title: Intravenous versus combined (intravenous and intra-arterial) thrombolysis in acute ischemic stroke: a transcranial color-coded duplex sonography--guided pilot study.
abstract: OBJECTIVE
  Determine feasibility and safety of intravenous (IV) versus combined (IV-IA [intra-arterial]) thrombolysis guided by transcranial color-coded duplex sonography (TCCD).
  
  
  METHODS
  Thirty-three patients eligible for IV thrombolysis, within 3 hours of onset of symptoms, with occlusion in middle cerebral artery territory (TCCD monitoring, thrombolysis in brain ischemia [TIBI] flow grade [0-3]), underwent IV thrombolysis (tissue plasminogen activator, 0.9 mg/kg). In case of recanalization (modification of TIBI score > or =1) after 30 minutes IV thrombolysis was continued over 1 hour; otherwise, it was discontinued, with subsequent IA thrombolysis. Recanalization was determined by TIBI (TCCD) and angiographically by thrombolysis in myocardial infarction (TIMI) flow grades. Clinical outcome measures were assessed at baseline, 24 hours (NIHSS) and 3 months (modified Rankin Scale).
  
  
  RESULTS
  In the IV group, 10/17 patients (59%) with complete or partial recanalization after 30 minutes had a favorable outcome at 3 months (modified Rankin Scale 0 to 2). TIBI flow grades 3 to 5 after 30 minutes of IV thrombolysis predicted a good prognosis compared with TIBI grades 1 to 2 (P<0.05). In the combined IV/IA therapy group (no recanalization after 30 minutes), 9/16 patients (56%) had a favorable outcome at 3 months. One symptomatic intracerebral hemorrhage occurred in each group.
  
  
  CONCLUSIONS
  Combined IV-IA versus IV thrombolysis guided by TCCD was feasible and safe. Recanalization after 30 minutes of IV thrombolysis led to a favorable outcome in 59% of the patients, provided TIBI flow grades were of 3 to 5. In the absence of early recanalization during IV thrombolysis, there was clinical benefit to proceed to IA therapy for a significative proportion of patients (56%).
authors.affiliation: Department of Internal Medicine, University Hospital and Medical School Geneva, Switzerland.
authors.forename: Lucka
authors.initials: L
authors.lastname: Sekoranja
authors.forename: Jaouad
authors.initials: J
authors.lastname: Loulidi
authors.forename: Hasan
authors.initials: H
authors.lastname: Yilmaz
authors.forename: Karl
authors.initials: K
authors.lastname: Lovblad
authors.forename: Philippe
authors.initials: P
authors.lastname: Temperli
authors.forename: Mario
authors.initials: M
authors.lastname: Comelli
authors.forename: Roman F
authors.initials: RF
authors.lastname: Sztajzel
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000188:drug therapy* / Q000503:physiopathology; D007261:Infusions, Intra-Arterial; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D010865:Pilot Projects; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D015424:Reperfusion; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000627:therapeutic use; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator