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2. Intravenous thrombolysis for acute ischemic stroke associated to extracranial internal carotid artery occlusion: the ICARO-2 study

Author

Andrea Zini, Tiziana Tassinari, Alessandro Pezzini, Domenico Consoli, Paolo Frigio Nichelli, Domenico Inzitari, Alessandro Padovani, Giorgio Silvestrelli, Giovanni Orlandi, Alberto Chiti, Serena Monaco, Mascia Nesi, Simona Marcheselli, Danilo Toni, Alessio Pieroni, Gino Gialdini, Carlo Ferrarese, Michele Venti, Alfonso Ciccone, Giampiero Galletti, Caso, M. Del Sette, Manuel Cappellari, Michele Augusto Riva, Mauro Silvestrini, Raffaella Cerqua, M. L. Delodovici, Claudia Trentini, Rossana Tassi, Elisabetta Traverso, P Bovi, Emilio Luda, Patrizia Nencini, Paolo Previdi, Giancarlo Agnelli, Maurizio Paciaroni, Giorgio Bono, Alessia Lanari, Andrea Alberti, Simone Beretta, Cataldo D'Amore, Monica Acciarresi, Giuseppe Martini, Paciaroni, M, Agnelli, G, Caso, V, Pieroni, A, Bovi, P, Cappellari, M, Zini, A, Nichelli, P, Inzitari, D, Nesi, M, Nencini, P, Pezzini, A, Padovani, A, Tassinari, T, Orlandi, G, Chiti, A, Gialdini, G, Alberti, A, Venti, M, Acciarresi, M, D'Amore, C, Luda, E, Tassi, R, Martini, G, Ferrarese, C, Beretta, S, Trentini, C, Silvestrelli, G, Lanari, A, Previdi, P, Ciccone, A, Delodovici, M, Bono, G, Galletti, G, Marcheselli, S, Del Sette, M, Traverso, E, Riva, M, Silvestrini, M, Cerqua, R, Consoli, D, Monaco, S, and Toni, D

Subjects
Carotid Artery Diseases, Male, Neurology, patent foramen ovale, medicine.medical_treatment, stroke, trombolysis ischemic, Tissue plasminogen activator, Brain Ischemia, Brain ischemia, Cohort Studies, Systemic thrombolysis, Outcome Assessment, Health Care, Occlusion, 80 and over, Acute stroke, Multicenter Studies as Topic, Thrombolytic Therapy, carotid occlusion, acute stroke, systemic thrombolysis, outcome, Stroke, Carotid occlusion, Outcome, Aged, 80 and over, Fibrinolytic Agent, Thrombolysis, Middle Aged, Administration, Intravenous, Aged, Case-Control Studies, Female, Fibrinolytic Agents, Humans, Outcome Assessment (Health Care), Tissue Plasminogen Activator, Treatment Outcome, Neurology (clinical), Cardiology and Cardiovascular Medicine, Administration, Cardiology, Internal carotid artery, Case-Control Studie, Intravenous, Human, medicine.drug, medicine.medical_specialty, Intravenous thrombolysis, education, Administration, Intravenou, Systemic thrombolysi, Carotid Artery Occlusion, Internal medicine, medicine.artery, medicine, cardiovascular diseases, Carotid Artery Disease, business.industry, medicine.disease, Acute Ischemic Stroke, Cohort Studie, business, Fibrinolytic agent
Abstract

Background and Purposes: In a case-control study in patients with acute ischemic stroke and extracranial internal carotid artery (eICA) occlusion, thrombolytic treatment was associated with increased mortality. The aim of this cohort study was to assess the efficacy and safety of thrombolysis in patients with eICA occlusion compared to those without eICA occlusion. Methods: Consecutive patients treated with intravenous tissue-type plasminogen activator within 4.5 h from symptom onset included in the Safe Implementation of Thrombolysis in Stroke – International Stroke Thrombolysis Registry (SITS-ISTR) in 20 Italian centres were analyzed. Acute carotid occlusion was diagnosed using ultrasound examination, angio-CT scan or angio-MRI. Since the SITS-ISTR database did not plan to report the site of vessel occlusion, each participating center provided the code of the patient with eICA occlusion. Patients were divided into 2 groups, those with and those without eICA occlusion. Main outcome measures were: death, disability (modified Rankin Scale, mRS, 3–6) and any intracranial bleeding at 3 months. Multiple logistic regression analysis was performed to reveal predictors for main outcomes. The following variables of interest were included in the analysis: presence of eICA occlusion, age, gender, diabetes mellitus, hyperlipidemia, atrial fibrillation, congestive heart failure, previous stroke, current smoking, antiplatelet treatment at stroke onset, baseline NIHSS score, baseline blood glucose, cholesterol and blood pressure, history of hypertension and stroke onset to treatment time. Results: A total of 1,761 patients without eICA occlusion and 137 with eICA occlusion were included in the study. At 3 months, 42 patients were lost to follow-up (3 with eICA occlusion). Death occurred in 30 (22.4%) patients with eICA occlusion and in 175 (10.2%) patients without (p < 0.0001). Death or disability at 3 months occurred in 91 of 134 patients with eICA occlusion (67.9%) compared with 654 of 1,722 patients without eICA occlusion (37.9%, p < 0.0001). No or minimal disability at 3 months (mRS 0–1) was reported in 25 (18.7%) patients with eICA occlusion and in 829 (48.2%) patients without (p < 0.0001). Any intracranial bleeding detected by CT or MRI at posttreatment imaging was seen in 16 (11.7%) patients with eICA occlusion and in 314 (17.8%) of those without (p = 0.09). The proportion of symptomatic intracerebral hemorrhage was 5.8% for patients with eICA occlusion and 8.0% for patients without (p = 0.16). At logistic regression analysis, eICA occlusion was associated with mortality (odds ratio, OR 5.7; 95% confidence interval, CI 2.9–11.1) and mortality or disability (OR 5.0; 95% CI 2.9–8.7) at 90 days. Conclusions: This cohort study in patients with acute ischemic stroke treated with thrombolysis showed an association between eICA occlusion and adverse outcome.

Published
2012

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