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Use of a fixed stroke computer tomography ( CT ) protocol improves selection strategies for revascularisation techniques for patients admitted with acute ischaemic stroke with minimal time delays and improved safety, researchers said here on October 30 at the 4th World Congress on Controversies in Neurology (CONy).

The indications, safety and efficacy of intra-arterial (IA) therapies for acute ischaemic stroke remain incompletely understood. Thus, this study compared intravenous (IV) tissue plasminogen activator (tPA) and IA thrombolysis, alone or combined, following admission of patients with ischaemic stroke, with treatment according to results of a fixed stroke CT protocol.

Linda Catalli, Family Nurse Practitioner and Specialist in Neurology, Regional Medical Centre of San Jose, San Jose, and colleagues enrolled patients with ischaemic stroke who presented at 4 different primary stroke centres within 8 hours of onset (n = 175).

Those presenting within 3 hours received a non-contrast CT head scan immediately after Emergency Department evaluation. In the absence of haemorrhage or other exclusionary findings, this was followed by CT-perfusion (CT-P).

Ten minutes later (after washout), CT-angiography (CT-A) of head and neck was performed. If IV tPA was indicated, infusion was started without delay (n = 106). Of note, even with CT-P and CT-A proceeding before serum creatinine levels were known, there were no instances of nephrotoxicity attributable to the procedures.

Patients showing measurable penumbral tissue and/or major blood vessel occlusion were treated with IA thrombolysis, with IV tPA if within the 4.5-hour window (n = 27), or without (n = 42).

As expected, due to the protocol, the IV/IA group had increased IV treatment delay over the IV group (146.0 vs 133.6 minutes), but less IA treatment delay over the IA group (316.0 vs 375.0 minutes).

For the early outcomes, the IV/IA group showed greatest mean National Institute of Health Stroke Scale (NIHSS) improvements than the other groups (P <.04 vs IV; P <.01 vs IA).

Good early outcomes were obtained, with initial stroke severity significantly lower in these survivors (P <.001).

Mortality was lower in the IV group (14.0%), but similar for IV/IA (18.2%) and IA (21.5%), while incidence of symptomatic haemorrhage was similar across groups (10.3% vs 11.1% vs 9.5%, respectively).

Following discharge home or to acute rehabilitation, the 3-month modified Rankin Scale (mRS) score was <3.0 in all groups (1.8 vs. 2.9 vs. 2.6). With mRS <=2 across groups at 72%, 54%, and 50%, this was also reflected in baseline NIHSS scores (8.3 vs 17.3 for mRS >2; P <.00016). There was no correlation between 3-month mRS scores and either onset-to-needle or onset-to-procedure times.

"The sooner that we treated, the better the outcome for the patient," said Catalli, noting that long-term outcomes favoured the IV group, probably due to earlier access to treatment.

However, use of IA therapy with or without pretreatment with IV tPA still provided significant improvement at 3 months, with a modest penalty in terms of mortality and symptomatic haemorrhage.

"By using this CT protocol procedure, we are able to predict the stroke, with or without a clot, and save more tissue," added Catalli.

Source: DG News

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