THROMBOLYSIS WITH INTRAVENOUS RTPA IN A SERIES OF 100 CASES OF ACUTE CAROTID TERRITORY STROKE - DETERMINATION OF ETIOLOGIC, TOPOGRAPHIC, AND RADIOLOGICAL OUTCOME FACTORS
P. Trouillas et al., THROMBOLYSIS WITH INTRAVENOUS RTPA IN A SERIES OF 100 CASES OF ACUTE CAROTID TERRITORY STROKE - DETERMINATION OF ETIOLOGIC, TOPOGRAPHIC, AND RADIOLOGICAL OUTCOME FACTORS, Stroke, 29(12), 1998, pp. 2529-2540
Background and Purpose-Although new, large, double-blind, randomized s
tudies are needed to establish the efficiency of intravenous thromboly
sis, open trials of sufficient size may also provide novel data concer
ning specific outcomes after thrombolysis. Methods-An open study of in
travenous rtPA in 100 patients with internal carotid artery (ICA) terr
itory strokes between 20 and 81 years of age, with a baseline Scandina
vian Stroke Scale (SSS); score of <48 at entry was conducted. Inclusio
n time was within 7 hours after stroke onset. rtPA (0.8 mg/kg) was inf
used for 90 minutes, with an initial 10% bolus. Heparin was given acco
rding to 3 consecutive protocols. The SSS evaluation was done on days
0, 1, 7, 30, and 90. CT scan was performed before treatment, on days 1
and 7. Etiological investigations included echocardiography and carot
id Doppler sonography and/or angiography. Outcome at 1 year was docume
nted by SSS score, the modified Rankin Scale (mRS) score, and a 10-poi
nt invalidity scale. Multivariate logistic regression was used to iden
tify predictors of poor versus good outcome. Results-At day 90, 45 pat
ients (45%) had a good result, defined as complete regression or sligh
t neurological sequelae (mRS score of 0-1), 18 patients had a moderate
outcome (mRS 2-3), and 31 patients had serious neurological sequelae
(mRS 4-5). Six patients died, 2 with intracerebral hematoma after imme
diate heparin. Five of 11 patients (45.5%) treated between 6 and 7 hou
rs had a good result. The overall intracerebral hematoma rate was 7%.
Higher values of fibrin degradation products at 2 hours were observed
in the subgroup with intracerebral hematomas. Significant predictors o
f poor outcome on multivariate logistic regression analysis were basel
ine SSS score of <15 (odds ratio [OR], 3.38; 95% confidence interval [
CI], 1.07 to 10.74; P=0.04), indistinction between white and gray matt
er on CT scan (OR, 6.59; 95% CI, 2.19 to 19.79; P=0.0008), and proxima
l internal carotid thrombosis (OR, 3.29; 95% CI, 0.99 to 10.95; P=0.05
). Conclusions-Our study confirms the safety of intravenous rtPA at a
dose of 0.8 mg/kg and suggests efficacy for this drug even within 7 ho
urs. Outcome and hematoma rates were at least as favorable as for tria
ls of therapy with a 3-hour time window. Subgroups with a poor prognos
is include low baseline neurological score, baseline CT changes, and p
roximal ICA thrombosis. However, approximately 30% of patients with ea
ch of these characteristics show a good outcome, so their inclusion in
future routine rtPA protocols is still justified.