Skip to main content

Brain Imaging Findings and Response to Intravenous Thrombolysis in Posterior Circulation Stroke

Abstract

Introduction

Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischaemic stroke (ACIS) and posterior circulation ischaemic stroke (PCIS). Our aim was to evaluate the predictors for a good clinical outcome and intracerebral haemorrhage (ICH) in patients undergoing posterior circulation IVT based on the initially performed CT or MR imaging.

Methods

The study cohort consisted of 1643 consecutive patients with acute ischaemic stroke (1440 ACIS, 203 PCIS cases) who underwent IVT. ICH was classified according to the European Cooperative Acute Stroke Study (ECASS) I protocol. Clinical outcome was assessed using the modified Rankin scale (mRS). Early ischaemic signs and pre-existing structural signs were assessed.

Results

Good clinical outcomes (mRS 0–1) were noted in 45.3% of patients with PCIS, with a mortality rate of 14.8%. ICH was noted in 8.3%, and a large haemorrhage was found in 2.4% of patients. Some early ischaemic signs and pre-existing structural signs on initial CT/MR imaging correlated significantly with the 90-day clinical outcome.

Conclusions

Early ischaemic signs and pre-existing structural signs should be considered during the assessment of patients with PCIS eligible for IVT. Tissue hypoattenuation on initial CT scans correlates with an increased risk of death. Similarly to anterior circulation, atrophy on initial MRI may negatively predict good clinical outcome in posterior circulation.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. 1.

    Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischemic stroke. Cochrane Database Syst Rev. 2014;29(7):CD000213.

    Google Scholar 

  2. 2.

    Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929–35.

    CAS  Article  Google Scholar 

  3. 3.

    Wardlaw JM, Sandercock P, Cohen G, et al. Association between brain imaging signs, early and late outcomes, and response to intravenous alteplase after acute ischemic stroke in the third International Stroke Trial (IST-3): secondary analysis of a randomised controlled trial. Lancet Neurol. 2015;14(5):485–96.

    Article  Google Scholar 

  4. 4.

    von Kummer R, Bourquain H, Bastianello S, et al. Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology. 2001;219(1):95–100.

    Article  Google Scholar 

  5. 5.

    Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995;274(13):1017–25.

    CAS  Article  Google Scholar 

  6. 6.

    Appleton JP, Woodhouse LJ, Adami A, et al. Imaging markers of small vessel disease and brain frailty, and outcomes in acute stroke. Neurology. 2020;94(5):e439–52.

    Article  Google Scholar 

  7. 7.

    Whiteley WN, Emberson J, Lees KR, et al. Risk of intracerebral haemorrhage with alteplase after acute ischemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol. 2016;15(9):925–33.

    Article  Google Scholar 

  8. 8.

    Dorňák T, Král M, Šaňák D, Kaňovský P. Intravenous thrombolysis in posterior circulation stroke. Front Neurol. 2019;10:417.

    Article  Google Scholar 

  9. 9.

    Dorňák T, Král M, Sedláčková Z, et al. Predictors for intracranial hemorrhage following intravenous thrombolysis in posterior circulation stroke. Transl Stroke Res. 2018;9(6):582–8.

    Article  Google Scholar 

  10. 10.

    Dornak T, Herzig R, Sanak D, Skoloudik D. Management of acute basilar artery occlusion: should any treatment strategy prevail? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2014;158(4):528–34.

    Article  Google Scholar 

  11. 11.

    Olsen TS, Langhorne P, Diener HC, et al. European Stroke Initiative recommendations for stroke management-update 2003. Cerebrovasc Dis. 2003;16(4):311–37.

    Article  Google Scholar 

  12. 12.

    European Stroke Organisation (ESO) Executive Committee ESO; Writing Committee. Guidelines for management of ischemic stroke and transient ischemic attack. Cerebrovasc Dis 2008; 25(5):457–507.

  13. 13.

    European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Should the time window for intravenous thrombolysis be extended? https://www.congrex-switzerland.com/fileadmin/files/2013/eso-stroke/pdf/ESO_Guideline_Update_Jan_2009.pdf. Accessed 4 Nov 2020.

  14. 14.

    Dorňák T, Král M, Hazlinger M, et al. Posterior vs. anterior circulation infarction: demography, outcomes, and frequency of hemorrhage after thrombolysis. Int J Stroke. 2015;10(8):1224–8.

    Article  Google Scholar 

  15. 15.

    Tei H, Uchiyama S, Usui T, Ohara K. Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome. J Neurol. 2010;257(5):767–73.

    Article  Google Scholar 

  16. 16.

    Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670–4.

    CAS  Article  Google Scholar 

  17. 17.

    Savoiardo M, Grisoli M. Computed tomography scanning. In: Barnett HJM, Mohr JP, Stein BM, Yatsu FM, editors. Stroke: pathophysiology, diagnosis and management. 4th ed. Philadelphia: Churchill Livingstone; 2004; p. 196–200.

  18. 18.

    Prakkamakul S, Yoo AJ. ASPECTS CT in acute ischemia: review of current data. Top Magn Reson Imaging. 2017;26(3):103–12.

    Article  Google Scholar 

  19. 19.

    van Swieten JC, Kappelle LJ, Algra A, van Latum JC, Koudstaal PJ, van Gijn J. Hypodensity of the cerebral white matter in patients with transient ischemic attack or minor stroke: influence on the rate of subsequent stroke. Dutch TIA Trial Study Group. Ann Neurol. 1992;32(2):177–83.

