Predictors of Tissue-Type Plasminogen Activator Nonresponders According to Location of Vessel Occlusion

• DOI: 10.1161/strokeaha.111.632653
• Publication Date: 2011-12-03T06:11:20Z
• Authors: Nuno Mendonça; David Rodriguez-Luna; Marta Rubiera; Sandra Boned-Riera; Marc Ribo; Jorge Pagola; Socorro Piñeiro; Pilar Meler; Jose Alvarez-Sabin; Joan Montaner; Carlos A. Molina
• Keywords: Adult; Aged, 80 and over; Male; Adolescent; Drug Resistance; Infarction, Middle Cerebral Artery; Recovery of Function; Cerebral Arteries; Middle Aged; Brain Ischemia; 3. Good health; Stroke; 03 medical and health sciences; 0302 clinical medicine; Fibrinolytic Agents; Intracranial Embolism; Risk Factors; Tissue Plasminogen Activator; Humans; Carotid Stenosis; Female; Prospective Studies; Aged

Background and Purpose— Information on the clinical and hemodynamic profile of intravenous tissue-type plasminogen activator nonresponders, at different locations of arterial occlusion, may improve the selection of candidates for rescue reperfusion therapies. Therefore, we aim to investigate predictors of failing intravenous tissue-type plasminogen activator therapy according to occluded vessel and location of the clot.

Methods— We prospectively evaluated consecutive patients with an acute ischemic stroke admitted within the first 6 hours of onset. Five hundred forty-eight patients with documented intracranial occlusion were included. Patients were categorized according to site of vessel occlusion into 4 distinct groups: proximal middle cerebral artery occlusion (n=251), distal middle cerebral artery occlusion (n=194), internal carotid artery bifurcation occlusion (n=61), and basilar artery occlusion (n=42). Recanalization was assessed on transcranial Doppler at 1 hour of tissue-type plasminogen activator bolus.

Results—

Among patients with proximal middle cerebral artery occlusion, the presence of severe extracranial internal carotid artery stenosis or occlusion (OR, 2.36; 95% CI, 1.15–4.84; P =0.02) and age >74 years (OR, 1.84; 95% CI, 1.02–3.31; P =0.04) independently predicted no recanalization. No independent predictors of no recanalization were identified in patients with distal middle cerebral artery occlusion. In patients with internal carotid artery bifurcation occlusion, a previous diagnosis of hypertension (OR, 12.77; 95% CI, 2.12–76.88; P =0.05), and absence of atrial fibrillation (OR, 8.15; 95% CI, 1.40–47.44; P =0.02) emerged as independent predictors of no recanalization. Similarly, among patients with basilar artery occlusion, absence of atrial fibrillation was as an independent predictor of no recanalization (OR, 7.50; 95% CI, 1.40–40.35; P =0.02).

Conclusions— The use of relevant predictors of no recanalization and a rapid neurovascular evaluation may improve the selection of patients for more aggressive rescue strategies.