Local intra-arterial fibrinolysis in acute hemispheric stroke: effect of occlusion type and fibrinolytic agent on recanalization success and neurological outcome.
BACKGROUND
To evaluate the effect of occlusion type and fibrinolytic agent on recanalization success and clinical outcome in patients undergoing local intra-arterial fibrinolysis (LIF) in acute hemispheric stroke.


METHODS
LIF was performed in 137 patients with angiographically established occlusion in the carotid circulation within 6 h of stroke onset. Retrospective analysis included recanalization success, recanalization time, type of occlusion and fibrinolytic treatment mode. Five types of occlusion were categorized: intracranial bifurcation (carotid 'T') of the internal carotid artery (ICA; n = 35); proximal segment of the middle cerebral artery (MCA; n = 66); distal segment of the MCA (n = 20); extracranial ICA with MCA embolism (n = 8); multiple peripheral branches of the anterior cerebral artery and the MCA (n = 8). Neurologic outcome was evaluated after 3 months by Barthel Index (BI) as good (BI >90), moderate (BI 50-90), poor (BI <50) or death.


RESULTS
Recanalization was achieved in 74 patients (54%). Mean recanalization time in recanalized patients was 91 min. Neurologic outcome was good in 48 patients (35%), moderate in 34 (25%), poor in 30 (22%) and 25 died (18%). Outcome was significantly better in recanalized than in nonrecanalized patients (p < 0.001). Treatment results were significantly better in proximal and distal MCA occlusion than in carotid 'T' occlusions (p < 0.001). Recanalization success hardly differed between urokinase and rt-PA. Combined treatment with rt-PA and lys-plasminogen tended toward a faster recanalization. Parenchymal hemorrhage occurred in 13 patients (9%).


CONCLUSIONS
The type of occlusion is of high prognostic value for successful fibrinolysis in the anterior circulation. However, recanalization is a time-consuming process even with an intra-arterial approach. Recanalization did not differ between type or dosage of plasminogen activators. Further innovative attempts are warranted towards hastening recanalization time in endovascular acute stroke treatment.
Eckert
Bernd
B
Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. b.eckert@uke.uni-hamburg.de
Kucinski
Thomas
T
Neumaier-Probst
Eva
E
Fiehler
Jens
J
Röther
Joachim
J
Zeumer
Hermann
H
D000293:Adolescent; D000328:Adult; D000368:Aged; D020771:Anterior Cerebral Artery / Q000000981:diagnostic imaging / Q000187:drug effects*; D001157:Arterial Occlusive Diseases / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000187:drug effects*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D006801:Humans; D007261:Infusions, Intra-Arterial; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000187:drug effects*; D017063:Outcome Assessment, Health Care; D010960:Plasminogen Activators / Q000008:administration & dosage* / Q000627:therapeutic use*; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage* / Q000627:therapeutic use*
D005343:Fibrinolytic Agents; D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator; D014568:Urokinase-Type Plasminogen Activator