Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis.
OBJECTIVE
Intraarterial and intravenous thrombolysis are often ineffective for the treatment of acute ischemic stroke and are associated with a significant risk of intracranial hemorrhage (ICH). Multimodal rescue therapy combining mechanical disruption and platelet GPIIb/IIIa receptor antagonists may improve recanalization.


METHODS
Patients who did not recanalize with thrombolysis were treated with GPIIb/IIIa antagonists, angioplasty, or an embolectomy device. Treatment was individualized based on vascular anatomy, stroke mechanism, patient status, and symptom duration.


RESULTS
Twelve patients were treated within 3.8+/-2.2 hours. The mean National Institutes of Health Stroke Scale (NIHSS) score was 19.4+/-4.1. Six patients had carotid terminus occlusion, whereas 5 had middle cerebral artery and 1 had basilar artery occlusion. The average doses of intraarterial tPA and reteplase were 17.1+/-8.6 mg and 2+/-0.6 units, respectively. All patients received either an intravenous or intraarterial abciximab bolus (mean 11.8+/-5.8 mg) and heparin (mean 3278+/-1716U). Eleven were treated with angioplasty and 4 had mechanical embolectomy or stenting. Complete (8) or partial (3) recanalization was achieved in 11 cases. There was only one (8.3%) symptomatic hemorrhage. Patients had a favorable outcome at discharge (mean NIHSS 8.9+/-8.7) and 6 (50%) had an NIHSS < or =4 at discharge.


CONCLUSIONS
Multimodal rescue therapy was effective at recanalizing occluded cerebral vessels that failed thrombolysis without an excess risk of ICH.
Abou-Chebl
Alex
A
Department of Neurology, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Bajzer
Christopher T
CT
Krieger
Derk W
DW
Furlan
Anthony J
AJ
Yadav
Jay S
JS
D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000379:methods*; D002545:Brain Ischemia / Q000628:therapy*; D016893:Carotid Stenosis / Q000628:therapy; D002544:Cerebral Infarction / Q000628:therapy; D003131:Combined Modality Therapy; D017128:Embolectomy / Q000379:methods; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000628:therapy; D020300:Intracranial Hemorrhages / Q000517:prevention & control; D008875:Middle Aged; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011446:Prospective Studies; D012306:Risk; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D017211:Treatment Failure; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D010959:Tissue Plasminogen Activator