tPA for stroke remains controversial, to say the least. The reasons behind the Emergency Medicine/Neurology disconnect are complex and covered elsewhere. Regardless, thrombolysis is here to stay – and probably helps some patients. The hard part is finding those patients with the most favorable risk/benefit ratio.
This is a study that looked at diffusion-weighted imaging to try and predict which patients were most likely to rapidly improve with tPA. These authors enrolled sixty-six patients with acute stroke eligible for tPA under the Japanese license and performed diffusion-weighted MRI on each of them. Previous studies had suggested an ASPECTS score > 7 predicted response to tPA – and this study confirmed it. Essentially, this translates as larger vascular territories showing greater improvement in NIHSS after tPA than smaller vascular territories.
There's a bit of a bias in this study, since smaller vascular territories may have produced smaller initial NIHSS. The population was quite old for a stroke study – median age 79. And, truly, the more interesting data presented is the breakdown demonstrating the massively favorable impact of early (within 1 hour) recanalization after tPA administration.
But, mildly interesting paper, important as part of a slow, gradual trend of attempts to delineate which patients have the best potential to benefit from tPA.
"DWI-ASPECTS as a Predictor of Dramatic Recovery After Intravenous Recombinant
Tissue Plasminogen Activator Administration in Patients With Middle Cerebral Artery