Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke.

BACKGROUND AND PURPOSE It has been shown that thrombolytic therapy can improve clinical outcome in a subgroup of patients with acute cerebral ischemia. This subgroup was characterized by certain clinical and imaging findings (eg, moderate to severe neurological deficit for less than 3 to 6 hours, occlusion of the middle cerebral artery, lack of extended infarct signs on CT, and efficient leptomeningeal collaterals). Although not part of published prospective randomized rtPA trials, information about the status of the brain vessels would be helpful in the selection of patients who may benefit the most. Our purpose was to determine the feasibility of CT angiography (CTA) in patients with acute hemispheric ischemia and to evaluate its relevance for thrombolytic therapy. METHODS CTA was performed in 40 consecutive patients (11 women and 29 men; age range, 19 to 80 years) with moderate or severe symptoms (National Institutes of Health Stroke Scale score of > or =8) of acute hemispheric ischemia. CTA findings were compared with Doppler ultrasonography (US; n=22) and intra-arterial digital subtraction angiography (DSA; n=7). Twenty patients received thrombolytic therapy, the remaining patients received intravenous heparin. RESULTS Images and 3-dimensional reconstructions of diagnostic quality could be obtained in all patients. Thirty-four patients had a vessel occlusion. The extent of leptomeningeal collaterals correlated significantly with the outcome after thrombolytic therapy (rs=0.46, P<0.05). The evaluation of diagnostic accuracy showed a high agreement with US (22 of 22) and DSA (6 of 7). CONCLUSIONS CTA can provide important information for the initiation of therapy in patients with acute hemispheric ischemia. Identification of patients with autolyzed thrombi, occlusion of the internal carotid artery bifurcation, and poor leptomeningeal collaterals is feasible with the use of CTA. These patients may have little potential for benefit from thrombolytic therapy.

[1]  K. Sartor,et al.  Potential of CT angiography in acute ischemic stroke. , 1997, AJNR. American journal of neuroradiology.

[2]  Koroshetz Wj,et al.  Tissue plasminogen activator for acute ischemic stroke. , 1996, The New England journal of medicine.

[3]  W. Hacke,et al.  Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. , 1995, AJNR. American journal of neuroradiology.

[4]  M. Kaste,et al.  Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS) , 1995, JAMA.

[5]  P. Pech.  Book Review: Ultrasound Diagnosis of Cerebrovascular Disease. Doppler Sonography of the Extra- and Intracranial Arteries, Duplex Scanning , 1995 .

[6]  S. Napel,et al.  Circle of Willis: evaluation with spiral CT angiography, MR angiography, and conventional angiography. , 1995, Radiology.

[7]  W. Hacke,et al.  Does arterial recanalization improve outcome in carotid territory stroke? , 1995, Stroke.

[8]  M. Cumming,et al.  Carotid artery stenosis: a prospective comparison of CT angiography and conventional angiography. , 1994, AJR. American journal of roentgenology.

[9]  T. Hayakawa,et al.  Intravenous Tissue Plasminogen Activator Ameliorates the Outcome of Hyperacute Embolic Stroke , 1993 .

[10]  D. Krieger,et al.  The Prognostic Value of Collateral Blood Flow in Acute Middle Cerebral Artery Occlusion , 1993 .

[11]  A. Yamadori,et al.  Intravenous recombinant tissue plasminogen activator in acute carotid artery territory stroke , 1992, Neurology.

[12]  W. Hacke,et al.  Safety and Efficacy of Intravenous Tissue Plasminogen Activator and Heparin in Acute Middle Cerebral Artery Stroke , 1992, Stroke.

[13]  J. Broderick,et al.  Urgent Therapy for Stroke: Part I. Pilot Study of Tissue Plasminogen Activator Administered Within 90 Minutes , 1992, Stroke.

[14]  W A Kalender,et al.  Physical performance characteristics of spiral CT scanning. , 1991, Medical physics.

[15]  T. Kozuka,et al.  Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. , 1990, Radiology.

[16]  H. Mattle,et al.  Transcranial Doppler sonographic findings in middle cerebral artery disease. , 1988, Archives of neurology.

[17]  G. Lenzi,et al.  Therapeutic Window for Pharmacological Treatment in Acute Focal Cerebral Ischemia a , 1988, Annals of the New York Academy of Sciences.