(Beth Israel, Boston) Lanfante et al, Stroke 2002.
This is not a summary of the article but presentation of a few facts pulled out from it. With initial NIHSS score of 16 or above most do not recanalize with iv tpa. At NIH of 14 or below, MCA strokes recanalize much better than ICA strokes.Outcome correlates closely with recanlization.
Christou et al showed that recanalization after iv tpa in 60 patients with TIMI 2 or 3, 80 % MCA recanalized, 25 % ICA, 19% MCA-ICA, 7 % BA recanalized.
Frequency of iv tpa use: national estimate is 1-2%. 30,000 ischemic strokes per month, 500 get iv tpa, 29,500 do not.
There are 3 categories of patients to consider. 1) Those excluded from iv tpa (time,recent stroke, 2 weeks surgery, trauma, coagulopathy or INR>1.7) 2) Nonresponders 3) Reooclusion after initial reperfusion.
Mechanical reperfusion-- no thrombolytics used to reduce chance of bleeding (MERCI 1st and 2d generation, angioplasty and stenting). "Requires a learning curve." Soft clots don't respond as well.
MultiMERCI
use of iv tPA allowed, newer device MERCI 1.5
mean age 66, baseline NIHSS 19, 34 %mRS <2 90 days, 30 % mortality at 90 days, 9 % SICH, 10 % procedure related SAE's (dissection, vessel perforation, distal embolization). Comment one third get better whereas they had been doomed to death or disability previously. Across trials all had about one third good outcome by mRS.
Patient selection:
How to select patients better.
MR rescue up to 8 hours
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