Stroke severity and residual flow determined by transcranial colour-coded ultrasound (TCCD) predict recanalization and clinical outcome during thrombolysis.

OBJECTIVE: To determine clinical, neuroradiological or ultrasonographic parameters associated with early recanalization and clinical outcome in patients treated with intravenous (IVT) or combined intravenous-intra-arterial (IVT-IAT) thrombolysis. METHODS: From 2004 to 2007, all consecutive ischemic stroke patients admitted within a 3-hour window and who underwent thrombolytic therapy were reviewed. Degree of occlusion and recanalization during IVT was assessed by transcranial color-coded ultrasound (TCCD) using Thrombolysis In Brain Ischemia (TIBI) classification. According to our protocol, in case of recanalization (modification of TIBI grade > or = 1) after 30 min of IVT, the procedure was maintained over 1h. When TIBI grade failed to improve after 30 min, IVT was discontinued and IAT performed using the remaining tPA dose. The study endpoints were early recanalization defined as achievement of TIBI > or = 3 grade at 30 min (for this endpoint all patients presenting a TIBI grade 3 at admission were excluded from the model) and clinical outcome at 3 months assessed by the modified Rankin scale. RESULTS: Seventy-one patients underwent either IVT (n=41) or IVT-IAT (n=30). Among all the variables, NIHSS and TIBI grades assessed at baseline were the only independent factors associated with early recanalization and clinical outcome. Furthermore, the combination of these two parameters was superior in predicting early recanalization and outcome to either one of them taken separately. An inverse correlation between NIHSS, TIBI grades and early recanalization was found: the lower the TIBI grade, the lower the probability to recanalize for any given NIHSS. CONCLUSION: Baseline NIHSS and TIBI grades were the only independent factors associated with early recanalization and clinical outcome. The combination of these two parameters was superior to each single variable in predicting the study endpoints and could therefore be used to improve the selection of patients for IVT or more aggressive therapies.

Microbubble potentiated transcranial duplex ultrasound enhances IV thrombolysis in acute stroke.

BACKGROUND: We studied whether 2 MHz transcranial color-coded duplex ultrasound (TCCD), combined with a second generation ECA, accelerate IV rtPA-thrombolysis in the acute phase of MCA stroke more than TCCD monitoring alone. METHODS: Non-randomized acute MCA stroke patients undergoing IV rtPA-thrombolysis and 2 MHZ-TCCD monitoring over 60 min, with (N = 11) or without (N = 15) additional continuous ECA (5 ml, SonoVue perfusion, were compared. Recanalization of the MCA was measured pre- and post-thrombolysis with the thrombolysis in brain ischemia (TIBI) grading system, clinical outcome was assessed at admission and 24 h after treatment using the NIH stroke scale (NIHSS). RESULTS: Patients who received ECA improved their NIHSS significantly more than those who were only TCCD monitored (Mann-Whitney U = 48.0; P = 0.050), and their flow signal improved more (Mann-Whitney U = 40.0; P < 0.03). CONCLUSIONS: The results of this pilot study show that in IV-thrombolysis the use of ECA in addition to TCCD monitoring lead to a greater immediate clinical improvement and to a better flow signal.

Intravenous versus combined (intravenous and intra-arterial) thrombolysis in acute ischemic stroke: a transcranial color-coded duplex sonography--guided pilot study.

BACKGROUND AND PURPOSE: Determine feasibility and safety of intravenous (IV) versus combined (IV-IA [intra-arterial]) thrombolysis guided by transcranial color-coded duplex sonography (TCCD). METHODS: Thirty-three patients eligible for IV thrombolysis, within 3 hours of onset of symptoms, with occlusion in middle cerebral artery territory (TCCD monitoring, thrombolysis in brain ischemia [TIBI] flow grade [0-3]), underwent IV thrombolysis (tissue plasminogen activator, 0.9 mg/kg). In case of recanalization (modification of TIBI score > or =1) after 30 minutes IV thrombolysis was continued over 1 hour; otherwise, it was discontinued, with subsequent IA thrombolysis. Recanalization was determined by TIBI (TCCD) and angiographically by thrombolysis in myocardial infarction (TIMI) flow grades. Clinical outcome measures were assessed at baseline, 24 hours (NIHSS) and 3 months (modified Rankin Scale). RESULTS: In the IV group, 10/17 patients (59%) with complete or partial recanalization after 30 minutes had a favorable outcome at 3 months (modified Rankin Scale 0 to 2). TIBI flow grades 3 to 5 after 30 minutes of IV thrombolysis predicted a good prognosis compared with TIBI grades 1 to 2 (P<0.05). In the combined IV/IA therapy group (no recanalization after 30 minutes), 9/16 patients (56%) had a favorable outcome at 3 months. One symptomatic intracerebral hemorrhage occurred in each group. CONCLUSIONS: Combined IV-IA versus IV thrombolysis guided by TCCD was feasible and safe. Recanalization after 30 minutes of IV thrombolysis led to a favorable outcome in 59% of the patients, provided TIBI flow grades were of 3 to 5. In the absence of early recanalization during IV thrombolysis, there was clinical benefit to proceed to IA therapy for a significative proportion of patients (56%).

[Cerebrovascular accident: a medical emergency]. / Accident vasculaire cérébral: une urgence médicale.

Although stroke mortality varies very widely between the different countries, about 10-15% of swiss patients die from stroke complications within the first 2 weeks and around 30% within the first 6 months. In Switzerland 40% of the patients who experienced a first ever stroke remain dependent 6 months after the beginning of symptoms. After the positive results obtained with thrombolysis in myocardial infarction, several studies demonstrated the benefit of thrombolytic agents when administered within the very first hours of stroke. Moreover, besides thrombolysis, early control of different general parameters (blood pressure, temperature, blood sugar level) also favorably influences the prognosis of the patients. For these different reasons, every stroke has to be considered as a medical emergency.