Clinical deterioration after intravenous recombinant tissue plasminogen activator treatment: a multicenter transcranial Doppler study.
OBJECTIVE
Patients may experience clinical deterioration (CD) after treatment with intravenous recombinant tissue plasminogen activator (rt-PA). We evaluated the ability of flow findings on transcranial Doppler to predict CD and outcomes on modified Rankin Scale.


METHODS
Patients with acute stroke received intravenous rt-PA within 3 hours of symptom onset at four academic centers. CD was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by 4 points or more within 24 hours. Poor long-term outcome was defined by modified Rankin Scale > or =2 at 3 months. Transcranial Doppler findings were interpreted using the Thrombolysis in Brain Ischemia flow grading system as persistent arterial occlusion, reocclusion, or complete recanalization. Multiple regression analysis was used to identify transcranial Doppler flow as a predictor for CD after controlling for age, sex, baseline NIHSS, hypertension, and glucose.


RESULTS
A total of 374 patients received intravenous rt-PA at 142+/-60 minutes (median pretreatment NIHSS score 16 points). At the end of intravenous rt-PA infusion, transcranial Doppler showed persistent arterial occlusion in 219 patients (59%), arterial reocclusion in 54 patients (14%), and complete recanalization in 101 patients (27%). CD occurred in 44 patients: 36 had persistent arterial occlusion or reocclusion (82%), 13 symptomatic intracerebral hemorrhage (29%), and both persistent occlusion/reocclusion and symptomatic intracerebral hemorrhage in 10 patients (23%). After adjustment, patient risk for CD with persistent occlusion was OR 1.7 (95% CI: 0.7 to 4) and with arterial reocclusion 4.9 (95% CI: 1.7 to 13) (P=0.002). Patient risk for poor long-term outcomes with persistent occlusion, partial recanalization, or reocclusion was OR 5.2 (95% CI: 2.7 to 9, P=0.001).


CONCLUSIONS
Inability to achieve or sustain vessel patency at the end of rt-PA infusion correlates with the likelihood of clinical deterioration and poor long-term outcome. Early arterial reocclusion on transcranial Doppler is highly predictive of CD and poor outcome.
Saqqur
Maher
M
University of Alberta, Department of Medicine, Division of Neurology, 2 E3 Walter Mckenzie Center, 8440 112 Ave, Edmonton, Alberta T6G 2B7, Canada. msaqqur@ualberta.ca
Molina
Carlos A
CA
Salam
Abdul
A
Siddiqui
Muzaffar
M
Ribo
Marc
M
Uchino
Ken
K
Calleja
Sergio
S
Garami
Zsolt
Z
Khan
Khaurshid
K
Akhtar
Naveed
N
O'Rourke
Finton
F
Shuaib
Ashfaq
A
Demchuk
Andrew M
AM
Alexandrov
Andrei V
AV
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000188:drug therapy* / Q000503:physiopathology; D002536:Cerebral Arteries / Q000000981:diagnostic imaging / Q000187:drug effects / Q000503:physiopathology; D002543:Cerebral Hemorrhage / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000503:physiopathology; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011993:Recombinant Fusion Proteins / Q000009:adverse effects; D012008:Recurrence; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging* / Q000188:drug therapy* / Q000503:physiopathology; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000009:adverse effects*; D017585:Ultrasonography, Doppler, Transcranial
D005343:Fibrinolytic Agents; D011993:Recombinant Fusion Proteins; D010959:Tissue Plasminogen Activator