title: Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator.
abstract: OBJECTIVE
  Early reperfusion is a predictor of good outcome in acute ischemic stroke. We investigated whether middle cerebral artery (MCA) occlusions have a better clinical outcome and proportion of recanalization compared with internal carotid artery (ICA) occlusion after standard treatment with intravenous (IV) tissue plasminogen activator (tPA).
  
  
  METHODS
  In a retrospective analysis of our prospective stroke database between January 7, 1998, and January 30, 2002, we identified 36 consecutive patients who were treated with IV tPA within 3 hours after symptom onset of a stroke in the distribution of a documented ICA or MCA occlusion. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before tPA, at 24 hours, 3 days, and 3 months after stroke. Three-month outcome was recorded by modified Rankin scale. Magnetic resonance angiography or computed tomographic angiography was obtained before tPA. The presence of recanalization was assessed by transcranial Doppler and/or magnetic resonance angiography within 3 days after stroke onset.
  
  
  RESULTS
  Nineteen patients had MCA occlusion, and 17 had ICA-plus-MCA occlusion before tPA. Although there was no difference in age and NIHSS at day 0 between the 2 groups, the MCA group had a lower day 3 NIHSS score compared with the ICA group (P=0.006) in an ANCOVA. In addition, patients who had a MCA occlusion had lower day 1 and 3 NIHSS scores compared with the ICA group (P=0.04 and P=0.03, respectively; Wilcoxon rank sum). Similarly, NIHSS was significantly lower in patients who recanalized on days 1 and 3 (P=0.004 and P=0.003 respectively, Wilcoxon rank sum). When we adjusted for NIHSS score at day 0 in an ANCOVA, the adjusted mean was lower in the group that recanalized compared with the group that did not recanalize (P<0.001). There was a significant difference between the proportion of recanalization in the MCA group (15 of 17 recanalized, 88%) at 3 days after tPA compared with that of the ICA group (5 of 16 recanalized, 31%; P=0.001, Fisher exact test). The 3-month modified Rankin scale was not different between the 2 groups.
  
  
  CONCLUSIONS
  Despite comparable age and NIHSS scores before IV tPA, MCA occlusions have lower day 1 and 3 NIHSS scores and higher proportion of recanalization compared with ICA occlusions. A combined IV/intra-arterial or mechanical thrombolysis may be needed to achieve early recanalization in ICA occlusions.
authors.affiliation: Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Mass 02115, USA. ilinfant@caregroup.harvard.edu
authors.forename: Italo
authors.initials: I
authors.lastname: Linfante
authors.forename: Rafael H
authors.initials: RH
authors.lastname: Llinas
authors.forename: Magdy
authors.initials: M
authors.lastname: Selim
authors.forename: Claudia
authors.initials: C
authors.lastname: Chaves
authors.forename: Sandeep
authors.initials: S
authors.lastname: Kumar
authors.forename: Robert A
authors.initials: RA
authors.lastname: Parker
authors.forename: Louis R
authors.initials: LR
authors.lastname: Caplan
authors.forename: Gottfried
authors.initials: G
authors.lastname: Schlaug
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002341:Carotid Artery Thrombosis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D003710:Demography; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D007275:Injections, Intravenous; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D015996:Survival Rate; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D010959:Tissue Plasminogen Activator