Arterial occlusion sites on magnetic resonance angiography influence the efficacy of intravenous low-dose (0.6 mg/kg) alteplase therapy for ischaemic stroke.
OBJECTIVE
To determine the predictors of efficacy, including magnetic resonance imaging information, for low-dose intravenous alteplase therapy for stroke patients.


METHODS
Seventy-eight patients were prospectively enrolled in a single Stroke Unit (SU) receiving alteplase at a dose of 0.6 mg/kg during the initial 27 months after its approval in Japan. Ischaemic changes and vascular lesions were identified using computed tomography, diffusion-weighted magnetic resonance imaging, and magnetic resonance angiography. Early ischaemic signs were assessed using the Alberta Stroke Program Early CT Score.


RESULTS
The median baseline National Institutes of Health Stroke Scale score of 78 patients was 12. In 19 patients (24%), the National Institutes of Health Stroke Scale score improved by >or=8 points at 24 h. After multivariate adjustment, occlusion at the internal carotid artery (odds ratio 11.82, 95% confidence interval 1.73-142.74), Alberta Stroke Program Early CT Score on diffusion-weighted imaging <or=6 (15.23, 1.88-351.50), and a lower National Institutes of Health Stroke Scale score (1.24, 1.08-1.47, per 1-point decrease) were inversely correlated with early improvement. Four patients (5%) had symptomatic intracranial haemorrhage. At 3 months, 76 patients (98%) survived, and 36 of 78 patients (46%) overall, but only two of 19 patients (11%) with internal carotid artery occlusion, had a favourable functional outcome, corresponding to a modified Rankin scale score <or=1. After multivariate adjustment, internal carotid artery occlusion (odds ratio 15.84, 95% confidence interval 3.12-128.69) and Alberta Stroke Program Early CT Score on diffusion-weighted imaging <or=6 (15.62, 1.78-410.12) were independent predictors of poor outcome.


CONCLUSIONS
Intravenous alteplase therapy at a dose of 0.6 mg/kg resulted in a relatively good overall outcome when compared with outcomes reported by western studies using an alteplase dose of 0.9 mg/kg. However, patients with occlusion at the internal carotid artery did not respond to this low-dose alteplase therapy.
Nakashima
T
T
Department of Medicine, National Cardiovascular Center; 5-7-1 Fujishirodai, Suita, Osaka, Japan. toyoda@ hsp.ncvc.go.jp
Toyoda
K
K
Koga
M
M
Matsuoka
H
H
Nagatsuka
K
K
Takada
T
T
Naritomi
H
H
Minematsu
K
K
D000368:Aged; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000188:drug therapy* / Q000473:pathology*; D001921:Brain / Q000473:pathology; D002545:Brain Ischemia / Q000150:complications / Q000473:pathology* / Q000628:therapy*; D016893:Carotid Stenosis / Q000150:complications / Q000473:pathology / Q000628:therapy; D038524:Diffusion Magnetic Resonance Imaging; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D020300:Intracranial Hemorrhages / Q000150:complications; D018810:Magnetic Resonance Angiography / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010960:Plasminogen Activators / Q000008:administration & dosage / Q000627:therapeutic use*; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology / Q000473:pathology*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator