Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator.
OBJECTIVE
Although early recanalization is a powerful predictor of stroke outcome after thrombolysis, some stroke patients remain disabled despite tissue plasminogen activator (tPA)-induced recanalization. Therefore, we sought to investigate whether the predictive accuracy of early recanalization on stroke outcome is improved when combined with clinical and radiological information.


METHODS
We evaluated 177 patients with nonlacunar strokes in the middle cerebral artery (MCA) treated with intravenous tPA who were followed up during 3 months. Transcranial Doppler monitoring of recanalization was conducted during the first hours after tPA administration. The relative contribution of clinical, transcranial Doppler, and radiological information on stroke outcome was evaluated. We used logistic regression to derive a predictive model for good outcome (modified Rankin Scale score < or =2) after thrombolysis.


RESULTS
Median National Institutes of Health Stroke Scale (NIHSS) score before tPA was 16. At 3 months, 87 patients (49.2%) became functionally independent (modified Rankin Scale score < or =2). In a logistic regression model, degree of recanalization within 300 minutes (P<0.001), proximal MCA occlusion (P<0.001), baseline NIHSS score (P=0.0013), systolic blood pressure (P=0.0116), and early ischemic changes on CT (P=0.0253) independently predicted outcome at 3 months. A 5-item score was developed on the basis of the factors significantly associated with stroke outcome in the logistic regression (total score range, 0 to 7). The likelihood of good outcome at 3 months was 0.82 (95% CI, 0.72 to 0.92) in patients who scored 0 to 2, 0.51 (95% CI, 0.36 to 0.66) in those who scored 3 to 4, and 0.15 (95% CI, 0.05 to 0.25) in those who scored 5 to 7 points.


CONCLUSIONS
The combination of clinical, radiological, and hemodynamic information predicts with a high accuracy long-term stroke outcome during or shortly after intravenous tPA administration.
Molina
Carlos A
CA
Neurovascular Unit, Department of Neurology, Hospital Vall d'Hebrón, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain. cmolina@vhebron.net
Alexandrov
Andrei V
AV
Demchuk
Andrew M
AM
Saqqur
Maher
M
Uchino
Ken
K
Alvarez-Sabín
José
J
D000046:Academic Medical Centers / Q000706:statistics & numerical data; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis / Q000188:drug therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial; D014654:Vascular Patency / Q000187:drug effects*
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator