Intravenous Thrombolysis in the Treatment of Ischemic Stroke Due to Spontaneous Artery Dissection Maja Stefanovic ´-Budimkic ´, MD,* Ivana Berisavac, MD, MSc,* Ljiljana Beslac ´-Bumbas ˇirevic ´, MD, PhD,w Olivera Savic ´, MD, MSc,z Predrag Stanarc ˇevic ´, MD,* Marko D. Ercegovac, MD, PhD,* Vis ˇnja PaXen, MD,* and Dejana R. Jovanovic ´, MD, PhDw Objectives: Data based on randomized clinical trials regarding intra- venous thrombolysis (IVT) versus placebo or any other antithrombotic treatment in ischemic stroke (IS) due to artery dissection (AD) are not available. Methods: We used data from our observational study to examine the efficacy and safety of IVT in patients with IS due to spontaneous AD, as compared with stroke patients of the same cause who were not treated with IVT. Outcome measures were modified Rankin score (mRS) for functional outcome, death from all causes, occurrence of any intracranial hemorrhage, local signs of an intramural hematoma extension, recurrent IS, and recurrent AD. Results: In a 4-year period, 19 of 46 patients with IS due to sponta- neous AD were treated with IVT. Favorable outcome (mRS 0-2) after the follow-up period reached 81.5% of non-IVT patients compared with 94.7% of IVT-treated patients (odds ratio, 4.09; 95% confidence interval, 0.44-38.26; P = 0.377). However, the patients who received IVT had a significantly higher chance of being without any neuro- logical deficit (mRS 0) after adjusting for age, sex, baseline National Institutes of Health Stroke Scale score, and site of dissection compared with non-IVT patients after the follow-up period (P = 0.012). No symptomatic intracerebral hemorrhage, worsening of local signs, cases of subarachnoid hemorrhage, or death occurred in both groups of patients. Conclusions: The efficacy of IVT in patients with IS due to the spontaneous AD seemed to be similar or even better to those of patients of the same cause who were not treated with IVT. The com- plication rate of IVT in spontaneous AD is low. Key Words: ischemic stroke, spontaneous artery dissection, intra- venous thrombolysis, outcome (The Neurologist 2012;18:273–276) I ntravenous thrombolysis (IVT) using recombinant tissue plasminogen activator for acute ischemic stroke (IS) seems to be safe and effective, independent of the underlying stroke mechanism. 1,2 Data from randomized controlled trials on IVT in IS due to spontaneous artery dissection (AD) are not available. Etiologic classification of the subtypes of strokes is usually established after IVT has been already performed. Therefore, patients with spontaneous AD have not been spe- cifically excluded from the randomized controlled trials of IVT in stroke. 3,4 However, there are potential hazards in using IVT in patients with craniocervical AD, including extension of the intramural hematoma, dislocation of the luminal thrombus leading to distal embolization, pseudoaneurysm formation, and subarachnoid hemorrhage (SAH). 5 In patients with stroke due to aortic dissection extending to the cervical arteries, IVT might be dangerous as it is in patients with IVT for myocardial infarction. 6,7 Data on IVT versus placebo or versus any other antithrombotic treatment in patients with spontaneous AD are not available. Our study aimed to determine the efficacy and safety of IVT therapy in patients with IS due to spontaneous AD com- pared with patients with IS from the same cause who were not treated with IVT. MATERIALS AND METHODS In the period from June 2006 to February 2010, 46 patients with IS due to spontaneous AD were treated in the Stroke Unit, Department of Emergency Neurology, Clinical Centre of Serbia. The data used in this analysis are the part of our prospective, observational, ongoing study on spontaneous AD and stroke. Moreover, all stroke patients with AD treated with IVT are the part of another ongoing, prospective, multi- centre, open, observational Serbian Experience with Throm- bolysis in Ischemic Stroke study that assesses the efficacy and safety of thrombolytic therapy in Serbia. 8,9 The diagnosis of AD was confirmed, apart from the use of clinical criteria, by at least one of the following findings: (1) mural hematoma visible on axial cervical magnetic resonance (MR) imaging or double lumen visible on MR angiography; (2) arteriographic signs of a nonatherosclerotic string-like stenosis or a tapered, flame-shaped arterial occlusion, or a long filiform stenosis; and (3) intimal flap or double lumen visible on carotid ultrasound or the presence of high-resistance blood flow velocity corresponding to an ipsilateral distal occlu- sion. 10–12 As computed tomography (CT) angiography has only recently become available in our center, only 3 patients received this kind of imaging. Apart from strong clinical sus- picion (head/neck/face pain, ipsilateral Horner syndrome, prior minor trauma, etc.), the diagnosis of spontaneous AD was established after the patient had received IVT. IVT was per- formed according to the current guideline up to a 4.5-hour time window for hemispheric IS, and up to 12 hours for posterior circulatiuon stroke. 1 Other possible causes of the IS were excluded by selective performance of diagnostic procedures according to clinical presentation (transthoracic/transesophageal Received for publication December 28, 2010; accepted June 6, 2012. From the *Neurology Clinic, Clinical Centre of Serbia; wNeurology Clinic, Clinical Centre of Serbia, Medical Faculty, University of Belgrade; and zPrivate Hospital Euromedic, Belgrade, Serbia. Supported by the Ministry of Science, Republic of Serbia (Project no. 175022). D.R.J. has received honoraria from Boehringer Ingelheim; L.B.-B. has received honoraria from Boehringer Ingelheim. The remaining authors declare no conflict of interest. Reprints: Dejana R. Jovanovic ´, MD, PhD, Neurology Clinic, Clinical Centre of Serbia, Dr Subotic ´a 6, P.O. Box 12, 11129 Belgrade 102, Serbia. E-mail: dejana.r.jovanovic@gmail.com. Copyright r 2012 by Lippincott Williams & Wilkins ISSN: 1074-7931/12/1805-0273 DOI: 10.1097/NRL.0b013e318266f721 ORIGINAL ARTICLE The Neurologist  Volume 18, Number 5, September 2012 www.theneurologist.org | 273