Effect on Cerebral Vasospasm of Coil Embolization Followed by Microcatheter Intrathecal Urokinase Infusion Into the Cisterna Magna

Background and Purpose— Vasospasm remains the leading cause of death and permanent neurological disability in patients with aneurysmal subarachnoid hemorrhage (SAH). The objective of our prospective randomized trial of coil embolization followed by intrathecal urokinase infusion into the cisterna magna (ITUKI therapy) was to test its effectiveness in preventing or alleviating the severity of ischemic neurological deficits caused by vasospasm.

Methods— We enrolled 110 patients with ruptured intracranial aneurysms eligible for coil embolization and randomly assigned them to embolization with (n=57) or without (n=53) ITUKI therapy performed within 24 hours of aneurysmal SAH. The incidence of symptomatic vasospasms and the clinical outcomes, based on the Glasgow Outcome Scale, 6 months after SAH onset were assessed.

Results— There were no side effects or adverse reactions attributable to ITUKI therapy. Symptomatic vasospasm occurred in 5 patients (8.8%) with and 16 (30.2%) without ITUKI therapy; the difference was significant ( P =0.012). Although the mortality rate did not differ between the groups, patients with ITUKI therapy had significantly better outcomes than those without ( P =0.036).

Conclusions— Our results demonstrate that ITUKI therapy significantly reduced the occurrence of symptomatic vasospasm. Although it did not completely prevent vasospasms, ITUKI therapy resulted in a lower rate of permanent neurological deficits.

Intraventricular administration of recombinant tissue plasminogen activator for intraventricular hemorrhage in the newborn

Intraventricular hemorrhage remains associated with high mortality and morbidity. Its most serious complication is posthemorrhagic hydrocephalus caused by multiple small blood clots obstructing the arachnoid villi. We treated three newborn infants (one term, two preterm) with posthemorrhagic hydrocephalus using recombinant tissue plasminogen activator, a thrombolytic agent, injected into the ventricles with a spinal needle. Sufficient fibrinolysis was achieved in these preterm patients. They all survived, and shunt surgery was only required in one. No adverse reactions or side effects have occurred. Intraventricular fibrinolysis with tissue plasminogen activator seems to be safe and effective for the treatment of intraventricular hemorrhage. However, controlled studies are needed for assessing treatment efficiency.

Interventionelle neuroradiologische Techniken zur frühen Behandlung des Schlaganfalles

Es werden Indikationen, Techniken und Ergebnisse interventioneller Eingriffe beim akuten Schlaganfall dargestellt, basierend auf über 300 Behandlungen, die im Verlauf der letzten Jahre in der Neuroradiologie in Bern als Akut-Eingriffe durchgeführt wurden. Techniken der intraarteriellen Thrombolyse, Thrombaspiration, der percutanen transluminalen Angioplastie (PTA) und Stenteinlage bei Okklusionen und Pseudookklusionen hirnversorgender Gefäße werden beschrieben. Darüber hinaus werden neue Techniken dargestellt, mit denen Experten anderer Zentren erste Erfahrungen machen konnten, wie die Auflösung der Thromben durch Ultraschall, durch Aspirationskatheter oder durch Laser.

Behandlung des akuten Hirninfarktes

Diese Arbeit gibt eine Übersicht über den aktuellen Stand der Akuttherapie von Patienten mit ischämischem Hirnschlag. Insbesondere werden die intravenöse und intraarterielle Thrombolyse, die antithrombotische Behandlung sowie die Therapie von internistischen und neurologischen Komplikationen diskutiert und Therapievorschläge präsentiert. Schließlich werden aktuelle Therapiestudien, insbesondere die Thrombolyse mit Glykoprotein IIb/IIIa Rezeptor Antagonisten und die Ultraschallgestützte Thrombolyse, vorgestellt.

[True isolated atherosclerotic aneurysm of the axillary artery]

The true atherosclerotic aneurysm of the axillary artery is a rare condition. It either presents as a pulsatile axillary mass or arterial emboli in the hand and fingers. We report the case of a 70-year-old man with a 5 cm aneurysm of the axillary artery presenting with embolic disease to the hand. Angiography is helpful and provides valuable preoperative anatomic details. Surgery remains the treatment of choice but endovascular treatment can also be considered.