    Article  Google Scholar 

  20. 20.

    Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. AJR Am J Roentgenol. 1987;149(2):351–6.

    CAS  Article  Google Scholar 

  21. 21.

    Kim KW, MacFall JR, Payne ME. Classification of white matter lesions on magnetic resonance imaging in elderly persons. Biol Psychiatr. 2008;64(4):273–80.

    Article  Google Scholar 

  22. 22.

    Renou P, Sibon I, Tourdias T, et al. Reliability of the ECASS radiological classification of postthrombolysis brain haemorrhage: a comparison of CT and three MRI sequences. Cerebrovasc Dis. 2010;29(6):597–604.

    CAS  Article  Google Scholar 

  23. 23.

    Sandercock P, Wardlaw JM, Lindley RI, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischemic stroke (the third International Stroke Trial [IST-3]): a randomised controlled trial. Lancet. 2012;379(9834):2352–63.

    Article  Google Scholar 

  24. 24.

    Shamy MC, Jaigobin CS. The complexities of acute stroke decision-making: a survey of neurologists. Neurology. 2013;81(13):1130–3.

    Article  Google Scholar 

  25. 25.

    Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR. Symptoms and signs of posterior circulation ischemia in the New England Medical Center posterior circulation registry. Arch Neurol. 2012;69(3):346–51.

    Article  Google Scholar 

  26. 26.

    Liberman AL, Prabhakaran S. Stroke chameleons and stroke mimics in the emergency department. Curr Neurol Neurosci Rep. 2017;17(2):15.

    Article  Google Scholar 

  27. 27.

    Rudkin S, Cerejo R, Tayal A, Goldberg MF. Imaging of acute ischemic stroke. Emerg Radiol. 2018;25(6):659–72.

    Article  Google Scholar 

  28. 28.

    Sato S, Toyoda K, Uehara T, et al. Baseline NIH Stroke Scale Score predicting outcome in anterior and posterior circulation strokes. Neurology. 2008;70(24 Pt2):2371–7.

    CAS  Article  Google Scholar 

  29. 29.

    Burns JD, Rindler RS, Carr C, et al. Delay in diagnosis of basilar artery stroke. Neurocrit Care. 2016;24(2):172–9.

    Article  Google Scholar 

  30. 30.

    Cumming TB, Marshall RS, Lazar RM. Stroke, cognitive deficits, and rehabilitation: still an incomplete picture. Int J Stroke. 2013;8(1):38–45.

    Article  Google Scholar 

  31. 31.

    Werner MF, López-Rueda A, Zarco FX, et al. Value of posterior circulation ASPECTS and Pons-Midbrain Index on non-contrast CT and CT angiography source images in patients with basilar artery occlusion recanalized after mechanical thrombectomy. Radiologia. 2019;61(2):143–52.

    CAS  Article  Google Scholar 

  32. 32.

    Marinković SV, Gibo H. The surgical anatomy of the perforating branches of the basilar artery. Neurosurgery. 1993;33(1):80–7.

    PubMed  Google Scholar 

  33. 33.

    Puetz V, Sylaja PN, Coutts SB, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke. 2008;39(9):2485–90.

    Article  Google Scholar 

  34. 34.

    Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–110.

    Article  Google Scholar 

Download references

Acknowledgements

Funding

This study was conducted on an academic basis and was supported by AZV CR – Health Research Council of the Czech Republic no. 17-29452A, 17-30101A and NV19-06-00216; by grant project LO1304 from the Ministry of Education of the Czech Republic; by the institutional support of the Ministry of Health of the Czech Republic MH CZ – DRO (FNOL, 00098892) –2018,2019,2020. The journal’s rapid service fee was also funded by the above mentioned grants.

Authorship

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Medical Writing, Editorial, and Other Assistance

The authors thank Anne Johnson for language editing (Rightedit) which was supported by AZV CR – Health Research Council of the Czech Republic no. 17-29452A, 17-30101A and NV19-06-00216; by grant project LO1304 from the Ministry of Education of the Czech Republic; by the institutional support of the Ministry of Health of the Czech Republic MH CZ – DRO (FNOL, 00098892) –2018,2019,2020.

Disclosures

Tomáš Dorňák, Zuzana Sedláčková, Jakub Čivrný, Michal Král, Petra Divišová, Petr Polidar, Daniel Šaňák, Jana Zapletalová and Petr Kaňovský have nothing to disclose.

Compliance with Ethics Guidelines

The entire study was conducted in accordance with the Helsinki Declaration of 1975 (as revised in 2004 and 2008). All subjects gave informed consent with anonymised data processing. The study protocol was approved by institutional review board: ethic committee of Palacký University and University Hospital Olomouc.

Data Availability

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Tomáš Dorňák.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dorňák, T., Sedláčková, Z., Čivrný, J. et al. Brain Imaging Findings and Response to Intravenous Thrombolysis in Posterior Circulation Stroke. Adv Ther 38, 627–639 (2021). https://doi.org/10.1007/s12325-020-01547-z

Download citation

Keywords

  • Alteplase
  • Imaging
  • Posterior circulation
  • Ischaemic stroke
  • Thrombolysis