***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Purpose — TIMI angiographic classification measures coronary residual flow and recanalization . We developed a Thrombolysis in Brain Ischemia ( TIBI ) classification by using transcranial Doppler ( TCD ) to noninvasively monitor intracranial vessel residual flow signals . We examined whether the emergent TCD TIBI classification correlated with stroke severity and outcome in patients treated with intravenously administered tPA ( IV-tPA ) .  Methods — TCD examination occurred acutely and on day 2 . TIBI flows were determined at distal MCA and basilar artery depths , depending on occlusion site . TIBI waveforms were grade d as follows : 0 , absent ; 1 , minimal ; 2 , blunted ; 3 , dampened ; 4 , stenotic ; and 5 , normal . National Institutes of Health Stroke Scale ( NIHSS ) scores were obtained at baseline and 24 hours after administration of tPA . Results — One hundred nine IV tPA patients were studied . Mean±SD age was 68±16 years ; median NIHSS score before administration of tPA ( pre-tPA ) was 17.5 . The tPA bolus was administered 143±58 minutes and the TCD examination 141±57 minutes after symptom onset . Pre-tPA NIHSS scores were higher in patients with TIBI grade 0 than TIBI grade 4 or 5 flow . TIBI flow improvement to grade 4 or 5 occurred in 35 % of patients ( 19/54 ) with an initial grade of 0 or 1 and in 52 % ( 12/23 ) with initial grade 2 or 3 . The 24-hour NIHSS scores were higher in follow-up in patients with TIBI grade 0 or 1 than those with TIBI grade 4 or 5 flow . TIBI flow recovery correlated with NIHSS score improvement . Lack of flow recovery predicted worsening or no improvement . In-hospital mortality was 71 % ( 5/7 ) for patients with posterior circulation occlusions ; it was 22 % ( 11/51 ) for patients with pre-tPA TIBI 0 or 1 compared with 5 % ( 1/19 ) for those with pre-tPA TIBI 2 or 3 anterior circulation occlusions . Conclusions — Emergent TCD TIBI classification correlates with initial stroke severity , clinical recovery , and mortality in IV-tPA – treated stroke patients . A flow- grade improvement correlated with clinical improvement BACKGROUND Trials of endovascular therapy for ischemic stroke have produced variable results . We conducted this study to test whether more advanced imaging selection , recently developed devices , and earlier intervention improve outcomes . METHODS We r and omly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR ( Flow Restoration ) stent retriever or to continue receiving alteplase alone .  All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic ( CT ) perfusion imaging . The co primary outcomes were reperfusion at 24 hours and early neurologic improvement ( ≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3 ) . Secondary outcomes included the functional score on the modified Rankin scale at 90 days . RESULTS The trial was stopped early because of efficacy after 70 patients had undergone r and omization ( 35 patients in each group ) . The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group ( median , 100 % vs. 37 % ; P<0.001 ) . Endovascular therapy , initiated at a median of 210 minutes after the onset of stroke , increased early neurologic improvement at 3 days ( 80 % vs. 37 % , P=0.002 ) and improved the functional outcome at 90 days , with more patients achieving functional independence ( score of 0 to 2 on the modified Rankin scale , 71 % vs. 40 % ; P=0.01 ) . There were no significant differences in rates of death or symptomatic intracerebral hemorrhage . CONCLUSIONS In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging , early thrombectomy with the Solitaire FR stent retriever , as compared with alteplase alone , improved reperfusion , early neurologic recovery , and functional outcome . ( Funded by the Australian National Health and Medical Research Council and others ; EXTEND-IA Clinical Trials.gov number , NCT01492725 , and Australian New Zeal and Clinical Trials Registry number , ACTRN12611000969965 . ) Background and Purpose There is little reported of the safety and efficacy of high-dose intravenous recombinant tissue plasminogen activator ( alteplase ) in combination with heparin anticoagulation in patients presenting with acute ischemic stroke . Methods Thirty-two patients with severe hemispheric stroke syndrome caused by angiographically proven middle cerebral artery and /or intracranial internal carotid artery occlusion were treated with 100 mg alteplase by intravenous infusion over 90 minutes within a mean±SD of 226±68 minutes after symptom onset Recanalization was assessed by digital subtraction angiography in all patients immediately after treatment and by transcranial Doppler monitoring ( n=30 ) and /or a third angiogram ( n=5 ) 12 - 24 hours later . Results Complete or partial reperfusion was observed in 11 patients ( 34 % ) 90 minutes after the initiation of alteplase infusion and in 17 patients ( 53 % ) within 12–24 hours . Hemorrhagic infa rct ion without clinical deterioration was detected by follow-up computed tomography in nine patients ( 28 % ) . Fatal parenchymal hemorrhage occurred in three patients ( 9 % ) with huge middle cerebral artery infa rcts . Serious hemorrhage from the puncture site occurred in two patients ( 6 % ) . Good clinical outcome correlated with reperfusion ( p<0.05 ) and the presence of grade 2 collateral blood flow ( p<0.01 ) . Conclusions When 100 mg of recombinant tissue plasminogen activator was given within the first 6 hours of acute stroke together with heparin the incidence of deleterious hemorrhage was < 10 % . Reperfusion and effective collateral blood flow seem to be two important factors associated with a small infa rct volume and good clinical outcome Background : We aim ed to analyse the course of early recanalization and corresponding functional outcome in patients with an acute occlusion of the carotid T who were treated conservatively or underwent intravenous thrombolysis .  