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Acute Stroke with Hyperdense Middle Cerebral Artery Sign Benefits from IV rtPA

Published online by Cambridge University Press:  02 December 2014

M C Tartaglia ,
S Di Legge ,
G Saposnik ,
V Jain ,
R Chan ,
M Bussière ,
V Hachinski ,
C Frank ,
K Hesser  and
D Pelz
M C Tartaglia*
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
S Di Legge
Affiliation:
Stroke Unit, University of Tor Vergata, Viale Oxford 81-00133 Rome, Italy
G Saposnik
Affiliation:
Department of Medicine, St. Michael's Hospital, University of Toronto, Ontario, Canada
V Jain
Affiliation:
Division of Research, Kaiser-Permanente Northern California, Oakland, CA, USA
R Chan
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
M Bussière
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
V Hachinski
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
C Frank
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
K Hesser
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON
D Pelz
Affiliation:
Department of Diagnostic Radiology and Nuclear Medicine, London Health Sciences Center, University of Western Ontario, London, ON
*
Division of Neurology, Dept. Clinical Neurological Sciences, University of Western Ontario, B7-005, 339 Windermere Rd, London, Ontario, N6A 5A5, Canada.
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Abstract

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Objectives:

The current management of acute ischemic stroke is intravenous (IV) recombinant tissue plasminogen activator (rtPA). The presence of a hyperdense middle cerebral artery sign (HMCAS) on pre-treatment head computed tomogram (CT) is considered a poor prognostic sign. We compared the clinical outcome in IV rtPA-treated patients with and without a HMCAS.

Design:

Retrospective analysis of prospectively collected cases treated with IV rtPA within three hours. Inclusion criteria were the presence of: i) an anterior circulation stroke; ii) a pre-treatment CT available; iii) a pre-treatment National Institutes of Health (NIH) stroke scale (NIHSS) score; and iv) a modified Rankin Score (mRS) at three months.

Results:

One hundred and thirty patients were eligible for the analysis, 64 (49%) had a HMCAS. The HMCAS group had a trend toward a higher mean (±SD) pre-treatment NIHSS score compared to the non-HMCAS group (13.9±6 vs. 12.2±6; p=0.12). Accordingly, there were more patients with severe strokes (NIHSS>10) in the HMCAS group compared to the non-HMCAS one (48/64=75% vs. 35/66=53%; p=0.009). The mean (±SD) NIHSS score 24 hours after treatment was 10.6 (±8) in the HMCAS group and 8.3 (±7) in the non-HMCAS group (p=0.08). In a multiple logistic regression analysis, the only independent predictor of poor outcome (mRS 3-6) was pre-treatment NIHSS score (p<0.001).

Conclusion:

Patients with a HMCAS receiving IV rtPA did not fare worse at three months despite a greater proportion of patients with more severe strokes. Based on the current knowledge, IV rtPA remains a good treatment for patients with a HMCAS within three hours of symptom onset.

Résumé:

RÉSUMÉ:Objectifs:

L'administration de l'activateur du plasminogène tissulaire recombinant (rt-PA) est le traitement actuel de l'accident vasculaire cérébral (AVC) ischémique aigu. La présence du signe de l'artère cérébrale moyenne hyperdense (SACMH) à la tomodensitométrie cérébrale avant traitement est considérée comme un signe de mauvais pronostic. Nous avons comparé le résultat clinique chez les patients avec et sans SACMH traités par rt-PA IV. Plan de l'étude: Nous avons effectué une analyse rétrospective de cas recueillis de façon prospective, traités au moyen de rt-PAIV dans les 3 heures du début des symptômes.

Les critères d'inclusion étaient les suivants:

la présence d'un AVC dans le territoire de la circulation antérieure ; la disponibilité d'un examen tomodensitométrique avant traitement, d'un score du NIH Stroke Scale (NIHSS) avant traitement et d'un score du Modified Rankin Scale (MRS) trois mois après l'AVC.

Résultats:

Cent trente patients rencontraient les critères d'inclusion, dont soixante-quatre (49%) avaient un SACMH. Dans le groupe avec SACMH, la moyenne du score du NIHSS avant traitement avait tendance à être plus élevée comparée à celle du groupe sans SACMH (13,9 ± 6 vs 12,2 ± 6 ; p = 0,12). Il y avait donc plus de patients atteints d'AVC sévères (NIHSS > 10) dans le groupe avec SACMH par rapport au groupe sans SACMH (48/64 = 75% vs 35/66 = 53% ; p = 0,009). Le score moyen du NIHSS 24 heures après le traitement était de 10,6 (± 8) dans le groupe avec SACMH et de 8,3 (± 7) dans le groupe sans SACMH (p = 0,08). À l'analyse de régression logistique multivariée, le seul prédicteur indépendant d'un mauvais pronostic (MRS 3-6) était le score du NIHSS avant traitement (p < 0,001).

Conclusion:

Les patients qui présentaient un SACMH et qui ont reçu du rt-PA IV n'étaient pas en plus mauvais état trois mois plus tard que ceux qui n'en présentaient pas malgré qu'une plus grande proportion d'entre eux étaient atteints d'AVC plus sévères. Selon les connaissances actuelles, le rt-PA IV administré dans les trois heures du début des symptômes est un bon traitement chez les patients porteurs d'un SACMH.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 35 , Issue 5 , November 2008 , pp. 583 - 587
Copyright
Copyright © The Canadian Journal of Neurological 2008

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