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September 24, 2002

Arterial reocclusion in stroke patients treated with intravenous tissue plasminogen activator

September 24, 2002 issue
59 (6) 862-867


Background: Arterial reocclusion has not been systematically studied despite the fact that 13% of patients in the National Institute of Neurological Diseases and Stroke rt-PA Trial deteriorated following initial improvement, suggesting that reocclusion might be responsible for poor clinical outcome in some of these patients.
Methods: Consecutive stroke patients treated with IV tissue plasminogen activator (TPA) within 3 hours and an M1 or M2 middle cerebral artery (MCA) occlusion on pre-TPA transcranial Doppler (TCD) were monitored up to 2 hours after TPA bolus. Reocclusion was defined as the Thrombolysis in Brain Ischemia flow decrease by ≥1 grades and no hemorrhage on repeat CT. The NIH Stroke Scale (NIHSS) and modified Rankin Scores (mRS) were obtained by a neurologist independently of TCD.
Results: Sixty patients with median prebolus NIHSS score of 16 (range 6 to 28, 90% with ≥10 points) had TPA bolus at 130 ± 32 minutes (median 120 minutes, 58% within the first 2 hours). Recanalization was complete in 18 (30%), partial in 29 (48%), and none in 13 (22%) patients. Reocclusion occurred in 34% of patients with any initial recanalization (16/47): in 4 of 16 patients with complete recanalization (22%), and in 12 of 29 patients with partial recanalization (41%). Reocclusion was detected in four patients (25%) before TPA bolus, in three (19%) by 30 minutes after bolus, in three (19%) by the end of infusion, and in six (37%) by 60 to 120 minutes. Before reocclusion, those patients had earlier median timing of recanalization: 130 versus 180 minutes after stroke onset compared with those who recanalized without reocclusion (p = 0.01). Median prebolus NIHSS score in the reocclusion group was 13.5 versus 17 (rest, NS), whereas at 2 and 24 hours, their NIHSS scores were higher: 14 versus 9 and 16 versus 6 points (p ≤ 0.04). Deterioration followed by improvement by ≥4 NIHSS points occurred in 8 of 16 (50%) patients with reocclusion versus 10% (rest) (p < 0.05). In-hospital mortality was 25 versus 3% (p < 0.0001). At 3 months, good outcome (mRS score of 0 to 1) was achieved by 8% of patients with no recanalization, by 33% of patients with reocclusion, and by 50% of patients with stable recanalization (p ≤ 0.05), and mortality was 42% with no early recanalization, 33% after reocclusion, and 8% in patients with stable recanalization (p ≤ 0.05).
Conclusions: Early reocclusion occurs in 34% of TPA-treated patients with any initial recanalization, accounting for two-thirds of deteriorations following improvement. Reocclusion occurs more often in patients with earlier and partial recanalization, leading to neurologic deterioration and higher in-hospital mortality. However, patients with reocclusion have better long-term outcomes than patients without any early recanalization.

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Grotta JC, Welch KM, Fagan SC, et al. Clinical deterioration following improvement in the NINDS rt-PA Stroke Trial. Stroke . 2001; 32: 661–668.
Davalos A, Toni D, Iweins F, Lesaffre E, Bastianello S, Castillo J. Neurological deterioration in acute ischemic stroke: potential predictors and associated factors in the European Cooperative Acute Stroke Study (ECASS) I. Stroke . 1999; 30: 2631–2636.
NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med . 1995; 333: 1581–1587.
Toni D, Fiorelli M, Zanette EM, et al. Early spontaneous improvement and deterioration of ischemic stroke patients. A serial study with transcranial Doppler ultrasonography. Stroke . 1998; 29: 1144–1148.
Toni D, Fiorelli M, Gentile M, et al. Progressing neurological deficit secondary to acute ischemic stroke. A study on predictability, pathogenesis, and prognosis. Arch Neurol . 1995; 52: 670–675.
Burgin WS, Alexandrov AV. Carotid thrombosis and re-occlusion. Neurology . 2001; 56: 568–570.
Demchuk AM, Christou I, Felberg R, et al. The accuracy and criteria for localizing arterial occlusion with transcranial Doppler. J Neuroimag . 2000; 10: 1–12.
Demchuk AM, Burgin WS, Christou I, et al. Thrombolysis in Brain Ischemia (TIBI) TCD flow grades predict clinical severity, early recovery and mortality in intravenous TPA treated patients. Stroke . 2001; 32: 89–93.
Burgin WS, Malkoff M, Felberg RA, et al. Transcranial Doppler ultrasound criteria for recanalization after thrombolysis for middle cerebral artery stroke. Stroke . 2000; 31: 1128–1132.
TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: phase I findings. N Engl J Med . 1985; 312: 932–936.
Alexandrov AV, Demchuk AM, Felberg RA, et al. High rate of complete recanalization and dramatic clinical recovery during TPA infusion when continuously monitored by 2 MHz transcranial Doppler monitoring. Stroke . 2000; 31: 610–614.
Haley EC, Lewandowski C, Tilley BC. Myths regarding NINDS rt-PA Stroke Trial: setting the record straight. Ann Emerg Med . 1997; 30: 676–682.
Toni D, Fiorelli M, Bastianello S, et al. Acute ischemic strokes improving during the first 48 hours of onset: predictability, outcome, and possible mechanisms. A comparison with early deteriorating strokes. Stroke . 1997; 28: 10–14.
Alexandrov AV, Burgin WS, Demchuk AM, El-Mitwalli A, Grotta JC. Speed of intracranial clot lysis with intravenous TPA therapy: sonographic classification and short term improvement. Circulation . 2001; 103: 2897–2902.
Baron JC, von Kummer R, del Zoppo GJ. Treatment of acute ischemic stroke. Challenging the concept of rigid and universal time window. Stroke . 1995; 26: 2219–2221.
Lewandowski CA, Frankel M, Tomsick TA, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke . 1999; 30: 2598–2605.
Grond M, Stenzel C, Schmulling S, et al. Early intravenous thrombolysis for acute ischemic stroke in a community-based approach. Stroke . 1998; 1544–1549.
Trouillas P, Nighoghossian N, Derex L, et al. Thrombolysis with intravenous rtPA in a series of 100 cases of acute carotid territory stroke: determination of etiological, topographic, and radiological outcome factors. Stroke . 1998; 29: 2529–2540.
Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA . 1999 Dec

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Published In

Volume 59Number 6September 24, 2002
Pages: 862-867
PubMed: 12297567

Publication History

Received: November 5, 2001
Accepted: May 31, 2002
Published online: September 24, 2002
Published in print: September 24, 2002


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Affiliations & Disclosures

Andrei V. Alexandrov, MD
From the Stroke Treatment Team, University of Texas–Houston Medical School, Houston, TX.
James C. Grotta, MD
From the Stroke Treatment Team, University of Texas–Houston Medical School, Houston, TX.


Address correspondence and reprint requests to Dr. A.V. Alexandrov, MSB 7.044, 6431 Fannin St., University of Texas, Houston, TX 77030; e-mail: [email protected]

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