(Circulation. 2001;103:2897.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Speed of Intracranial Clot Lysis With Intravenous Tissue Plasminogen Activator Therapy
Sonographic Classification and Short-Term Improvement
From the Center for Noninvasive Brain Perfusion Studies (A.V.A., W.S.B., A.E.-M., J.C.G.), Stroke Treatment Team, University of Texas–Houston Medical School, Houston, Tex, and Department of Clinical Neurosciences (A.M.D.), University of Calgary, Alberta, Canada.
Correspondence to Dr A. Alexandrov, MSB 7.044 6431 Fannin St, University of Texas, Houston, TX 77030. E-mail avalexandrov{at}worldnet.att.net
Background—Arterial recanalization precedes clinical improvement or may lead to hemorrhage or reperfusion injury. Speed of clot lysis was not previously measured in human stroke.
Methods and
Results—Transcranial Doppler
(TCD) and the National Institutes of Health Stroke Scale (NIHSS) were
used to monitor consecutive patients receiving intravenous
tissue plasminogen activator (tPA), before tPA
bolus and at 24 hours. Patients with complete or partial
recanalization of the middle cerebral or basilar
artery on TCD were studied. Recanalization was
classified a priori as sudden (abrupt appearance of a normal or
stenotic low-resistance signal), stepwise (flow improvement
over 1 to 29 minutes), or slow (
30 minutes).
Recanalization was documented in 43 tPA-treated
patients (age 68±17 years; NIHSS score 16.8±6, median 15 points). tPA
bolus was given at a mean of 135±61 minutes after symptom onset.
Recanalization began at a median of 17 minutes and
was completed at 35 minutes after tPA bolus, with mean duration of
recanalization of 23±16 minutes.
Recanalization was sudden in 5, stepwise in 23, and
slow in 15 patients. Faster recanalization
predicted better short-term improvement
(P=0.03). At 24 hours, 80%,
30%, and 13% of patients in these respective
recanalization groups had NIHSS scores of 0 to 3.
Symptomatic hemorrhage occurred in only 1 patient,
who had stepwise recanalization 5.5 hours after
stroke onset. Slow or partial recanalization with
dampened flow signal was found in 53% of patients with total NIHSS
scores >10 points at 24 hours
(P=0.01). Complete
recanalization (n=25) occurred faster (median 10
minutes) than partial recanalization (n=18; median
30 minutes;
P=0.0001).
Conclusions—Rapid
arterial recanalization is associated
with better short-term improvement, mostly likely because of faster and
more complete clot breakup with low resistance of the distal
circulatory bed. Slow (30 minutes) flow improvement and dampened flow
signal are less favorable prognostic signs. These findings may be
evaluated to assist with selection of patients for additional
pharmacological or interventional treatment.
Key Words: ultrasonics • thrombolysis • stroke • recanalization • prognosis
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