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Improved Outcomes in Stroke Thrombolysis with Pre-specified Imaging Criteria

Published online by Cambridge University Press:  24 February 2017

Brian Silver ,
Bart Demaerschalk ,
José G. Merino ,
Edward Wong ,
Arturo Tamayo ,
Ashok Devasenapathy ,
Christina O'Callaghan ,
Andrew Kertesz ,
G. Bryan Young  and
Allan J. Fox
...Show all authors
Brian Silver*
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
Bart Demaerschalk
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON Department of Neurology, St. Joseph's Hospital, London Health Sciences Centre, London, ON
José G. Merino
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
Edward Wong
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
Arturo Tamayo
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
Ashok Devasenapathy
Affiliation:
Department of Neurology, Penn State University/Geisinger Health System, PA, USA
Christina O'Callaghan
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
Andrew Kertesz
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON Department of Neurology, St. Joseph's Hospital, London Health Sciences Centre, London, ON
G. Bryan Young
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON Department of Neurocritical Care, London Health Sciences Centre, London, ON
Allan J. Fox
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON Department of Neuroradiology, London Health Sciences Centre, London, ON
J. David Spence
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
Vladimir Hachinski
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON
*
London Health Sciences Centre, Department of Clinical Neurological Sciences, 339 Windermere Road, Room 7GE-5, London, Ontario N6A 5A5, Canada
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Abstract:

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Background:

A 1995 National Institute of Neurological Disorders (NINDS) study found benefit for intravenous tissue plasminogen activator (tPA) in acute ischemic stroke (AIS). The symptomatic intracranial hemorrhage (SICH) rate in the NINDS study was 6.4%, which may be deterring some physicians from using this medication.

Methods:

Starting December 1, 1998, patients with AIS in London, Ontario were treated according to NINDS criteria with one major exception; those with approximately greater than one-third involvement of the idealized middle cerebral artery (MCA) territory on neuroimaging were excluded from treatment. The method used to estimate involvement of one-third MCA territory involvement bears the acronym ICE and had a median kappa value of 0.80 among five physicians. Outcomes were compared to the NINDS study.

Results:

Between December 1, 1998 and February 1, 2000, 30 patients were treated. Compared to the NINDS study, more London patients were treated after 90 minutes (p<0.00001) and tended to be older. No SICH was observed. Compared to the treated arm of the NINDS trial, fewer London patients were dead or severely disabled at three months (p=0.04). Compared to the placebo arm of the trial, more patients made a partial recovery at 24 hours (p=0.02), more had normal outcomes (p=0.03) and fewer were dead or severely disabled at three months (p=0.004).

Conclusions:

The results of the NINDS study were closely replicated and, in some instances, improved upon in this small series of Canadian patients, despite older age and later treatment. These findings suggest that imaging exclusion criteria may optimize the benefits of tPA.

Résumé:

RÉSUMÉ:Introduction:

Une étude du NINDS effectuée en 1995 a démontré les bénéfices de l'administration intraveineuse de l'activateur du plasminogène tissulaire (tPA) en phase aiguë de l'accident vasculaire cérébral ischémique (AVCI). Le taux d'hémorragie intracrânienne symptomatique (HICS) dans l'étude NINDS était de 6.4%, ce qui peut décourager certains médecins d'utiliser ce médicament.

Méthodes:

Depuis le premier décembre 1998, les patients porteurs d'un AVCI à London, Ontario ont été traités selon les critères de l'étude NINDS avec une exception importante: ceux qui avaient une lésion impliquant plus d'un tiers du territoire de l'artère cérébrale moyenne reproduit par la neuro-imagerie ont été exclus du traitement. La méthode utilisée pour estimer le territoire impliqué porte l'acronyme ICE et avait une valeur kappa médiane de 0.80 parmi cinq médecins. Les résultats ont été comparés à ceux de l'étude NINDS.

Résultats:

30 patients ont été traités entre le premier décembre 1998 et le premier février 2000. Plus de patients de London ont été traités après 90 minutes (p<0.00001) et ils étaient en général plus âgés que ceux qui ont participé à l'étude NINDS. Aucun cas de HICS n'a été observé. Moins de patients sont décédés ou avaient une invalidité sévère à trois mois (p=0.04) par rapport aux patients du bras avec traitement dans l'étude NINDS. Plus de patients ont eu une récupération partielle à 24 heures (p=0.02), plus de patients ont eu une récupération complète (p=0.03) et il y a eu moins de décès ou d'invalidité sévère à trois mois (p=0.004) par rapport aux patients à qui on avait administré le placebo dans l'étude.

Conclusions:

Les résultats de l'étude NINDS ont été reproduits et même améliorés dans certains cas, dans cette série de patients Canadiens, malgré l'âge plus avancé des patients et un traitement plus tardif. Ces observations suggèrent que des critères d'exclusion neuroradiologiques peuvent optimiser les bénéfices du traitement par le tPA.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 28 , Issue 2 , May 2001 , pp. 113 - 119
Copyright
Copyright © The Canadian Journal of Neurological 2001

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