BACKGROUND AND PURPOSE: There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke. METHODS: Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0-3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated. RESULTS: Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2-3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0-1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0-2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72-20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21-5.51]). CONCLUSIONS: Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.

AMRI Mukundapur Kolkata India

Bezmialem Vakif Univesitesi Noroloji Istanbul Turkey

Calgary Stroke Program Hotchkiss Brain Institute Departments of Clinical Neurosciences and Radiology Cumming School of Medicine University of Calgary Canada

Charles LeMoyne Hospital Greenfield Park QC Canada

Department of Medicine

Department of Medicine University of Ottawa and Ottawa Hospital Research Institute Canada

Department of Neurology Keimyung University Daegu Republic of Korea

Department of Neurology Kyoto Prefectural University of Medicine Kyoto Japan

Department of Neurology Universitary Clinical Hospital of Valladolid Spain

Department of Neurosciences University of Montreal Canada

Division of Neurology University of British Columbia Vancouver British Columbia Canada

Gosford Hospital Gosford NSW Australia

Gwangju Institute of Science and Technology Republic of Korea

IDI IDIBGI Dr Josep Trueta University Hospital Girona Spain

International Clinical Research Center Department of Neurology St Anne's University Hospital Masaryk University Brno Czech Republic

Istituto Don Calabria IRCCS Sacro Cuore Hospital Negrar Italy

King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia

University of Miami FL

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