Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

G Tsivgoulis; N Goyal; A H Katsanos; K Malhotra; M F Ishfaq; A Pandhi; M T Frohler; A M Spiotta; M Anadani; M Psychogios; V Maus; A Siddiqui; M Waqas; P D Schellinger; M Groen; C Krogias; D Richter; M Saqqur; P Garcia-Bermejo; M Mokin; R Leker; J E Cohen; G Magoufis; K Psychogios; V A Lioutas; M Van Nostrand; V K Sharma; M Paciaroni; A Rentzos; H Shoirah; J Mocco; C Nickele; P D Mitsias; V Inoa; D Hoit; L Elijovich; A S Arthur; A V Alexandrov

doi:10.1111/ene.14199

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

Eur J Neurol. 2020 Jun;27(6):1039-1047. doi: 10.1111/ene.14199. Epub 2020 Mar 23.

Authors

G Tsivgoulis^{1

2}, N Goyal^{1

3}, A H Katsanos², K Malhotra⁴, M F Ishfaq¹, A Pandhi¹, M T Frohler⁵, A M Spiotta⁶, M Anadani⁶, M Psychogios⁷, V Maus⁷, A Siddiqui⁸, M Waqas⁸, P D Schellinger⁹, M Groen⁹, C Krogias¹⁰, D Richter¹⁰, M Saqqur^{11

12}, P Garcia-Bermejo¹¹, M Mokin¹³, R Leker¹⁴, J E Cohen¹⁵, G Magoufis¹⁶, K Psychogios¹⁶, V A Lioutas¹⁷, M Van Nostrand¹⁷, V K Sharma^{18

19}, M Paciaroni²⁰, A Rentzos²¹, H Shoirah²², J Mocco²², C Nickele³, P D Mitsias^{23

24}, V Inoa³, D Hoit³, L Elijovich^{1

3}, A S Arthur³, A V Alexandrov¹

Affiliations

¹ Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
² Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece.
³ Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA.
⁴ Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA.
⁵ Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA.
⁶ Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
⁷ Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany.
⁸ Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA.
⁹ Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany.
¹⁰ Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany.
¹¹ Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
¹² Department of Neurology, Hamad General Hospital, Doha, Qatar.
¹³ Department of Neurosurgery, University of South Florida, Tampa, FL, USA.
¹⁴ Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
¹⁵ Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
¹⁶ Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
¹⁷ Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
¹⁸ Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
¹⁹ Division of Neurology, National University Hospital, Singapore, Singapore.
²⁰ Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy.
²¹ Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
²² Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA.
²³ Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.
²⁴ Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece.

PMID: 32149450
DOI: 10.1111/ene.14199

Abstract

Background and purpose: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points.

Methods: The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding.

Results: We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy.

Conclusions: Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.

Keywords: intravenous thrombolysis; large vessel occlusion; medical management; mild-deficits stroke; outcome; thrombectomy.

MeSH terms

Administration, Intravenous
Aged
Brain Ischemia* / drug therapy
Female
Fibrinolytic Agents / therapeutic use
Humans
Intracranial Hemorrhages
Male
Middle Aged
Retrospective Studies
Stroke* / drug therapy
Thrombectomy
Thrombolytic Therapy
Treatment Outcome

Substances

Fibrinolytic Agents