tPA administration and venous outflow profile in acute ischemic stroke patients

Good venous outflow (VO) is associated with favorable outcomes and a higher likelihood of reperfusion following endovascular thrombectomy (EVT). Can early tPA administration in acute ischemic stroke patients improve the VO profile in the baseline CTA performed before EVT?

The study authors (Dr. Tobias Faizy et al.) hypothesize that tPA administration within 4.5 hours after stroke onset and before EVT triage can result in favorable VO profiles on baseline CTA in LVO patients.

Key takeaways:

• Administering tPA before EVT in acute ischemic stroke patients with LVO was independently associated with favorable VO profiles on baseline CTA imaging.
• Patients who received tPA before EVT also had more favorable functional outcomes 90 days after treatment.

Imaging analysis

The retrospective cohort study included 717 patients from two hospitals, Stanford University and University Medical Centre Hamburg-Eppendorf. The patients had anterior LVO, and baseline NCCT, CTA, and CTP scans were available. They received tPA, EVT, or both within 16 hours of symptoms onset.

The patients were divided into two groups: those who received tPA before performing baseline CTA and those who didn't receive tPA.

• The Alberta Stroke Program Early CT Score was determined on baseline NCCT.
• The VO profile was assessed using Cortical Vein Opacification Score (COVES) on baseline CTA.
• Pial arterial collaterals were evaluated using a modified Tan scale on baseline CTA.
• The CTP scans were processed using Rapid CTP to determine the core and penumbra volumes.
• The final infarct volume was evaluated on follow-up NCCT scans.

tPA administration and VO profile

Administering tPA before EVT was independently associated with favorable VO profiles on baseline CTA imaging (p<0.001). Patients who received tPA before EVT also had more favorable functional outcomes 90 days after treatment (p<0.001).

In addition to tPA administration, good pial collaterals in baseline CTA, lower presenting NIHSS, and age were also independently associated with favorable VO profiles on baseline CTA.

The benefits of tPA plus EVT versus EVT alone have been widely debated and studied in several trials. This study shows that tPA administration could help improve VO before EVT and increase the likelihood of successful reperfusion in LVO patients. 

Rapid CTP is the only FDA-cleared software to aid patient selection for acute stroke therapy.