Hostname: page-component-76fb5796d-22dnz Total loading time: 0 Render date: 2024-04-26T21:13:43.629Z Has data issue: false hasContentIssue false
  • English
  • Français

Acute Stroke with Hyperdense Middle Cerebral Artery Sign Benefits from IV rtPA

Published online by Cambridge University Press:  02 December 2014

M C Tartaglia ,
S Di Legge ,
G Saposnik ,
V Jain ,
R Chan ,
M Bussière ,
V Hachinski ,
C Frank ,
K Hesser  and
D Pelz
M C Tartaglia*
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
S Di Legge
Affiliation:
Stroke Unit, University of Tor Vergata, Viale Oxford 81-00133 Rome, Italy
G Saposnik
Affiliation:
Department of Medicine, St. Michael's Hospital, University of Toronto, Ontario, Canada
V Jain
Affiliation:
Division of Research, Kaiser-Permanente Northern California, Oakland, CA, USA
R Chan
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
M Bussière
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
V Hachinski
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
C Frank
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
K Hesser
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
D Pelz
Affiliation:
Department of Diagnostic Radiology and Nuclear Medicine, London Health Sciences Center, University of Western Ontario, London, ON
*
Division of Neurology, Dept. Clinical Neurological Sciences, University of Western Ontario, B7-005, 339 Windermere Rd, London, Ontario, N6A 5A5, Canada.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objectives:

The current management of acute ischemic stroke is intravenous (IV) recombinant tissue plasminogen activator (rtPA). The presence of a hyperdense middle cerebral artery sign (HMCAS) on pre-treatment head computed tomogram (CT) is considered a poor prognostic sign. We compared the clinical outcome in IV rtPA-treated patients with and without a HMCAS.

Design:

Retrospective analysis of prospectively collected cases treated with IV rtPA within three hours. Inclusion criteria were the presence of: i) an anterior circulation stroke; ii) a pre-treatment CT available; iii) a pre-treatment National Institutes of Health (NIH) stroke scale (NIHSS) score; and iv) a modified Rankin Score (mRS) at three months.

Results:

One hundred and thirty patients were eligible for the analysis, 64 (49%) had a HMCAS. The HMCAS group had a trend toward a higher mean (±SD) pre-treatment NIHSS score compared to the non-HMCAS group (13.9±6 vs. 12.2±6; p=0.12). Accordingly, there were more patients with severe strokes (NIHSS>10) in the HMCAS group compared to the non-HMCAS one (48/64=75% vs. 35/66=53%; p=0.009). The mean (±SD) NIHSS score 24 hours after treatment was 10.6 (±8) in the HMCAS group and 8.3 (±7) in the non-HMCAS group (p=0.08). In a multiple logistic regression analysis, the only independent predictor of poor outcome (mRS 3-6) was pre-treatment NIHSS score (p<0.001).

Conclusion:

Patients with a HMCAS receiving IV rtPA did not fare worse at three months despite a greater proportion of patients with more severe strokes. Based on the current knowledge, IV rtPA remains a good treatment for patients with a HMCAS within three hours of symptom onset.

Résumé:

RÉSUMÉ:Objectifs:

L'administration de l'activateur du plasminogène tissulaire recombinant (rt-PA) est le traitement actuel de l'accident vasculaire cérébral (AVC) ischémique aigu. La présence du signe de l'artère cérébrale moyenne hyperdense (SACMH) à la tomodensitométrie cérébrale avant traitement est considérée comme un signe de mauvais pronostic. Nous avons comparé le résultat clinique chez les patients avec et sans SACMH traités par rt-PA IV. Plan de l'étude: Nous avons effectué une analyse rétrospective de cas recueillis de façon prospective, traités au moyen de rt-PAIV dans les 3 heures du début des symptômes.

Les critères d'inclusion étaient les suivants:

la présence d'un AVC dans le territoire de la circulation antérieure ; la disponibilité d'un examen tomodensitométrique avant traitement, d'un score du NIH Stroke Scale (NIHSS) avant traitement et d'un score du Modified Rankin Scale (MRS) trois mois après l'AVC.

