الفهرس 
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Abstract
Stroke remains the second-leading cause of death and the third-leading cause of death and disability combined in the world. In Egypt, the most populated nation in the Middle East, the overall crude prevalence rate of stroke is high (963/100,000 inhabitants). The official national statistics indicate that diseases of the circulatory system, including stroke, are the primary cause of death in Egypt. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. The present study was designed to explore the influence of intracranial collaterals on clinical outcome in patients with anterior acute ischemic stroke (AAIS) treated with thrombolysis therapy during period from January 2018 to February 2021, in addition to provide a comparative assessment of various grading methods for intracranial collaterals. Our study passed through four stages: First stage: all patients with AAIS treated with IV-tPA underwent pretreatment and day 2 CTA. Also, demographic characteristics and various vascular risk factors were collected. NIHSS was recorded for all patients before the IV-tPA bolus and at 2 and 24 hours after treatment initiation. Second stage: intracranial collaterals on CTA were evaluated according to the Mittef, Mass and modified Tan scoring system. Also, ASPECT score was applied to plain CT brain. Third stage: Functional outcome was assessed by modified Rankin Scale after 3 months. Fourth stage (results): The current study included 40 patients with acute ischemic stroke. Mean age of enrolled patients was 58.55 ± 11.47 years a. Majority (65%) of enrolled patients was men and 14 (35%) patients were women. A relative higher proportion of patients (20, 50%) had hypertension. In majority (70%) of patients, large artery atherosclerosis was the etiology of stroke. Mean time from onset of symptoms till time of injection was 193.85 ± 38.33 minute. The pre-tPA mean NIHSS score was 12.20 ± 3.50. after injection, majority (70%) of patients their NIHSS was improved with mean NIHSS was 6.05 ± 2.79. All patients (26 patients) with good functional outcome had ASPECT score ≥8 in addition to good collaterals in the pre-tPA CTA based on Miteff method while only 22 (84.6%), and 16 (61.5%) patients of this group showed good collaterals by Tan and Maas method, respectively. After injection, all patients who showed poor functional outcome had poor collaterals on the second day CTA based on Miteff and Maas methods while 8 (57.1%) of patients despite having good collateral based on Tan method they had a poor functional outcome. Nearly all patients with good functional outcome in the different methods had good collaterals in the follow up CTA after injection. Based on the current study, it was found that predictors of good functional outcome among patients with acute ischaemic stroke were low NIHSS (odd’s ratio= 1.23, 95%CI=1.01-2.34, p= 0.01), ASPECT> 8 (odd’s ratio= 4.56, 95%CI=3.40-7.89, p< 0.001), and Miteff (odd’s ratio= 1.23, 95%CI=2.22-6.79, p< 0.001). It was found that ASPECTS method had 100% sensitivity and 92.9% specificity for prediction of good functional outcome while Miteff method before injection had 100% sensitivity and 71.4% specificity for prediction of good functional outcome. It was found that frequency of collateral failure was 8 (20%), 2 (5%) and 2 (5%) of patients based on Miteff, Tan and Maas method, respectively. Those patients had poor functional outcome. Functional outcome was assessed by modified Rankin Scale at 3 months. Good and poor functional outcomes were defined by mRS scores of 0–2 and 3– 6, respectively where 26 (65%) patients had good outcome and 14 (35%) patients had poor outcome. Our study has shown that favorable collateral status is associated with milder strokes and with successful reperfusion and improved clinical outcome in the setting of IV thrombolysis and conversely, that poor collaterals reduce the odds of favorable outcome in patients reperfused at later time intervals. Favorable collaterals may slow the pace of metabolic deterioration of the ischemic penumbra. Collaterals behave dynamically following vascular occlusion and may fail over time. CTA permits the direct assessment of both the spatial extent and sufficiency of collateral filling. This study also provides a comparative assessment of various grading methods for intracranial collaterals for establishing an early prognosis in patients with AIS treated with IV-tPA. Low NIHSS, ASPECT score ≥ 8 and the Miteff system were found to be a reliable predictors of favorable outcome in IV-treated patients with AAIS. We believe that routine grading and reporting of intracranial collaterals will rapidly become a part of the standard stroke CTA reports, with evaluation of additional information about cerebral hemodynamics, are recommended to develop better grading criteria for intracranial collaterals in AIS. The above considerations constitute a strong rationale for the development of adjunctive therapeutic agents to enhance collateral perfusion following stroke onset. Therapeutic scenarios might include the following: An agent could be administered following stroke onset but prior to hospital admission, with the goal of slowing the tempo of penumbral deterioration; as ischemic and hemorrhagic stroke would not yet have been differentiated, safety would need to be demonstrated for both conditions. 2) In patients presenting at later times following stroke onset, an agent that enhanced collateral perfusion might be able to forestall penumbral deterioration and sustain a favorable mismatch ratio so as to increase the odds of success of late-instituted endovascular intervention.