Should Patients With Acute Minor Ischemic Stroke With Isolated Internal Carotid Artery Occlusion Be Thrombolysed?
Authors: Boulenoir Naouel , Turc Guillaume , Ter Schiphorst Adrien , Heldner Mirjam R. , Strambo Davide , Laksiri Nadia , Girard Buttaz Isabelle , Papassin Jérémie , Sibon Igor , Chausson Nicolas , Michel Patrik , Rosso Charlotte , Bourdain Frédéric , Lamy Chantal , Weisenburger-Lile David , Agius Pierre , Yger Marion , Obadia Michael , Sablot Denis , Legris Nicolas , Jung Simon , Pilgram-Pastor Sara , Henon Hilde , Bernardaud Lucy , Arquizan Caroline , Baron Jean-Claude , Seners Pierre , Ben Hassen Wagih , Lapergue Bertrand , Lucas Ludovic , Leys Didier , Philippeau Frédéric , Bennani Omar , Mechtouff Laura , Klapczynski Frédéric , Detante Olivier , Costalat Vincent , Mione Gioia , Gazzola Sébastien , Debiais Séverine , Cakmak Serkan , Grigoras Valer , Denier Christian , Smadja Didier , Mounier-Vehier François , Peres Roxane , Spelle Laurent , Bricout Nicolas , Bracard Serge , Triquenot Aude , Lyoubi Aïcha , Cottier Jean-Philippe , Duong Duc-Long , Ollivier Camille 
Published: September 2022

Background:
We recently reported a worrying 30% rate of early neurological deterioration (END) occurring within 24 hours following intravenous thrombolysis (IVT) in minor stroke with isolated internal carotid artery occlusion (ie, without additional intracranial occlusion), mainly due to artery-to-artery embolism. Here, we hypothesize that in this setting IVT—as compared to no-IVT—may foster END, in particular by favoring artery-to-artery embolism from thrombus fragmentation.

Methods:

From a large multicenter retrospective database, we compared minor stroke (National Institutes of Health Stroke Scale score <6) isolated internal carotid artery occlusion patients treated within 4.5 hours of symptoms onset with either IVT or antithrombotic therapy between 2006 and 2020 (inclusion date varied among centers). Primary outcome was END within 24 hours (≥4 National Institutes of Health Stroke Scale points increase within 24 hours), and secondary outcomes were END within 7 days (END
7d
) and 3-month modified Rankin Scale score 0 to 1.

Results:

Overall, 189 patients were included (IVT=95; antithrombotics=94 [antiplatelets, n=58, anticoagulants, n=36]) from 34 centers. END within 24 hours and END
7d
occurred in 46 (24%) and 60 (32%) patients, respectively. Baseline clinical and radiological variables were similar between the 2 groups, except significantly higher National Institutes of Health Stroke Scale (median 3 versus 2) and shorter onset-to-imaging (124 versus 149min) in the IVT group. END within 24 hours was more frequent following IVT (33% versus 16%, adjusted hazard ratio, 2.01 [95% CI, 1.07–3.92];
P
=0.03), driven by higher odds of artery-to-artery embolism (20% versus 9%,
P
=0.09). However, END
7d
and 3-month modified Rankin Scale score of 0 to 1 did not significantly differ between the 2 groups (END
7d
: adjusted hazard ratio, 1.29 [95% CI, 0.75–2.23];
P
=0.37; modified Rankin Scale score of 0–1: adjusted odds ratio, 1.1 [95% CI, 0.6–2.2];
P
=0.71). END
7d
occurred earlier in the IVT group: median imaging-to-END 2.6 hours (interquartile range, 1.9–10.1) versus 20.4 hours (interquartile range, 7.8–34.4), respectively,
P
<0.01.

Conclusions:
In our population of minor strokes with iICAO, although END rate at 7 days and 3-month outcome were similar between the 2 groups, END—particularly END due to artery-to-artery embolism—occurred earlier following IVT. Prospective studies are warranted to further clarify the benefit/risk profile of IVT in this population.