[Facilitated revascularisation in myocardial infarction with ST-segment elevation]

AIMS

The authors performed urgent coronarography and revascularisation after administering a combined half dose of alteplase (tissue plazminogen activator) and eptifibatide (glycoprotein II/bIIIa receptor blocking agent) to patients suffering from acute coronary syndromes with persistent ST-segment elevation.

METHODS

During the period between 01 April to 15 December, 2001. 20 patients (16 men and 4 women, mean age: 55.6 years) were treated. The localization of infarction on the basis of ST-segment elevation was: 9 cases inferior, 10 cases anterior and patient with left bundle branch block in 1 cases. The mean time between the infarct related angina and hospital admission was 158 (30-600) minutes. The combined medical therapy was initiated after 34 (15-150) minutes on the average admission, and 123 (71-210) minutes later the patients were in the catheter laboratory.

RESULTS

Coronarography showed TIMI-0 flow in 4 cases, TIMI-2 flow in 3 cases and TIMI-3 flow in 13 cases. Acute percutan coronary intervention was done in 14 cases, aorto-coronary bypass surgery was performed in 4 cases (2 of them were emergency operations, the other 2 were done electively). Besides postpunctional haematomas, hemorrhagic complications in the form of haematemesis were observed in 2 cases, but there was no need for transfusion. The mean CK-MB release (between 14 patients) was 230.4 (30-1176) U/l. One patient died after the emergency bypass surgery.

CONCLUSIONS

On the basis of initial results the authors emphasize the importance of working out the optimal revascularisation strategy for acute coronary syndrome patients with ST-segment elevation in every Hungarian catheter centre. The authors find this method--in their case the catheter laboratory is 60 kms away, time of transport is approximately 70-90 minutes--an effective and safe alternative therapy in patients under the age of 75 years with acute myocardial infarction.

Local intra-arterial fibrinolysis in acute hemispheric stroke: effect of occlusion type and fibrinolytic agent on recanalization success and neurological outcome

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%).

CONCLUSION

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.

Successful thrombolysis by prolonged low-dose alteplase in catheter-directed infusion

Catheter-directed thrombolysis is a sophisticated method in the treatment of thromboembolism with maximum effect on the thrombus and minimal systemic effect. The consequences are enhanced local thrombolysis and a reduction in general bleeding tendency, compared with systemic thrombolysis. At our institution, two children had successful thrombolysis by prolonged continuous catheter-directed low-dose alteplase. The first patient, a boy with Fontan physiology, was successfully treated for a massive pulmonary thromboembolism by catheter-directed very low-dose alteplase for five days. The second patient, who suffered from relapsing nephrotic syndrome, achieved satisfactory thrombolysis of an arterial leg thrombosis after four days of continuous catheter-directed low-dose alteplase.

CONCLUSION

Although catheter-directed thrombolysis seems to be a valuable method in thrombolytic therapy, there is a lack of evidence-based recommendations concerning dosage, effect of bolus, simultaneous anticoagulation and duration of treatment for children.

Intravenous catheter declotting: same outcomes with lower dose urokinase?

This study aims to assess, in terms of catheter salvage and economic cost, the effect of a low dose (2000 IU) urokinase lock technique to clear multilumen central venous catheters (CVC) and peripherally inserted central catheters (PICCs) when occluded. A total of 100 catheters were included in the analysis. Results indicate this lower dose technique to be effective in restoring the patency of multilumen CVCs, but not as effective when clearing PICCs. No catheters were lost because of occlusion.

[Treatment of empyema and complicated pleural effusion with intrapleural fibrinolysis]

BACKGROUND AND OBJECTIVE

Intrapleural fibrinolysis (IPF) can avoid surgery in patients with loculated pleural effusions. Few clinical trials on IPF for the treatment of empyemas (PEM) and complicated pleural effusions (CPE) have been reported. We describe here our experience with IPF in the treatment of PEM/CPE patients.

PATIENTS AND METHOD

81 patients with PEM/CPE were included. Urokinase, 100000 U, was instilled into the pleural cavity, three times a day. A mean of 12.9 doses of urokinase were administered.

RESULTS

The mean of days having a chest tube was 7.7 days and the mean hospital stay was 22.2 days. No radiological sequelae were observed or these were mild in 66 cases (81.5%). There were four deaths and three patients needed surgery.

CONCLUSIONS

IPF is an efective and reliable method for the treatment of PEM/CPE.

Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions

OBJECTIVES

To determine the safety, efficacy, and predictors of favourable outcome of intra-arterial thrombolysis in acute stroke attributable to internal carotid "T"occlusion

METHODS

The authors analysed 24 consecutive patients with T occlusions of the internal carotid artery treated by local intra-arterial thrombolysis using urokinase.

RESULTS

The median baseline National Institutes of Health Stroke Scale was 19. The average time from symptom onset to treatment was 237 minutes. Four patients (16.6%) had a favourable (modified Rankin Scale score (mRS</=2)) and 10 patients (41.7%) a poor outcome (mRS 3 or 4) after three months. Ten patients (41.7%) died. One symptomatic intracerebral haemorrhage (4.2%) occurred. Partial recanalisation of the intracranial internal carotid artery was achieved in 15 (63%), of the middle cerebral artery in four (17%), and of the anterior cerebral artery in eight patients (33%). Complete recanalisation never occurred. Sufficient leptomeningeal collaterals as seen on arteriography (p=0.02) and age <60 years (p=0.012) were the only predictors of favourable clinical outcome.

CONCLUSIONS

Acute stroke attributable to carotid T occlusion remains a condition with a generally poor prognosis even when intra-arterial thrombolysis is performed. Favourable outcome was seen only in patients with sufficient leptomeningeal collaterals.

Recombinant tissue plasminogen activator for treatment of hepatic veno-occlusive disease following bone marrow transplantation in children: effectiveness and a scoring system for initiating treatment

Hepatic veno-occlusive disease (HVOD) following bone marrow transplantation is potentially fatal. Criteria for diagnosis and starting treatment are mainly based on adult studies. Recombinant tissue plasminogen activator (rtPA) has been used with variable success. rtPA and heparin were given to 12 children (nine with immunodeficiency, two malignancy, one thalassaemia) with moderate to severe HVOD. Of the 12, 10 responded with a fall in bilirubin concentration; eight survived with complete resolution of HVOD. Four of the five patients with associated multiorgan failure (MOF) died despite rtPA treatment. One child suffered significant, and one minor, bleeding during rtPA treatment. A scoring system for quantifying the severity of HVOD in children is proposed, incorporating the criteria used to diagnose HVOD, risk factors for its development and also parameters reflective of the patient's general condition. This will facilitate early diagnosis and management of those cases which, if not treated promptly, are likely to deteriorate with an adverse outcome. Our experience suggests rtPA and heparin are an effective treatment for HVOD in children, with relatively little toxicity provided therapy is started before MOF develops.

Low-dose tissue plasminogen activator in the management of anterior chamber fibrin formation

PURPOSE

To investigate the efficacy of tissue plasminogen activator (tPA) in the treatment of severe fibrinous anterior chamber reactions after intraocular surgery.

SETTING

Ophthalmology Department, AHEPA University Hospital, Thessaloniki, Greece.

METHODS

The study comprised routine surgical and postoperative cases selected in a nonrandomized fashion. Low-dose tPA infusion (0.2 mL of 125 microg/mL) was administered through a side-port in the anterior chamber in 25 patients with recent or long-standing fibrin formation after cataract extraction (n = 13), trabeculectomy (n = 5), combined procedure (n = 5), or penetrating keratoplasty (n = 2). Patients were treated 4 to 25 days postoperatively (mean 7 days).

RESULTS

Fibrin lysis was observed 2 to 12 hours after tPA infusion. No hemorrhage or other complications occurred, and no further treatment was necessary in any patient. Three cases of delayed partial fibrin lysis resolved with intense topical steroid treatment. There were no recurrences over the 3-month follow-up.

CONCLUSIONS

Low-dose tPA was an effective and safe method for the management of anterior chamber fibrin formation. Treatment was well tolerated and gave excellent results with no complications.

In vitro and in vivo induction of antiangiogenic activity by plasminogen activators and captopril

BACKGROUND

Many antiangiogenic molecules are proteolytically cleaved from larger plasma proteins. For example, plasminogen activators cleave plasminogen into plasmin, and plasmin is converted into angiostatin in the presence of sulfhydryl donors. We thus investigated whether the antiangiogenic activity in plasma could be increased by treatment with recombinant tissue plasminogen activator (rt-PA) and the sulfhydryl donor captopril.

