London, United Kingdom 2013 Cerebrovasc Dis 2013; 35 (suppl 3)1-854 169 3 Acute stroke: clinical patterns and practice 16:50 - 17:00 Acute stroke involving more than one-third MCA territory on plain CT brain should not be a contraindication for IV thrombolysis V.K. Sharma1, H.L. Teoh2, B.P.L. Chan3, E.Y. Ting4, V.F. Chong5, R.C. Seet6, R. Rathakrish-nan7, L.L. Yeo8 National University of Singapore, Singapore, SINGAPORE1,National University Health System, Singapore, 2, National University Health System, Singapore, 3, National University Health System, Singapore, 4, National University Health System, Singapore, 5, National Univer-sity of Singapore, Singapore, 6, National University Health System, Singapore, 7, National Uni-versity Health System, Singapore, SINGAPORE8 Background and Purpose: Intravenous tissue plasminogen activator (IV- tPA) remains the only approved therapeutic agent to achieve arterial recanalization in acute ischemic stroke (AIS). Involvement of more than one-third of middle cerebral artery (MCA) territory on initial brain CT is a relative contraindication for IV-tPA and often associated with poor functional outcome at 3 months. We present our results of IV-thrombolysis among these patients. Methods: Data for consecutive stroke patients treated with IV-tPA within 4.5 hours of symp-tom onset were analyzed. Data were collected for demography, risk factors, NIHSS scores and blood pressure levels before IV-tPA bolus. The presence of early ischemic signs involving more than one-third of the MCA on the initial CT scan was measured by Alberta Stroke Program Ear-ly CT score (ASPECTS <8 points). Outcomes were assessed by modified Rankin Scale (mRS) score at 3 months. Results: A total of 97 AIS patients with more than one-third MCA involvement received IV-tPA during the study period. Median age was 70 yrs (range 38-89), 54% male, median NIHSS score 20 points (range 3-30) and median onset-to-treatment time 152 minutes (range 55-270). Forty-two (43.5%) patients achieved good functional outcomes at 3 months (mRS score 0-1). Factors associated with good outcome at 3 months on univariate analysis were younger age and lower NIHSS score at presentation. After multivariate analysis, lower NIHSS scores at presen-tation was noted as the only independent predictor of good outcome at 3 months (OR 0.918 95%CI 0.880-0.958 p= <0.001 ). The presence of >1/3 MCA involvement on the initial CT scan (ASPECTS <8) was not associated with a poor functional outcome at 3 months (OR 1.495 95% CI 0.881-2.540; p=0.136). Conclusions: Patients with acute ischemic stroke involving more than one-third of the MCA on initial brain CT scan, especially if associated with lower NIHSS score, should not be excluded from systemic thrombolysis. 4 Acute stroke: clinical patterns and practice 17:00 - 17:10 Predictions of intracranial haemorrhage and the risks and benefits of rtPA in acute isch-aemic stroke: an analysis of the IST-3 trial W.N. Whiteley1, D. Thompson2, G. Cohen3, R Lindley4, J.M. Wardlaw5, P.A.G. Sandercock6 on behalf of the IST-3 collaborative group University of Edinburgh, Edinburgh, UNITED KINGDOM1,University of Edinburgh, Ed-inburgh, UNITED KINGDOM2, University of Edinburgh, Edinburgh, UNITED KINGDOM3, Sydney Medical School – Westmead Hospital and The George Institute for Global Health, Uni-versity of Sydney, Sydney, UNITED KINGDOM4, University of Edinburgh, Edinburgh, UNIT-ED KINGDOM5, University of Edinburgh, Edinburgh, UNITED KINGDOM6 BACKGROUND Intracranial haemorrhage (ICH) is a serious complication of intravenous thrombolysis for isch-aemic stroke. We sought: to evaluate the predictions of post rtPA ICH by prognostic models; and to determine whether or not ischaemic stroke patients at a higher predicted risk of ICH had a lesser overall benefit from rtPA. METHODS The IST-3 trial randomised 3035 acute ischaemic stroke patients to receive either intravenous rtPA or standard treatment. In patients treated with rtPA, we calculated the predicted risk of post rtPA ICH with 5 clinical prognostic models (HATS, SEDAN, SITS, GRASPS and an NI-HSS/ age model), and calculated statistics of discrimination and calibration for each model. In all patients in the trial, we determined whether those patients at a higher predicted risk of ICH were on average harmed by rtPA relative to patients at a lower predicted risk by calculating the statistical significance of a continuous (predicted risk of ICH x treatment) interaction term in an ordinal ’shift’ analysis of the whole Oxford Handicap Scale. RESULTS In the rtPA arm of IST-3, 6.9% (104/1505) patients had a symptomatic ICH. Each previously developed prognostic model discriminated modestly between patients who did and did not de-velop post rtPA ICH. The areas under receiver operator curves were: HAT 0.62 (95%CI:0.57- 0.68); SEDAN 0.62 (0.57-0.68); SITS 0.63 (0.57-0.68); GRASPS 0.60 (0.55-0.66); and NI-HSS/ age 0.63 (0.58-0.69). Each model was well calibrated. There was no evidence (P>0.05) that patients at higher predicted risk of ICH calculated with any prognostic model had statisti-cally significant less benefit from rtPA relative to patients with lower risk. CONCLUSIONS In this dataset, prognostic models based on simple baseline clinical variables discriminate mod-erately between patients who develop a post rtPA ICH and those who do not. However these prognostic models for ICH do not identify acute stroke patients more or less likely to benefit from intravenous rtPA.
Karger_ESC London_2013
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