Early ischemic changes after stroke do not affect rt-PA treatment outcome

By Karla Gale

NEW YORK (Reuters Health) – Ischemic changes observed by computed tomography within 3 hours of stroke onset are common. However, the results of a prospective study by the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group show that such changes do not affect outcome after treatment with recombinant tissue plasminogen activator (rt-PA).

Dr. Suresh C. Patel, of the Henry Ford Hospital and Health Science Centers in Detroit, and associates reviewed CT scans obtained within 3 hours of symptom onset from 616 patients presenting at 43 sites between 1991 and 1994.

Early ischemic changes included at least one of the following: loss of gray/white matter distinction; hypodensity or hypoattenuation; or compression of cerebrospinal fluid spaces. No such changes were observed in CT scans of 69% of cases. Ischemic changes involving up to one third of the middle cerebral artery territory were found in 18% of the scans, and changes involving in more than one third of the middle cerebral artery territory were found in 14%.

The presence of ischemic changes was associated with baseline National Institutes of Health Stroke Scale (NIHSS) scores, and time from symptom onset to initial CT scan, the investigators report in The Journal of the American Medical Association for December 12.

After adjusting for such baseline variables as age, diabetes, NIHSS score, mean arterial pressure, aspirin use, and old lesion volume, there was no relationship between the presence of early ischemic changes and treatment response to rt-PA.

Treatment response was also unaffected by extent of the ischemic changes, Dr. Patel told Reuters Health. After adjusting for NIHSS score, the ischemic changes were not associated with symptomatic intracerebral hemorrhage within 36 hours of treatment.

"So if the patient is certain that the symptoms began within the previous 3 hours, subtle ischemic changes are not a contraindication for giving thrombolytic therapy," the investigator added.

Dr. Patel's group points out that their findings conflict with those reported by European Cooperative Acute Stroke Study (ECASS) investigators. However, the authors note, "it does not appear that the [ECASS] investigators adjusted for baseline variables nor did they test directly for an early ischemic change X treatment interaction as was done in this study."

When it comes to treatment of ischemic stroke, Dr. Patel said, "time is brain, and the earlier treatment is implemented, the better the outcome."

JAMA 2001;286:2830-2838.

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