Determinants of early outcomes in patients with acute ischemic stroke and proximal artery occlusion

J Stroke Cerebrovasc Dis. Nov-Dec 2014;23(10):2527-2532. doi: 10.1016/j.jstrokecerebrovasdis.2014.03.020. Epub 2014 Sep 18.

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.

Keywords: Stroke; endovascular treatment; outcome; proximal artery occlusion; tPA.

Publication types

  • Evaluation Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Intravenous
  • Aged
  • Aged, 80 and over
  • Arterial Occlusive Diseases / complications
  • Arterial Occlusive Diseases / mortality
  • Arterial Occlusive Diseases / therapy*
  • Brain Ischemia / etiology
  • Brain Ischemia / mortality
  • Brain Ischemia / rehabilitation
  • Brain Ischemia / therapy*
  • Combined Modality Therapy / methods
  • Endovascular Procedures / methods*
  • Female
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Injections, Intra-Arterial / methods*
  • Logistic Models
  • Male
  • Middle Aged
  • Patient Discharge / statistics & numerical data
  • Prospective Studies
  • Regional Blood Flow / drug effects
  • Stroke / etiology
  • Stroke / mortality
  • Stroke / therapy*
  • Stroke Rehabilitation
  • Time Factors
  • Tissue Plasminogen Activator / administration & dosage
  • Tissue Plasminogen Activator / therapeutic use*
  • Treatment Outcome

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator