• R Gilberto González, Karen L Furie, Gregory V Goldmacher, Wade S Smith, Shervin Kamalian, Seyedmehdi Payabvash, Gordon J Harris, Elkan F Halpern, Walter J Koroshetz, Erica C S Camargo, William P Dillon, and Michael H Lev.
• From the Department of Radiology (R.G.G., K.L.F., G.V.G., S.K., S.P., G.J.H., E.F.H., E.C.S.C., M.H.L.), and Department of Radiology and Institute for Technology Assessment (E.F.H.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; ICON Medical Imaging (Beacon Bioscience), North Wales, PA (G.V.G.); Department of Neurology (W.S.S.), and Department of Radiology (W.P.D.), University of California at San Francisco, CA; Department of Radiology, University of Minnesota, Minneapolis (S.P.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (W.J.K.); Department of Neurology, Boston University Medical Center, MA (E.C.S.C.); and Department of Neurology, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, RI (K.L.F.).
• Stroke. 2013 Nov 1;44(11):3109-13.

Background And PurposeTo determine the effect of intravenous tissue plasminogen activator (IV-tPA) on outcomes in patients with severe major anterior circulation ischemic stroke.MethodsProspectively, 649 patients with acute stroke had admission National Institutes of Health stroke scale (NIHSS) scores, noncontrast computed tomography (CT), CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale. IV-tPA treatment decisions were made before CTA, at the time of noncontrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as modified Rankin scale >2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed.ResultsOf 649 patients, 188 (29%) patients presented with NIHSS>10, and 64 out of 188 (34%) patients received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes; however, a significant interaction existed between IV-tPA and occlusion (P<0.001). Of the patients who presented with NIHSS>10 with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17 out of 49 patients, 35%) than if they did not (13 out of 77 patients, 17%; P=0.031). The number needed to treat was 7 (95% confidence interval, 3-60).ConclusionsIV-tPA treatment resulted in significantly better outcomes in patients with severely symptomatic stroke with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies.

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