title: Local intra-arterial fibrinolysis in acute hemispheric stroke: effect of occlusion type and fibrinolytic agent on recanalization success and neurological outcome.
abstract: 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.
authors.affiliation: Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. b.eckert@uke.uni-hamburg.de
authors.forename: Bernd
authors.initials: B
authors.lastname: Eckert
authors.forename: Thomas
authors.initials: T
authors.lastname: Kucinski
authors.forename: Eva
authors.initials: E
authors.lastname: Neumaier-Probst
authors.forename: Jens
authors.initials: J
authors.lastname: Fiehler
authors.forename: Joachim
authors.initials: J
authors.lastname: Röther
authors.forename: Hermann
authors.initials: H
authors.lastname: Zeumer
mesh_terms: 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*
chemical_list: D005343:Fibrinolytic Agents; D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator; D014568:Urokinase-Type Plasminogen Activator