Résultats:

Cent trente patients rencontraient les critères d'inclusion, dont soixante-quatre (49%) avaient un SACMH. Dans le groupe avec SACMH, la moyenne du score du NIHSS avant traitement avait tendance à être plus élevée comparée à celle du groupe sans SACMH (13,9 ± 6 vs 12,2 ± 6 ; p = 0,12). Il y avait donc plus de patients atteints d'AVC sévères (NIHSS > 10) dans le groupe avec SACMH par rapport au groupe sans SACMH (48/64 = 75% vs 35/66 = 53% ; p = 0,009). Le score moyen du NIHSS 24 heures après le traitement était de 10,6 (± 8) dans le groupe avec SACMH et de 8,3 (± 7) dans le groupe sans SACMH (p = 0,08). À l'analyse de régression logistique multivariée, le seul prédicteur indépendant d'un mauvais pronostic (MRS 3-6) était le score du NIHSS avant traitement (p < 0,001).

Conclusion:

Les patients qui présentaient un SACMH et qui ont reçu du rt-PA IV n'étaient pas en plus mauvais état trois mois plus tard que ceux qui n'en présentaient pas malgré qu'une plus grande proportion d'entre eux étaient atteints d'AVC plus sévères. Selon les connaissances actuelles, le rt-PA IV administré dans les trois heures du début des symptômes est un bon traitement chez les patients porteurs d'un SACMH.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 35 , Issue 5 , November 2008 , pp. 583 - 587
Copyright
Copyright © The Canadian Journal of Neurological 2008

