Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset

L. Derex, T. A. Tomsick, Thomas G Brott, C. A. Lewandowski, M. R. Frankel, W. Clark, S. Starkman, J. Spilker, G. J. Udsten, J. Khoury, J. C. Grotta, J. P. Broderick

Research output: Contribution to journalArticle

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Abstract

BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.

Original languageEnglish (US)
Pages (from-to)685-690
Number of pages6
JournalAmerican Journal of Neuroradiology
Volume22
Issue number4
StatePublished - 2001
Externally publishedYes

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Stroke
Angiography
Cerebral Infarction
Tissue Plasminogen Activator
Emergencies
Cerebral Angiography
Thrombolytic Therapy
Arterioles
Neurologic Manifestations
Microvessels
Neuroimaging
Infarction
Ischemia
Placebos
Safety

ASJC Scopus subject areas

  • Clinical Neurology
  • Radiology Nuclear Medicine and imaging
  • Radiological and Ultrasound Technology

Cite this

Derex, L., Tomsick, T. A., Brott, T. G., Lewandowski, C. A., Frankel, M. R., Clark, W., ... Broderick, J. P. (2001). Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset. American Journal of Neuroradiology, 22(4), 685-690.

Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset. / Derex, L.; Tomsick, T. A.; Brott, Thomas G; Lewandowski, C. A.; Frankel, M. R.; Clark, W.; Starkman, S.; Spilker, J.; Udsten, G. J.; Khoury, J.; Grotta, J. C.; Broderick, J. P.

In: American Journal of Neuroradiology, Vol. 22, No. 4, 2001, p. 685-690.

Research output: Contribution to journalArticle

Derex, L, Tomsick, TA, Brott, TG, Lewandowski, CA, Frankel, MR, Clark, W, Starkman, S, Spilker, J, Udsten, GJ, Khoury, J, Grotta, JC & Broderick, JP 2001, 'Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset', American Journal of Neuroradiology, vol. 22, no. 4, pp. 685-690.
Derex, L. ; Tomsick, T. A. ; Brott, Thomas G ; Lewandowski, C. A. ; Frankel, M. R. ; Clark, W. ; Starkman, S. ; Spilker, J. ; Udsten, G. J. ; Khoury, J. ; Grotta, J. C. ; Broderick, J. P. / Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset. In: American Journal of Neuroradiology. 2001 ; Vol. 22, No. 4. pp. 685-690.
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abstract = "BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29{\%}) of the 34 patients. Eight (80{\%}) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 {"}no-clot{"} patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.",
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T1 - Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset

AU - Derex, L.

AU - Tomsick, T. A.

AU - Brott, Thomas G

AU - Lewandowski, C. A.

AU - Frankel, M. R.

AU - Clark, W.

AU - Starkman, S.

AU - Spilker, J.

AU - Udsten, G. J.

AU - Khoury, J.

AU - Grotta, J. C.

AU - Broderick, J. P.

PY - 2001

Y1 - 2001

N2 - BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.

AB - BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.

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