Intra-arterial thrombolysis for acute ischemic stroke: preliminary experience with platelet glycoprotein IIb/IIIa inhibitors as adjunctive therapy.
OBJECTIVE
To evaluate the safety profile of platelet glycoprotein IIb/IIIa inhibitors administered as adjunctive therapy to patients with large-vessel occlusion and acute ischemic stroke refractory to pharmacological thrombolysis with recombinant tissue plasminogen activator (rtPA) and mechanical disruption, balloon angioplasty, or both.


METHODS
Twenty-one patients (mean age, 62 yr; range, 29-88 yr) met the following criteria: 1) large-vessel occlusion and acute ischemic stroke syndrome at presentation, 2) failure to recanalize after administration of rtPA (intra-arterial and/or intravenous) with or without mechanical thrombolysis, and 3) subsequent treatment with IIb/IIIa inhibitors (intra-arterial or intravenous).


RESULTS
Eleven patients had ischemia in the dominant hemisphere, 8 in the vertebrobasilar system, and 2 in the nondominant hemisphere. Twelve patients received intravenous rtPA without significant improvement; 9 patients were not candidates for intravenous rtPA. All patients received intra-arterial rtPA. The IIb/IIIa inhibitors were administered intravenously in 3 patients, intra-arterially in 16, and both intravenously and intra-arterially in 2. Balloon angioplasty was performed in 18 patients. Complete or partial recanalization was achieved in 17 of the 21 patients. After thrombolysis, 15 improved clinically. Three patients (14%) sustained an asymptomatic intracerebral hemorrhage after thrombolytic therapy. No patient was clinically worse after intervention. At last follow-up (mean, 8.5 mo), 13 patients were functionally independent (modified Rankin score, 0-3) and 8 were disabled or dead.


CONCLUSIONS
IIb/IIIa inhibitors are an alternative for achieving recanalization. The risk of hemorrhage may be low. As part of an escalating protocol that includes pharmacological and mechanical thrombolysis, IIb/IIIa inhibitors may improve clinical outcomes.
Deshmukh
Vivek R
VR
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
Fiorella
David J
DJ
Albuquerque
Felipe C
FC
Frey
James
J
Flaster
Murray
M
Wallace
Robert C
RC
Spetzler
Robert F
RF
McDougall
Cameron G
CG
D000077284:Abciximab; D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy*; D017024:Chemotherapy, Adjuvant; D000077542:Eptifibatide; D005260:Female; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010455:Peptides / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011446:Prospective Studies; D020521:Stroke / Q000150:complications / Q000188:drug therapy*; D015912:Thrombolytic Therapy; D000077466:Tirofiban; D014443:Tyrosine / Q000031:analogs & derivatives* / Q000627:therapeutic use
D000911:Antibodies, Monoclonal; D007140:Immunoglobulin Fab Fragments; D010455:Peptides; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D000077466:Tirofiban; D000077542:Eptifibatide; D000077284:Abciximab