Methods : Forty-two patients with an acute occlusion of the carotid T within 6 h were recruited from consecutive admissions to a neurological department participating in the Duplex Sonography in Acute Stroke study . All patients underwent a st and ardized admission and follow-up procedure . Colour-coded duplex sonography was performed on admission , 30 min after thrombolysis , and at 6 and 24 h after onset of symptoms . Recanalization of the carotid T was classified as complete , partial and absent . Functional outcome was rated with the modified Rankin scale ( mRS ) at 3 months as favourable ( mRS 0–2 ) or poor ( mRS 3–6 ) . Results : Within 6 h , complete or partial recanalization occurred in 1 of 27 patients treated conservatively and in 6 of 15 thrombolysed patients . Intravenous thrombolysis predicted early recanalization also after adjustment for age , sex , cardioembolic stroke aetiology and time to treatment ( adjusted odds ratio , OR , 39.7 ; 95 % confidence interval , CI , 2.0–801.7 ; p = 0.016 ) . An early recanalization was the only selected predictor of a favourable outcome ( OR , 13.6 ; 95 % CI , 1.0–179.0 ; p = 0.047 ) at regression analysis , and was achieved in 3 thrombolysed patients but in none with conservative medical treatment . Conclusions : In patients treated conservatively , functional outcome is poor and early recanalization rarely occurs . The latter can be achieved by intravenous thrombolysis with a rate comparable to that found at an intra-arterial approach without major intracranial bleeding complications . Early recanalization is associated with a better functional outcome Background and Purpose — Sonothrombolysis is a new treatment approach in acute ischemic stroke . The results of a monocenter , r and omized clinical study are presented . Methods — Subjects with acute middle cerebral artery main stem occlusion were r and omized into a target group receiving 1-hour transcranial continuous insonation using a 1.8-MHz Doppler ultrasound ( US ) probe or a control group . All underwent st and ard thrombolysis with intravenous recombinant tissue-type plasminogen activator . Results — Thirty-seven subjects were included ; 19 subjects were treated in the target ( US ) group and 18 in the control ( no-US ) group , all with no residual flow in the middle cerebral artery main stem occlusion ( Thrombolysis in Brain Ischemia recanalization grade 0 ) . Compared with the no-US group , the US group showed greater improvement in National Institutes of Health Stroke Scale values at days 1 and 4 and a higher median Thrombolysis in Brain Ischemia grade 1 hour after recombinant tissue-type plasminogen activator initiation . Recanalization ( complete or partial ) after 1 hour occurred in 57.9 % of the US group and 22.2 % of the no-US group ( P=0.045 ) . After 90 days , 4 subjects from the US group had a modified Rankin Score ≤1 ( none from the no-US group ) and 8 had a Barthel Index ≥95 ( none from the no US group ; P=0.106 and P=0.003 , respectively ) . Three subjects from the US group ( 15.8 % ) developed a symptomatic intracranial hemorrhage as did one ( 5.6 % ) in the no-US group ( P=0.60 ) . Conclusions — This small r and omized study indicates a beneficial impact of transcranial ultrasound on recanalization and short-term outcome in subjects with middle cerebral artery main stem occlusion and recombinant tissue-type plasminogen activator treatment BACKGROUND The efficacy of intravenous ( IV ) alteplase is restricted by the speed of recanalisation and the site of the occlusion . The aim of this study was to ascertain the effect of a combined IV-endovascular approach ( intra-arterial alteplase and , if required , additional thrombectomy ) in patients with stroke due to arterial occlusion . METHODS We compared recanalisation rates , neurological improvement at 24 h , and functional outcome at 3 months between two periods ( February , 2002 , to March , 2007 , vs April , 2007 , to October , 2008 ) in patients in a prospect i ve registry who were treated with different regimens of alteplase within 3 h of symptom onset . Patients with confirmed occlusion who were treated before April , 2007 , were treated with IV alteplase ; after April , 2007 , patients were treated with a systematic IV-endovascular approach . Analysis was by intention to treat . FINDINGS 46 ( 87 % ) of 53 patients treated with the IV-endovascular approach achieved recanalisation versus 56 ( 52 % ) of 107 patients in the IV group ( adjusted relative risk [ RR ] 1.49 , 95 % CI 1.21 - 1.84 ; p=0.0002 ) . Early neurological improvement ( NIHSS score of 0 or 1 or an improvement of 4 points or more at 24 h ) occurred in 32 ( 60 % ) patients in the IV-endovascular group and 42 ( 39 % ) patients in the IV group ( adjusted RR 1.36 , 0.97 - 1.91 ; p=0.07 ) . Favourable outcome ( mRS of 0 - 2 at 90 days ) occurred in 30 ( 57 % ) patients in the IV-endovascular group and 47 ( 44 % ) patients in the IV group ( adjusted RR 1.16 , 0.85 - 1.58 ; p=0.35 ) . The mortality rate at 90 days was 17 % in both groups , and symptomatic intracranial haemorrhage was reported in five ( 9 % ) patients in the IV-endovascular group and in 12 ( 11 % ) patients in the IV group . Better clinical outcome was associated with recanalisation in both groups and with time to recanalisation in the IV-endovascular group . INTERPRETATION An IV-endovascular approach is associated with higher recanalisation rates than is IV alteplase in patients with stroke and confirmed arterial occlusion . In patients treated with an IV-endovascular approach , a shorter time from symptom onset to recanalisation is associated with better clinical outcomes Background and Purpose — The acute stroke literature lacks a st and ard convention regarding the 
    Output:
    
The overall incidence of ER after intravenous thrombolysis is substantial , highlighting the importance of reliably predicting ER to limit futile , interhospital transfers .
Incidence of no-ER is particularly high for proximal occlusion and severe strokes .