References

1. Derex, L, Hermier, M, Adeleine, P, Pialat, JB, Wiart, M, Berthezene, Y, et al. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator. J Neurol Neurosurg Psychiatry. 2005;76:70–5.Google Scholar
2. Ciccone, A, Boccardi, E, Cantisani, TA, Coppola, C, Gatti, A, Guccione, A, et al. A randomized comparison of intra-arterial with intravenous thrombolysis for acute ischemic dtroke: The SYNTHESIS trial. International Stroke Conference. New Orleans: 2005.Google Scholar
3. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–7.Google Scholar
4. Garg, N, Eshkar, N, Tanenbaum, L, Cohen, B, Sen, S. Computed tomography angiographic correlates of early computed tomography signs in acute ischemic stroke. J Neuroimaging. 2004;14:242–5.CrossRefGoogle ScholarPubMed
5. Tomsick, T, Brott, T, Barsan, W, Broderick, J, Haley, EC, Spilker, J, et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. AJNR Am J Neuroradiol. 1996;17:79–85.Google Scholar
6. Pressman, BD, Tourje, EJ, Thompson, JR. An early CT sign of ischemic infarction: increased density in a cerebral artery. AJR Am J Roentgenol. 1987;149:583–6.Google Scholar
7. Schuierer, G, Huk, W. The unilateral hyperdense middle cerebral artery: an early CT-sign of embolism or thrombosis. Neuroradiology. 1988;30:120–2.CrossRefGoogle ScholarPubMed
8. Tomsick, TA, Brott, TG, Olinger, CP, Barsan, W, Spilker, J, Eberle, R, et al. Hyperdense middle cerebral artery: incidence and quantitative significance. Neuroradiology. 1989;31:312–5.Google Scholar
9. Tomsick, T, Brott, T, Barsan, W, Broderick, J, Haley, EC, Spilker, J. Thrombus localization with emergency cerebral CT. AJNR Am J Neuroradiol. 1992;13:257–63.Google Scholar
10. Schuknecht, B, Ratzka, M, Hofmann, E. The “dense artery sign”- major cerebral artery thromboembolism demonstrated by computed tomography. Neuroradiology. 1990;32:98–103.CrossRefGoogle Scholar
11. Bastianello, S, Pierallini, A, Colonnese, C, Brughitta, G, Angeloni, U, Antonelli, M, et al. Hyperdense middle cerebral artery CT sign. Comparison with angiography in the acute phase of ischemic supratentorial infarction. Neuroradiology. 1991;33:207–11.CrossRefGoogle ScholarPubMed
12. Albers, GW, Bates, VE, Clark, WM, Bell, R, Verro, P, Hamilton, SA. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA. 2000;283:1145–50.Google Scholar
13. Manelfe, C, Larrue, V, von Kummer, R, Bozzao, L, Ringleb, P, Bastianello, S, et al. Association of hyperdense middle cerebral artery sign with clinical outcome in patients treated with tissue plasminogen activator. Stroke. 1999;30:769–72.Google Scholar
14. Qureshi, AI, Ezzeddine, MA, Nasar, A, Suri, MF, Kirmani, JF, Janjua, N, et al. Is IV tissue plasminogen activator beneficial in patients with hyperdense artery sign? Neurology. 2006;66:1171–4.Google Scholar
15. Berge, E, Nakstad, PH, Sandset, PM. Large middle cerebral artery infarctions and the hyperdense middle cerebral artery sign in patients with atrial fibrillation. Acta Radiol. 2001;42:261–8.Google Scholar
16. Derex, L, Nighoghossian, N, Hermier, M, Adeleine, P, Froment, JC, Trouillas, P. Early detection of cerebral arterial occlusion on magnetic resonance angiography: predictive value of the baseline NIHSS score and impact on neurological outcome. Cerebrovasc Dis. 2002;13:225–9.Google Scholar
17. Wolpert, SM, Bruckmann, H, Greenlee, R, Wechsler, L, Pessin, MS, del Zoppo, GJ. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group. AJNR Am J Neuroradiol. 1993;14:3–13.Google Scholar
18. Roberts, HC, Dillon, WP, Furlan, AJ, Wechsler, LR, Rowley, HA, Fischbein, NJ, et al. Computed tomographic findings in patients undergoing intra-arterial thrombolysis for acute ischemic stroke due to middle cerebral artery occlusion: results from the PROACT II trial. Stroke. 2002;33:1557–65.CrossRefGoogle ScholarPubMed
19. Lewandowski, CA, Frankel, M, Tomsick, TA, Broderick, J, Frey, J, Clark, W, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke. 1999;30:2598–605.Google Scholar
20. Zaidat, OO, Suarez, JI, Santillan, C, Sunshine, JL, Tarr, RW, Paras, VH, et al. Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion. Stroke. 2002;33:1821–6.CrossRefGoogle ScholarPubMed
21. Mattle, HP, Arnold, M, Georgiadis, D, Baumann, C, Nedeltchev, K, Benninger, D, et al. Comparison of intraarterial and intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign. Stroke. 2008;39:379–83.Google Scholar
22. Saposnik, G, Young, B, Silver, B, Di Legge, S, Webster, F, Beletsky, V, et al. Lack of improvement in patients with acute stroke after treatment with thrombolytic therapy: predictors and association with outcome. JAMA. 2004;292:1839–44.CrossRefGoogle ScholarPubMed
23. Merino, JG, Silver, B, Wong, E, Foell, B, Demaerschalk, B, Tamayo, A, et al. Extending tissue plasminogen activator use to community and rural stroke patients. Stroke. 2002;33:141–6.Google Scholar
24. Foell, RB, Silver, B, Merino, JG, Wong, EH, Demaerschalk, BM, Poncha, F, et al. Effects of thrombolysis for acute stroke in patients with pre-existing disability. CMAJ. 2003; 169:193–7.Google Scholar
25. Brott, T, Adams, HP Jr., Olinger, CP, Marler, JR, Barsan, WG, Biller, J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989; 20:864–70.Google Scholar
26. Adams, HP Jr, Davis, PH, Leira, EC, Chang, KC, Bendixen, BH, Clarke, WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999;53:126–31.CrossRefGoogle ScholarPubMed
27. Bonita, R, Beaglehole, R. Recovery of motor function after stroke. Stroke. 1988;19:1497–500.CrossRefGoogle ScholarPubMed
28. Wardlaw, JM, Mielke, O. Early signs of brain infarction at CT: observer reliability and outcome after thrombolytic treatment-systematic review. Radiology. 2005;235:444–53.CrossRefGoogle ScholarPubMed
29. Schellinger, PD, Chalela, JA, Kang, DW, Latour, LL, Warach, S. Diagnostic and prognostic value of early MR imaging vessel signs in hyperacute stroke patients imaged > 3 hours and treated with recombinant tissue plasminogen activator. AJNR Am J Neuroradiol. 2005;26:618–24.Google Scholar