title: Determinants of early outcomes in patients with acute ischemic stroke and proximal artery occlusion.
abstract: BACKGROUND
  Proximal artery occlusions (PAO) recanalize in only a small percentage of acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV tPA) alone, yet the benefits of adjunctive or substitutive intra-arterial therapy (IAT) in this patient subgroup are not well established. We evaluated early poststroke outcomes in a cohort of AIS patients with PAO categorized as "likely to benefit" (LTB) from IAT using prespecified criteria.
  
  
  METHODS
  Using a prespecified protocol, 193 patients from our institutional stroke database admitted between January 1, 2007, and December 31, 2011, were prospectively deemed LTB from IAT. Logistic regression was used to determine independent predictors of favorable (discharge to home or acute rehabilitation) versus unfavorable (discharge to skilled nursing facility, hospice, or in-hospital mortality) outcome.
  
  
  RESULTS
  Of the patients included, 29.5% received IV tPA only, 11.4% underwent IAT only, and 37.8% had both. Overall in-hospital mortality was 19.2%. In a univariate analysis, age (odds ratio [OR], .95; 95% confidence interval [CI], .93-.98), IV tPA (OR, 2.3; 95% CI, 1.2-4.3), and history of atrial fibrillation (OR, .5; 95% CI, .28-.97) were associated with outcome. Effect of IAT was not statistically significant (OR, 1.3; 95% CI, .7-2.3; P = .4). In multivariate analysis, the only independent predictor of favorable outcome was IV tPA administration (OR, 2.4; 95% CI, 1.2-5.0). The odds of favorable poststroke outcome were significantly lowered (OR, .3; 95% CI, .1-.6; P = .0006) in those receiving neither IV tPA nor IAT.
  
  
  CONCLUSIONS
  In AIS patients with PAO thought most likely to benefit from IAT, IV tPA independently predicted favorable outcomes. These data reinforce the recommendation to provide early IV tPA to all eligible patients.
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Jamie Nicole
authors.initials: JN
authors.lastname: LaBuzetta
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Albert J
authors.initials: AJ
authors.lastname: Yoo
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Syed
authors.initials: S
authors.lastname: Ali
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Kaitlin
authors.initials: K
authors.lastname: Fitzpatrick
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Thabele
authors.initials: T
authors.lastname: Leslie-Mazwi
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hirsch
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Lee
authors.initials: L
authors.lastname: Schwamm
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts. Electronic address: nrost@partners.org.
authors.forename: Natalia
authors.initials: N
authors.lastname: Rost
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000401:mortality / Q000628:therapy*; D002545:Brain Ischemia / Q000209:etiology / Q000401:mortality / Q000534:rehabilitation / Q000628:therapy*; D003131:Combined Modality Therapy / Q000379:methods; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D007269:Injections, Intra-Arterial / Q000379:methods*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D011446:Prospective Studies; D012039:Regional Blood Flow / Q000187:drug effects; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D000071939:Stroke Rehabilitation; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Stroke; endovascular treatment; outcome; proximal artery occlusion; tPA