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Stroke following internal carotid artery occlusion - a contra-indication for intravenous thrombolysis?
J Rudolf1, M Neveling, M Grond
1Klinik fur Neurologie der Universitat zu Koln, Joseph-Stelzmann-Strasse 9, D-50924 Koln, Germany.
Insights
This study on intravenous recombinant tissue plasminogen activator (rt-PA) for carotid artery occlusion found no major complications. Results suggest rt-PA may benefit stroke patients with internal carotid artery dissection or atherothrombotic occlusion.
Area of Science:
- Neurology
- Vascular Medicine
- Interventional Radiology
Background:
- Carotid artery occlusion is a significant cause of ischemic stroke.
- Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is a standard treatment for acute ischemic stroke.
- The efficacy and safety of rt-PA in patients with carotid artery occlusion, particularly those with dissection or atherothrombosis, require further investigation.
Purpose of the Study:
- To evaluate the safety and efficacy of intravenous rt-PA in patients with carotid artery occlusion.
- To compare outcomes between patients with internal carotid artery dissection (ICD) and atherothrombotic internal carotid artery (ICA) occlusion treated with rt-PA.
- To determine if patients with acute ischemic stroke following ICA occlusion should be excluded from intravenous thrombolysis.
Main Methods:
- A consecutive series of 15 patients with carotid artery occlusion diagnosed via duplex sonography were treated with intravenous rt-PA.
- Treatment followed a protocol similar to the National Institute of Neurological Disorders and Stroke (NINDS) study.
- Patients were categorized into internal carotid artery dissection (ICD) or atherothrombotic internal carotid artery (ICA) occlusion groups based on ultrasound findings.
Main Results:
- No significant hemorrhagic complications were observed following rt-PA treatment for ICA occlusion.
- Three of 15 patients with ICA occlusion achieved excellent late functional outcomes; four had moderate to poor outcomes.
- Four patients died, with mortality linked to stroke severity at admission.
- A potentially better outcome was observed in the small group of patients with ICD compared to those with atherothrombotic ICA occlusion.
Conclusions:
- Intravenous rt-PA treatment for carotid artery occlusion did not result in devastating complications in this case series.
- The data do not support the a priori exclusion of patients with acute ischemic stroke following ICA occlusion from intravenous thrombolysis.
- This pilot study suggests that the potential benefit of rt-PA in stroke following acute or chronic ICA occlusion warrants assessment in larger prospective trials.
Abstract:
Between March 1996 and December 1997, 15 consecutive patients with carotid artery occlusion diagnosed with duplex sonography were treated with intravenous recombinant tissue plasminogen activator (rt-PA), following a protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) study. On the basis of ultrasound findings, six of the 15 patients had internal carotid artery dissection (ICD), and the remaining nine had atherothrombotic internal carotid artery (ICA) occlusion. No relevant haemorrhagic complications were observed after rt-PA treatment of ICA occlusion. Excellent late functional outcome was observed in three of the 15 patients with ICA occlusion, moderate and poor outcome in four patients. Four patients died, and mortality was related to stroke severity upon admission. A good outcome seemed to be more likely in the small group of patients with ICD, than in the patients suffering atherothrombotic ICA occlusion. As the results of rt-PA treatment in this case series are by no means devastating, our data do not corroborate the hypothesis that patients with acute ischemic stroke following ICA occlusion should a priori be excluded from intravenous thrombolysis. The possible benefit of rt-PA treatment in stroke following acute or chronic ICA occlusion should be assessed in a larger prospective trial, for which this case series might serve as a pilot study.