Role of Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke with Large Vessel Occlusion.

OBJECTIVE: The goal of the present study was to determine the safety and efficacy of intravenous tissue plasminogen activator (IVT) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing mechanical thrombectomy (MT). METHODS: We performed a retrospective analysis of prospectively collected data gathered during a 3-year period for all our patients with AIS and LVO. We analyzed the stroke outcomes and complications between patients who had received a combination of IVT and MT and those who had undergone MT only. Standardized selection criteria, including the uniform use of perfusion imaging, were used for selection for MT, irrespective of IVT administration. RESULTS: Of the patients who had received IVT, 10% had had successful reperfusion found at initial angiography and did not require MT. A door-to-puncture time within 1 hour of presentation was achieved in 19% of both groups. IVT+MT was not associated with an increased incidence of intracranial hemorrhage (IVT+MT, 47.1%; MT, 49%). Of the 73 patients in IVT+MT group, 8 had developed access-site hematomas compared with 9 of the 95 patients in the MT group (28.6% vs. 26.5%; P = 0.85). The IVT+MT group had a lower proportion of patients with a modified Rankin scale score of 5-6 at 90 days compared with the MT group (36% vs. 56%; P = 0.024). Both groups showed statistically similar proportions of patients with a Thrombolysis in Cerebral Infarction scale score of ≥2c (IVT+MT, 50%; MT, 43%; P = 0.58). The IVT+MT group had a greater proportion of patients with Thrombolysis in Cerebral Infarction scale score of 2c (IVT+MT, 29.6%; MT, 16.8%; P = 0.068). CONCLUSIONS: Administration of IVT before MT to patients with AIS with LVO resulted in reperfusion before MT in 10% of patients, reduced the incidence of mortality and severe disability at 90 days, did not affect the door-to-puncture time, and was associated with a similar incidence of systemic and intracranial hemorrhage compared with MT only.

Bilateral Limb-Shaking Transient Ischemic Attacks.

Limb shaking is a rare manifestation of transient ischemic attacks (TIA) associated with carotid occlusion, mostly unilateral events. We describe the case of a 69 year-old man who presented with repeated episodes of irregular jerking movements in the bilateral upper and lower extremities, precipitated by standing up. Cerebral angiograms revealed occlusion of both internal carotid arteries, and the patient's symptoms responded to targeted blood pressure management. Physicians should be mindful of bilateral limb-shaking TIA when presented with bilateral paroxysmal events that can mimic seizures or orthostatic hyperkinesia.