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Research ArticleInterventional
Open Access

Predictors of Functional Outcome after Emergency Carotid Artery Stenting and Intra-Arterial Thrombolysis for Treatment of Acute Stroke Associated with Obstruction of the Proximal Internal Carotid Artery and Tandem Downstream Occlusion

H.S. Kwak, S.B. Hwang, G.Y. Jin, D.S. Hippe and G.H. Chung
American Journal of Neuroradiology April 2013, 34 (4) 841-846; DOI: https://doi.org/10.3174/ajnr.A3304
H.S. Kwak
aFrom the Department of Radiology and Research Institute of Medical Science (H.S.K., S.B.H., G.Y.J., G.H.C.), Chonbuk National University Medical School and Hospital, Chonbuk, South Korea
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S.B. Hwang
aFrom the Department of Radiology and Research Institute of Medical Science (H.S.K., S.B.H., G.Y.J., G.H.C.), Chonbuk National University Medical School and Hospital, Chonbuk, South Korea
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G.Y. Jin
aFrom the Department of Radiology and Research Institute of Medical Science (H.S.K., S.B.H., G.Y.J., G.H.C.), Chonbuk National University Medical School and Hospital, Chonbuk, South Korea
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D.S. Hippe
bDepartment of Radiology (D.S.H.), University of Washington, Seattle, Washington.
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G.H. Chung
aFrom the Department of Radiology and Research Institute of Medical Science (H.S.K., S.B.H., G.Y.J., G.H.C.), Chonbuk National University Medical School and Hospital, Chonbuk, South Korea
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    Fig. 1.

    The NIHSS score on admission and at 3 months. A, NIHSS score of all patients (n = 31) excluding 4 patients who died. Median NIHSS scores were 12 on admission and 4 at 3 months (3 patients went from 9 to 2, three patients went from 8 to 1, and 2 patients went from 9 to 1). B, NIHSS scores of patients (n = 22) with favorable outcomes (mRS, 0–2) (3 patients went from 9 to 2, three patients went from 8 to 1, and 2 patients went from 9 to 1). Median NIHSS scores were 9 and 2. C, NIHSS scores of patients (n = 9) with unfavorable outcomes (mRS, 3–6). Median NIHSS scores were 17 and 9, respectively.

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    Table 1:

    Summary of patient demographics, preprocedural findings, periprocedural findings, and outcomes after 3 months

    Patient DemographicsNo. (%) or Median (IQR)Range
    Age (yr)65 (63–76)51–84
    Male31 (88.6)–
    Previous medical history––
        Diabetes mellitus7 (20.0)–
        Hypertension19 (54.3)–
        Hypercholesterolemia10 (28.6)–
        Smoking17 (48.6)–
        Cardiac disease5 (14.3)–
        Prior stroke6 (17.1)–
    Preprocedural findings
        Time to hospital (min)a180 (125–210)60–340
        Time to IA therapy (min)a270 (190–310)140–435
        NIHSS at admission12 (8–17)6–22
        Modified Rankin scale4 (3–4)3–5
            311 (31.4)–
            421 (60.0)–
            53 (8.6)–
        Right-sided occlusion15 (42.9)–
        Tandem occlusion site––
            M125 (71.4)–
            M25 (14.3)–
            Distal ICA thrombus5 (14.3)–
        Received IV rtPA8 (22.9)–
    Periprocedural findings
        Procedure duration (min)90 (68–120)40–180
        Urokinase dose (× 104 U)10 (10–30)10–50
        TICI grade––
            IIa9 (25.7)–
            IIb7 (20.0)–
            III19 (54.3)–
        Complications2 (5.7)–
            Symptomatic hemorrhage1 (2.9)–
            Brain swelling1 (2.9)–
    Follow-up evaluation at 3 months
        NIHSSb4 (2–7)1–17
        Modified Rankin Scale2 (1–3)0–6
            03 (8.6)–
            111 (31.4)–
            28 (22.9)–
            35 (14.3)–
            44 (11.4)–
            50 (0.0)–
            64 (11.4)–
        Favorable outcome22 (62.9)–
        Mortality4 (11.4)–
    • Note:—IQR indicates interquartile range; IA indicates intra-arterial.

