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AJNR - American Journal of Neuroradiology

Published ahead of print on September 26, 2007
doi: 10.3174/ajnr.A0702

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American Journal of Neuroradiology 28:1890-1894, November-December 2007
© 2007 American Society of Neuroradiology

INTERVENTIONAL

Anterior Cerebral Artery Emboli in Combined Intravenous and Intra-arterial rtPA Treatment of Acute Ischemic Stroke in the IMS I and II Trials

S. King^a, P. Khatri^a, J. Carrozella^a, J. Spilker^a, J. Broderick^a, M. Hill^a, T. Tomsick^a for the IMS & IIMS II Investigators

^a From the Clinical Coordinating Center, IMS Studies, University of Cincinnati, Cincinnati, Ohio

Please address correspondence to Thomas A. Tomsick, MD, Department of Radiology, University Hospital, 234 Goodman St, Cincinnati, OH 45267-0762; e-mail: tomsicta{at}healthall.com

BACKGROUND AND PURPOSE: Anterior cerebral artery (ACA) emboli may occur before or during fibrinolytic revascularization of middle cerebral artery (MCA) and internal carotid artery (ICA) T occlusions. We sought to determine the incidence and effect of baseline and new embolic ACA occlusions in the Interventional Management of Stroke (IMS) studies.

MATERIALS AND METHODS: Case report forms, pretreatment and posttreatment arteriograms, and CTs from 142 subjects entered into IMS I & II were reviewed to identify subjects with baseline ACA occlusion, new ACA emboli occurring during fibrinolysis, subsequent CT-demonstrated infarction in the ACA distribution, and to evaluate global and lower extremity motor clinical outcome.

RESULTS: During M1/M2 thrombolysis procedures, new ACA embolus occurred in 1 of 60 (1.7%) subjects. Baseline distal emboli were identified in 3 of 20 (15%) T occlusions before intra-arterial (IA) treatment, and new posttreatment distal ACA emboli were identified in 3 subjects. At 24 hours, 8 (32%) T occlusions demonstrated CT-ACA infarct, typically of small volume. Infarcts were less common following sonography microcatheter-assisted thrombolysis compared with standard microcatheter thrombolysis (P = .05). Lower extremity weakness was present in 9 of 10 subjects with ACA embolus/infarct at 24 hours. The modified Rankin 0 to 2 outcomes were achieved in 4 of 25 (16%) subjects with T occlusion overall, but in 0 of 10 subjects with distal ACA emboli or ACA CT infarcts (P = .07).

CONCLUSIONS: With IV/IA recombinant tissue plasminogen activator treatment for MCA emboli, new ACA emboli are uncommon events. Distal ACA emboli during T-occlusion thrombolysis are not uncommon, typically lead to small ACA-distribution infarcts, and may limit neurologic recovery.