title: Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset.
abstract: OBJECTIVE
  Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset.
  
  
  METHODS
  All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke.
  
  
  RESULTS
  Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5.
  
  
  CONCLUSIONS
  Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.
authors: Department of Radiology, University of Cincinnati, OH 45267-0762, USA.
authors: L
authors: L
authors: Derex
authors: T A
authors: TA
authors: Tomsick
authors: T G
authors: TG
authors: Brott
authors: C A
authors: CA
authors: Lewandowski
authors: M R
authors: MR
authors: Frankel
authors: W
authors: W
authors: Clark
authors: S
authors: S
authors: Starkman
authors: J
authors: J
authors: Spilker
authors: G J
authors: GJ
authors: Udsten
authors: J
authors: J
authors: Khoury
authors: J C
authors: JC
authors: Grotta
authors: J P
authors: JP
authors: Broderick
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002533:Cerebral Angiography; D002544:Cerebral Infarction / Q000000981:diagnostic imaging* / Q000188:drug therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007261:Infusions, Intra-Arterial; D007262:Infusions, Intravenous; D020766:Intracranial Embolism / Q000000981:diagnostic imaging* / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000187:drug effects; D010865:Pilot Projects; D015912:Thrombolytic Therapy / Q000401:mortality; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome
chemical_list: D010959:Tissue Plasminogen Activator