    • ↵a From onset of symptoms.

    • ↵b Excluding the 4 patients who died within 3 months. Favorable outcome was defined as a modified Rankin Scale score of ≤2 at 3 months.

    • View popup
    Table 2:

    Comparisons between patients who had favorable and unfavorable outcomes 3 months after recanalization

    Patient Demographics% or Median (IQR)P
    Favorable Outcome (n = 22)Unfavorable Outcome (n = 13)
    Age (yr)64 (61–69)73 (65–77).040
    Male90.984.6.618
    Medical history–––
        Diabetes mellitus22.715.4.689
        Hypertension54.553.81.000
        Hypercholesterolemia27.330.81.000
        Smoking45.553.8.733
        Cardiac disease18.27.7.630
        Prior stroke9.130.8.166
    Preprocedural findings
        Time to hospital (min)a180 (138–208)180 (100–210).851
        Time to IA therapy (min)a255 (200–279)280 (180–360).669
        NIHSS score at admission9 (8–14)17 (13–18).003
        Modified Rankin Scale score4 (3–4)4 (4–4).005
            345.57.7.027
            454.569.2.486
            50.023.1.044
        Right-sided occlusion27.369.2.032
    Tandem occlusion site––.247b
            M163.684.6.259
            M222.70.0.134
            Distal ICA thrombus13.615.41.000
        Received IV rtPA18.230.8.433
    Periprocedural findings
        Procedure duration (min)90 (66–128)95 (70–110).891
        Urokinase dose (×104 U)10 (10–30)20 (10–20).648
        TICI grade––.006c
            IIa9.153.8.006
            IIb22.715.4.689
            III68.230.8.043
    Complications0.015.4.144
            Symptomatic hemorrhage0.07.7.371
            Brain swelling0.07.7.371
    Follow-up evaluation at 3 months
        NIHSS scored2 (2–4)9 (6–16)<.001
    • Note:—IQR indicates interquartile range; IA, intra-arterial.

    • ↵a From onset of symptoms.

    • ↵b Fisher exact test.

    • ↵c χ2 test for trend. Favorable outcome was defined as a modified Rankin Scale score of ≤2 at 3 months.

    • ↵d Excluding the 4 patients who died within 3 months.

    • View popup
    Table 3:

    Multivariate logistic regression results for independent predictors of an unfavorable outcome after 3 monthsa

    PredictorUnivariateMultivariate
    OR (95% CI)POR (95% CI)P
    NIHSS score at admission (per unit change)1.4 (1.1–1.7).0031.8 (1.1–3.1).022
    TICI grade IIa11.7 (1.9–71.8).006458 (3.4–627).015
    Right-sided occlusion6.0 (1.3–27.0).03231.9 (1.1–9.1).043
    • Note:—OR indicates odds ratio; CI, confidence interval.

    • ↵a Variables were chosen by backward selection. Univariate columns show results for each variable fit separately. Multivariate columns show results from a single model fitting all variables simultaneously.

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American Journal of Neuroradiology: 34 (4)
American Journal of Neuroradiology
Vol. 34, Issue 4
1 Apr 2013
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Predictors of Functional Outcome after Emergency Carotid Artery Stenting and Intra-Arterial Thrombolysis for Treatment of Acute Stroke Associated with Obstruction of the Proximal Internal Carotid Artery and Tandem Downstream Occlusion
H.S. Kwak, S.B. Hwang, G.Y. Jin, D.S. Hippe, G.H. Chung
American Journal of Neuroradiology Apr 2013, 34 (4) 841-846; DOI: 10.3174/ajnr.A3304

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Predictors of Functional Outcome after Emergency Carotid Artery Stenting and Intra-Arterial Thrombolysis for Treatment of Acute Stroke Associated with Obstruction of the Proximal Internal Carotid Artery and Tandem Downstream Occlusion
H.S. Kwak, S.B. Hwang, G.Y. Jin, D.S. Hippe, G.H. Chung
American Journal of Neuroradiology Apr 2013, 34 (4) 841-846; DOI: 10.3174/ajnr.A3304
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