Endovascular administration after intravenous infusion of thrombolytic agents for the treatment of patients with acute ischemic strokes.
OBJECTIVE
To determine the feasibility of combined intravenous and intra-arterial thrombolytic therapy for acute ischemic strokes and to evaluate its associated risks, using magnetic resonance imaging as a triage tool. Intravenous treatment followed by intra-arterial infusion may increase the rate of recanalization and lead to better clinical results, with reduced frequency of intracranial hemorrhage.


METHODS
Our Brain Attack Team evaluated patients who presented within 3 hours after symptom onset. Patients who did not demonstrate improvement and exhibited no evidence of intracranial hemorrhage on head computed tomographic scans were treated with intravenously administered recombinant tissue plasminogen activator (0.6 mg/kg) and underwent emergency magnetic resonance imaging of the head. T2-weighted turbo-gradient and spin echo and echo-planar diffusion- and perfusion-weighted imaging scans were obtained. Patients with evidence of imaging abnormalities indicating acute cortical infarction underwent cerebral angiography. After determination of vessel occlusion, intra-arterially administered urokinase (up to 750,000 units) or intra-arterially administered recombinant tissue plasminogen activator (maximal dose, 0.3 mg/kg) was used to achieve recanalization.


RESULTS
We treated 45 patients with this protocol. The mean age was 67 +/- 13 years, and 58% of the patients were women. There was a significant improvement in National Institutes of Health Stroke Scale scores after treatment. There was good correlation between abnormal perfusion-weighted imaging findings and cerebral angiographic findings (complete vessel occlusion). The incidence of symptomatic intracranial hemorrhage was 4.4% in this cohort. Seven patients died in the hospital, and the majority of survivors (77%) experienced good outcomes (Barthel index of >or=95) 3 months after treatment.


CONCLUSIONS
Our data demonstrate that this protocol is feasible and that combined intravenous and intra-arterial thrombolysis to treat acute ischemic strokes is sufficiently safe to warrant further evaluation.
Suarez
Jose I
JI
Cerebrovascular Center and Neurosciences Critical Care, Department of Neurology, The University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio 44106, USA. jis4@po.cwru.edu
Zaidat
Osama O
OO
Sunshine
Jeffrey L
JL
Tarr
Robert
R
Selman
Warren R
WR
Landis
Dennis M D
DM
D000208:Acute Disease; D000328:Adult; D000368:Aged; D002544:Cerebral Infarction / Q000175:diagnosis / Q000188:drug therapy*; D003952:Diagnostic Imaging; D004305:Dose-Response Relationship, Drug; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007261:Infusions, Intra-Arterial; D007262:Infusions, Intravenous; D020766:Intracranial Embolism / Q000175:diagnosis / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000187:drug effects; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome
D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator