Sebina Bulic, MD

González RG, Furie KL,
 Goldmacher GV, Smith WS, Kamalian S, Payabvash S, et al. Good Outcome Rate of 35% in IV-tPA–Treated Patients With Computed Tomography Angiography Confirmed Severe Anterior CirculationOcclusive Stroke. Stroke 2013

González and colleagues evaluated retrospectively acquired data for 742 patients as part of Screening Technology and Outcomes Project in Stroke (STOPStroke) trial conducted at Massachusetts General Hospital and the University of California San Francisco Medical Center. 649 patients had admission NIH stroke scale scores (NIHSS), non-contrast CT, CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale (mRS). 188 patients had NIHSS >10 with anterior circulation occlusion (defined as occlusion of the terminal ICA and/or proximal MCA (M1, M2) segments), and 64 received-PA. Outcomes of these 64 patients were evaluated in this study (only patients resented within 3 hours from LTKW were included). Favorable outcome was defined as mRS less or equal to 2.

In summary, patients with NIHSS>10 and major anterior circulation occlusions who received IV-tPA had significantly better outcomes (17/49; 35%) than similar patients who did not receive IV-tPA (13/77; 17%, p=0.031). The proportion of good outcomes increased to 40% treated versus 17% untreated (p=0.05) if patients with CT ASPECTS of 7 or less were excluded. These results are similar with results of trials where endovascular treatment was combined with IV t-PA.

This paper highlights anterior circulation large vessel involvement and outcomes after t-PA administration, but overall mirrors results from recent studies. At this time there isn’t enough evidence to justify routine use of CTA prior to the decision weather to give t-PA or not. This paper is unlikely to change clinical practice, but adds to the accumulating evidence for t-PA in a range of clinical scenarios. For now, I am still going to make decision for t-PA administration and referral for the endovascular treatment based on individual presentation, applying standard inclusion and exclusion criteria. Routine use of ASPECTS score will help me in making those decisions. However, despite low numbers, this paper provides us with good quality data that could be used in discussion with patients about outcomes after t-PA administration when large vessel anterior circulation occlusion is identified on subsequent imaging.