Neurology -- Correspondence for Georgiadis et al., 63 (1) 22-26

Correspondence published:

Reply to Samson: Dimitrios Georgiadis, S. Schwarz, S. Schwab (21 January 2005)

Does acute occlusion of the carotid T invariably have a poor outcome?: Yves SAMSON, Sophie Crozier, Sandrine Deltour, Michael Obadia, Marie Bruandet and Anne Leger (27 December 2004)

Reply to Samson 21 January 2005

Dimitrios Georgiadis,
Department of Neurology, University of Zürich,
Frauenklinikstr. 26, 8091 Zürich, Switzerland,
S. Schwarz, S. Schwab
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Re: Reply to Samson

dg_de{at}yahoo.com Dimitrios Georgiadis, et al.

<P>We thank Dr. Samson for his letter concerning our article. The presented results together with those of our study, confirm that IV thrombolysis is a safe treatment in acute stroke patients with carotid-T occlusions, as symptomatic intracerebral hemorrhage was only observed in 2/72 cases.
<P>Although recanalization rate was higher in our study (66% versus 42%), outcome was worse (mRS 0-3 in 22% versus 74%). This marked difference could be due to age differences between the two groups, as noted by Dr. Samson. We concur that the presented results add weight to the hypothesis that IV thrombolysis should not be withheld in acute stroke patients with carotid T occlusion, although more potent therapeutic approach would certainly be needed in this specific patient group.

Does acute occlusion of the carotid T invariably have a poor outcome? 27 December 2004

Yves SAMSON,
Service Urgences Cérébrovasculaires
Hôpital Salpêtrière, 47-48 Bd de l'hôpital, 75013 PARIS, FRANCE,
Sophie Crozier, Sandrine Deltour, Michael Obadia, Marie Bruandet and Anne Leger
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Re: Does acute occlusion of the carotid T invariably have a poor outcome?

yves.samson{at}psl.ap-hop-paris.fr Yves SAMSON, et al.

Georgiadis et al [1] report that carotid T occlusion may have a better clinical outcome than previously thought, especially after IV thrombolysis. [2,3] In their series of 42 consecutive patients, 17% achieved Rankin's score 2 six months post -stroke and mortality rate was only 31 %. Furthermore, complete or partial middle cerebral artery (MCA) recanalization was observed in 12 of the 18 thrombolyzed patients. This is interesting because intracranial carotid occlusion is often considered as a contra-indication of IV and even IA thrombolysis because of very low recanalization rate.
The results obtained in our stroke center confirm and extend their findings. In a consecutive series of 100 patients treated with rTPA IV within a 5-hour time period [4], 30 had intra-cranial carotid occlusion as assessed by pre-thrombolysis MR (19 with T occlusion and 11 with intra- cavernous carotid and ipsilateral MCA occlusions). Three of them were subsequently treated by hemicraniectomy. Median NIHSS was 18,5 (range 7- 30), and 20 (range 7-30) in the T occlusion subgroup. At three months, 20% had Rankin's score 1, 70% Rankin 0-3, and mortality rate was only 10%. The percentages were respectively 16, 74 and 16% in the T occlusion subgroup. Complete MCA recanalization was documented on a 24-48 hours MRA control in 43% of the 30 patients and 42% of the T occlusion subgroup.
Surprisingly, none of the patients developed symptomatic hemorrhage. Thus outcome was even better than in Georgiadis report, perhaps because our patients were younger: 49 (44 to 54) versus 66 (56 to 74) years (median [interquartile range]). Both reports suggest that intra-cranial carotid occlusion should not be considered as a contra-indication to IV thrombolysis, although we obviously need new therapeutic approach since MCA recanalization is only achieved in less than half of the patients.
References
1) Georgiadis D, Oehler J, Schwarz S, Rousson V, Hartmann M, Schwab S. Does acute occlusion of the carotid T invariably have a poor outcome? Neurology, 2004; 63: 22-26.
2) Bogousslavsky J, Regli F. Prognosis of symptomatic intracranial obstruction of internal carotid artery. Eur Neurol 1983;22:351-358.
3) Jansen O, von Kummer R, Forsting M, Hacke W, Sartor K. Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol 1995;16:1977-1986.
4) Crozier S, Deltour S, Bruandet M, et al. Routine use of MRI before intravenous thrombolysis in a 5 hours time-window: initial experience in 100 patients with middle cerebral artery infarct. Neurology 2004, Suppl.5, 62: A537, S64.005.