ORIGINAL ARTICLES   

International Angiology 2001 September;20(3):208-13

Copyright © 2002 EDIZIONI MINERVA MEDICA

lingua: Inglese

Arterial status after intravenous TPA therapy for ischaemic stroke. A need for further interventions

Christou I., Burgin W. S., Alexandrov A. V., Grotta J. C.

From the Center for Noninvasive Brain Perfusion Studies, Stroke Treatment Team University of Texas-Houston Medical School

Back­ground. Intra­ve­nous tis­sue plas­mi­no­gen acti­va­tor (TPA) is an ­approved ther­a­py for acute ischaem­ic ­stroke in the Unit­ed ­States. We aimed to non­in­va­sive­ly mon­i­tor the ther­a­py to deter­mine arte­ri­al rec­a­nal­isa­tion and per­sist­ing vas­cu­lar abnor­mal­ities.
Meth­ods. We pros­pec­tive­ly stud­ied con­sec­u­tive ­patients with symp­toms of ischaem­ic ­stroke who ­received intra­ve­nous TPA and were mon­i­tored by 2 MHz trans­cra­ni­al Dop­pler (TCD) to deter­mine occlu­sion and rec­a­nal­isa­tion (TIMI ­grades equiv­a­lent). For out­come assess­ment we used the Nation­al Insti­tutes of ­Health ­Stroke Scale (NIHSS) score.
­Results. Sixty ­patients were stud­ied (age 71±15 years, pre-TPA NIHSS 18±6.1, TPA bolus at 141±68 min­ after ­stroke onset). The inter­nal carot­id ­artery (ICA) was occlud­ed in 25%, mid­dle cere­bral ­artery (MCA) in 80%; com­bined (ICA+MCA) occlu­sion was found in 19%; and bas­i­lar ­artery (BA) was occlud­ed in 7%. Also, 2% had nor­mal TCD and 8% of ­patients had no tem­po­ral win­dows. Com­plete rec­a­nal­isa­tion on TCD of all inso­nat­ed arter­ies was found in 19 ­patients (32%) at 44±22 min­ after a TPA bolus. How­ev­er, 67% of MCA, 25% of BA, and all ICA occlu­sions did not com­plete­ly recan­al­ise (TIMI ­grades 0-2). If flow impair­ment per­sist­ed for more than two hours after a TPA bolus, these ­patients con­tin­ued to have sig­nif­i­cant neu­ro­log­i­cal def­i­cits at 24 hours (15.0±8.2 vs 6.3±7.3 NIHSS ­points, p<0.001 in non-par­a­met­ric sta­tis­tics). High-grade resid­u­al ste­nos­es with micro­em­bol­ic sig­nals were seen on TCD in the MCA and BA (n=3) sug­gest­ing con­tin­u­ing clot dis­so­lu­tion. In ­patients with­out com­plete rec­a­nal­isa­tion (n=36, or 60%), TCD iden­ti­fied ­lesions poten­tial­ly amen­able to fur­ther inter­ven­tions.
Con­clu­sions. Per­sist­ing arte­ri­al occlu­sion after intra­ve­nous TPA ther­a­py leads to poor short-term out­come. Non­in­va­sive mon­i­tor­ing of TPA ther­a­py with TCD can iden­ti­fy these high-risk ­patients for com­bined inter­ven­tions such as intra-arte­ri­al throm­bol­y­sis, mechan­i­cal clot dis­rup­tion, stent­ing or anti­co­ag­u­la­tion.