen activator (rtPA) thrombolysis of anterior choroidal artery (AChA) stroke.

BACKGROUND: Outcome and response after rtPA thrombolysis are possibly better in small-vessel infarcts, but a specific study of AChA stroke has not yet been performed.

METHODS: The authors proposed an open trial of IV rtPA within 7 hours in patients age 20 and 81 years with all types of internal carotid artery territory stroke if the baseline Scandinavian Stroke Scale (SSS) score was less than 48. A dose of rtPA 0.8 mg/kg was infused over 90 minutes. Of 114 consecutive patients, 9 patients (7.9%) exhibited hypodensity in the AChA territory on day 1 brain CT.

RESULTS: Seven of nine patients with AChA infarct had a primary early recovery within 6 hours after the initiation of rtPA infusion. In addition, recovery was complete in five patients and partial in two patients. No intracerebral hematoma was observed. Three patients had a "reinfarct syndrome" at 12, 25, and 48 hours respectively. However, in the two latter patients treated with IV heparin, the deficit disappeared again with the increase of heparin dose in one patient and disappeared spontaneously in the other patient. The overall outcome at day 90 was six total recoveries in nine patients (66%). Patients with a final good outcome had a slight "unstructured" hypodensity in the AChA territory on day 1 brain CT, whereas patients with a bad outcome had the classic "structured" hypodensity of AChA territory stroke.

CONCLUSION: These data support a specific quick response of AChA territory stroke to IV rtPA thrombolysis, probably due to the small size of the artery and of the "clot." The high frequency of the reinfarct syndrome is a clinical fact that is difficult to explain. Efficient heparin treatment after 24 hours may control the reinfarct syndrome in some patients.

Key words: Recombinant tissue plasminogen activator—Intravenous—Choroidal artery—Reinfarct

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