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September 28, 2009

Good clinical outcome after ischemic stroke with successful revascularization is time-dependent

September 29, 2009 issue
73 (13) 1066-1072

Abstract

Background: Trials of IV recombinant tissue plasminogen activator (rt-PA) have demonstrated that longer times from ischemic stroke symptom onset to initiation of treatment are associated with progressively lower likelihoods of clinical benefit, and likely no benefit beyond 4.5 hours. How the timing of IV rt-PA initiation relates to timing of restoration of blood flow has been unclear. An understanding of the relationship between timing of angiographic reperfusion and clinical outcome is needed to establish time parameters for intraarterial (IA) therapies.
Methods: The Interventional Management of Stroke pilot trials tested combined IV/IA therapy for moderate-to-severe ischemic strokes within 3 hours from symptom onset. To isolate the effect of time to angiographic reperfusion on clinical outcome, we analyzed only middle cerebral artery and distal internal carotid artery occlusions with successful reperfusion (Thrombolysis in Cerebral Infarction 2–3) during the interventional procedure (<7 hours). Time to angiographic reperfusion was defined as time from stroke onset to procedure termination. Good clinical outcome was defined as modified Rankin Score 0–2 at 3 months.
Results: Among the 54 cases, only time to angiographic reperfusion and age independently predicted good clinical outcome after angiographic reperfusion. The probability of good clinical outcome decreased as time to angiographic reperfusion increased (unadjusted p = 0.02, adjusted p = 0.01) and approached that of cases without angiographic reperfusion within 7 hours.
Conclusions: We provide evidence that good clinical outcome following angiographically successful reperfusion is significantly time-dependent. At later times, angiographic reperfusion may be associated with a poor risk–benefit ratio in unselected patients.

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Information & Authors

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Published In

Neurology®
Volume 73Number 13September 29, 2009
Pages: 1066-1072
PubMed: 19786699

Publication History

Published online: September 28, 2009
Published in print: September 29, 2009

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Authors

Affiliations & Disclosures

P. Khatri, MD
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.
T. Abruzzo, MD
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.
S. D. Yeatts, PhD
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.
C. Nichols, MD
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.
J. P. Broderick, MD
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.
T. A. Tomsick, MD
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.
For the IMS I and II Investigators
From the University of Cincinnati (P.K., T.A., C.N., J.P.B., T.A.T.), OH; and Medical University of South Carolina (S.D.Y.), Charleston.

Notes

Address correspondence and reprint requests to Dr. Pooja Khatri, Department of Neurology, University of Cincinnati Academic Health Center, 260 Stetson St., Ste 2308, PO Box 670525, Cincinnati, OH 45267-0525 [email protected]

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