Endovascular treatment of an acute left middle cerebral artery > 6 h post stroke in a patient presenting with dysphasia and dense right hemiplegia
ABSTRACT This paper describes the case of a 32-year-old man presenting with dense right hemiplegia and global aphasia caused by an acute left middle cerebral artery infarct that underwent successful endovascular therapy after being determined ineligible for intravenous tissue plasminogen activator. Clot transversion and balloon disruption followed by intra-arterial Alteplase resulted in successful re-canalization of his middle cerebral artery at 7 h 30 min. At 3 months post stroke, the patient had moderately severe expressive dysphasia but was mobilizing independently with normal right upper and lower limb strength. In conclusion, the 3 month outcome suggests that the therapeutic time window for endovascular therapy might exceed 6 h post stroke.
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ABSTRACT: Intravenous tissue-type plasminogen activator (tPA) therapy using the National Institute of Neurological Disorders and Stroke criteria has been given with variable safety to less than 5% of the patients who have ischemic strokes nationwide. Our center is experienced in treating large numbers of stroke patients with intravenous tPA. To report our total 4-year experience in the treatment of consecutive patients who had an ischemic stroke. Prospective inception cohort registry of all patients seen by our stroke team and an additional retrospective medical record review of all patients treated between January 1, 1996, and June 1, 2000. A veteran stroke team composed of fellows and stroke-specialty faculty servicing 1 university and 3 community hospitals in a large urban setting. Consecutive patients with ischemic stroke treated within the first 3 hours of symptom onset. According to the National Institute of Neurological Disorders and Stroke protocol, 0.9 mg/kg of intravenous tissue-type plasminogen activator was administered. Number and proportion treated, patient demographics, time to treatment, hemorrhage rates, and clinical outcome. A total of 269 patients were treated between January 1, 1996, and June 1, 2000. Their mean age was 68 years (age range, 24-93 years); 48% were women. This represented 9% of all patients admitted with symptoms of cerebral ischemia at our most active hospital (over the final 6 months, 13% of all patients with symptoms of cerebral ischemia and 15% of all acute ischemic stroke patients). Before treatment the mean +/- SD National Institutes of Health Stroke Scale (NIHSS) score was 14.4 +/- 6.1 points (median, 14 points; range, 4-33 points). A tPA bolus was given at 137 minutes (range, 30-180 minutes); 28% of the patients were treated within 2 hours. The mean door-to-needle time was 70 minutes (range, 10-129 minutes). The symptomatic intracerebral hemorrhage rate was 5.6% of those patients with a second set of brain scans (4.5% of all patients), with a declining trend from 1996 to 2000. Protocol violations were found in 13% of all patients; the symptomatic intracerebral hemorrhage rate in these patients was 15%. At 24 hours, the NIHSS score was 10 +/- 8 points (median, 8 points; range, 0-36 points). In-hospital mortality was 15% and the patients' discharge NIHSS scores were 7 +/- 7 points (median, 3 points; range, 0-35 points). Intravenous tPA therapy can be given to up to 15% of the patients with acute ischemic stroke with a low risk of symptomatic intracerebral hemorrhage. Successful experience with intravenous tPA therapy depends on the experience and organization of the treating team and adherence to published guidelines.JAMA Neurology 01/2002; 58(12):2009-13. · 7.42 Impact Factor
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ABSTRACT: Endovascular therapies using mechanical and pharmacological modalities for large vessel occlusions in acute stroke are rapidly evolving. Our aim was to determine whether one modality is associated with higher recanalization rates. We retrospectively reviewed 168 consecutive patients treated with intra-arterial (IA) therapy for acute ischemic stroke between May 1999 and November 15, 2005. Demographic, clinical, radiographic, angiographic, and procedural notes were reviewed. Recanalization was defined as achieving thrombolysis in myocardial infarction 2 or 3 flow after intervention. A logistic regression model was constructed to determine independent predictors of successful recanalization. A total of 168 patients were reviewed with a mean age of 64+/-13 years and mean National Institutes of Health Stroke Scale score of 17+/-4. Recanalization was achieved in 106 (63%) patients. Independent predictors of recanalization include: the combination of IA thrombolytics and glycoprotein IIb/IIIa inhibitors (odds ratio [OR], 2.9 [95% CI, 1.04 to 6.7]; P<0.048), intracranial stent placement with angioplasty (OR, 4.8 [95% CI, 1.8 to 10.0]; P<0.001), or extracranial stent placement with angioplasty (OR, 4.2 [95% CI, 1.4 to 9.8]; P<0.014). Lesions at the terminus of the internal carotid artery were recalcitrant to revascularization (OR, 0.34 [95% CI, 0.16 to 0.73]; P value 0.006). Intracranial or extracranial stenting or combination therapy with IA thrombolytics and glycoprotein IIb/IIIa inhibitors in the setting of multimodal therapy is associated with successful recanalization in patients treated with multimodal endovascular reperfusion therapy for acute ischemic stroke.Stroke 05/2006; 37(4):986-90. DOI:10.1161/01.STR.0000209303.02474.27 · 5.72 Impact Factor
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ABSTRACT: Intravenous tissue-type plasminogen activator can be beneficial to some patients when given within 3 hours of stroke onset, but many patients present later after stroke onset and alternative treatments are needed. To determine the clinical efficacy and safety of intra-arterial (IA) recombinant prourokinase (r-proUK) in patients with acute stroke of less than 6 hours' duration caused by middle cerebral artery (MCA) occlusion. PROACT II (Prolyse in Acute Cerebral Thromboembolism II), a randomized, controlled, multicenter, open-label clinical trial with blinded follow-up conducted between February 1996 and August 1998. Fifty-four centers in the United States and Canada. A total of 180 patients with acute ischemic stroke of less than 6 hours' duration caused by angiographically proven occlusion of the MCA and without hemorrhage or major early infarction signs on computed tomographic scan. Patients were randomized to receive 9 mg of IA r-proUK plus heparin (n = 121) or heparin only (n = 59). The primary outcome, analyzed by intention-to-treat, was based on the proportion of patients with slight or no neurological disability at 90 days as defined by a modified Rankin score of 2 or less. Secondary outcomes included MCA recanalization, the frequency of intracranial hemorrhage with neurological deterioration, and mortality. For the primary analysis, 40% of r-proUK patients and 25% of control patients had a modified Rankin score of 2 or less (P = .04). Mortality was 25% for the r-proUK group and 27% for the control group. The recanalization rate was 66% for the r-proUK group and 18% for the control group (P<.001). Intracranial hemorrhage with neurological deterioration within 24 hours occurred in 10% of r-proUK patients and 2% of control patients (P = .06). Despite an increased frequency of early symptomatic intracranial hemorrhage, treatment with IA r-proUK within 6 hours of the onset of acute ischemic stroke caused by MCA occlusion significantly improved clinical outcome at 90 days.JAMA The Journal of the American Medical Association 01/2000; 282(21):2003-11. · 35.29 Impact Factor