title: Is intra-arterial thrombolysis safe after full-dose intravenous recombinant tissue plasminogen activator for acute ischemic stroke?
abstract: OBJECTIVE
  The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA.
  
  
  METHODS
  A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition.
  
  
  RESULTS
  Sixty-nine patients (mean+/-SD age, 60+/-13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124+/-32 minutes (median, 120 minutes) and IAT, at 288+/-57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%).
  
  
  CONCLUSIONS
  IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.
authors.affiliation: Department of Neurology, University of Texas--Houston Medical School, Houston, TX 77030, USA.
authors.forename: Hashem M
authors.initials: HM
authors.lastname: Shaltoni
authors.forename: Karen C
authors.initials: KC
authors.lastname: Albright
authors.forename: Nicole R
authors.initials: NR
authors.lastname: Gonzales
authors.forename: Raymond U
authors.initials: RU
authors.lastname: Weir
authors.forename: Aslam M
authors.initials: AM
authors.lastname: Khaja
authors.forename: Rebecca M
authors.initials: RM
authors.lastname: Sugg
authors.forename: Morgan S
authors.initials: MS
authors.lastname: Campbell
authors.forename: Edwin D
authors.initials: ED
authors.lastname: Cacayorin
authors.forename: James C
authors.initials: JC
authors.lastname: Grotta
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Noser
mesh_terms: D000208:Acute Disease / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D007269:Injections, Intra-Arterial / Q000009:adverse effects; D007275:Injections, Intravenous / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011993:Recombinant Fusion Proteins / Q000009:adverse effects; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D005343:Fibrinolytic Agents; D011993:Recombinant Fusion Proteins; D011994:Recombinant Proteins; C087896:reteplase; D010959:Tissue Plasminogen Activator; D014568:Urokinase-Type Plasminogen Activator