METHODS

Human plasma was treated with rt-PA (10 micro g/mL) and/or captopril (1 micro M). Angiogenesis was measured in vitro by human endothelial cell tube formation and endothelial cell proliferation and in vivo in mice with the Matrigel plug assay. Angiostatin was removed from treated plasma by affinity chromatography, immunoprecipitation, or ion-exchange chromatography, and the antiangiogenic activity of the depleted plasma was assessed by tube formation. Three cancer patients were treated with rt-PA and captopril, and their pretreatment and post-treatment plasmas were tested for antiangiogenic activity in vitro.

RESULTS

Angiogenesis in vitro was stimulated by untreated plasma and inhibited by plasma that had been treated with rt-PA and captopril but was not affected by treatment with rt-PA and/or captopril alone. In vivo angiogenesis in Matrigel plugs was substantially lower in mice treated with rt-PA and captopril than in untreated control mice. Antiangiogenic activity in treated plasma was largely retained after angiostatin was removed: treated plasma inhibited angiogenesis by 64.3% (95% confidence interval [CI] = 46.4% to 82.2%), relative to untreated plasma, and treated plasma depleted of angiostatin by affinity chromatography or immunoprecipitation inhibited angiogenesis by 65.1% (95% CI = 53.8% to 76.4%) or 63.7% (95% CI = 50.9% to 76.5%), respectively. Antiangiogenic activity of plasma from three cancer patients was higher after treatment with rt-PA and captopril than before such treatment.

CONCLUSION

Treatment with rt-PA and captopril induced antiangiogenic activity in vitro and in vivo that appears to be independent of angiostatin.

The safety, efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter-directed thrombolysis of arterial and venous occlusions

PURPOSE

The purpose of this study was to compare the efficacy, complications, and costs associated with low-dose (<2 mg/h) alteplase (tissue plasminogen activator [t-PA]) versus urokinase for the catheter-directed treatment of acute peripheral arterial occlusive disease (PAO) and deep vein thrombosis (DVT).

MATERIALS AND METHODS

A retrospective review was performed during sequential time periods on two groups with involved extremities treated with either t-PA with subtherapeutic heparin (TPA group) or urokinase with full heparin (UK group) at a single center. Treatment group characteristics, success rates, complications, dosages, infusion time, and costs were compared.

RESULTS

Eighty-nine patients with 93 involved limbs underwent treatment (54 with DVT, 39 with PAO). The treatment groups were statistically identical (TPA: 45 limbs; 24 with DVT, 53.3%; 21 with PAO, 46.7%; UK: 48 limbs; 30 with DVT, 62.5%; 18 with PAO, 37.5%). The overall average hourly infused dose, total dose, infusion time, success rates, and cost of thrombolytic agent were as follows (+/- standard deviation): TPA, 0.86 +/- 0.50 mg/h, 21.2 +/- 15.1 mg, 24.6 +/- 11.2 hours, 89.4%, $466 +/- $331; and UK, 13.5 +/- 5.6 (10(4)) U/h, 4.485 +/- 2.394 million U, 33.3 +/- 13.3 hours, 85.7%, $6871 +/- $3667, respectively. Major and minor complication rates were: TPA, 2.2% and 8.9%; and UK, 2.1% and 10.4%, respectively. No statistical differences in success rates or complications were observed; however, t-PA was significantly (P <.05) less expensive and faster than urokinase.

CONCLUSION

Low-dose t-PA combined with subtherapeutic heparin is equally efficacious and safe compared with urokinase. Infusions with t-PA were significantly shorter and less expensive than those with urokinase.

Resolution of ST-segment elevation after thrombolytic therapy in elderly patients with acute myocardial infarction

We examined the resolution of ST-segment elevation after thrombolytic therapy in elderly versus younger patients with acute myocardial infarction. Electrocardiograms were recorded before, on completion of, and on day 1 and day 2 post-thrombolytic therapy (streptokinase or tissue thromboplastin activator) in 36 patients older than 65 years and 36 patients younger than 65 years. There was no significant different in the pre-thrombolytic ST-segment elevation per lead in both elderly and younger patients (3.7 +/- 0.7 versus 3.5 +/- 0.8 mm; P = NS). On completion of thrombolytic therapy, both groups demonstrated resolution of ST-segment elevation and, although the ST-segment elevation per lead was higher in elderly patients (3.0 +/- 0.9 versus 2.5 +/- 0.9 mm; P = 0.008), the percentage resolution per lead was not significantly different (19% versus 29%; P = NS). On day 1 post-thrombolytic therapy, there was further resolution of ST-segment elevation in both groups, but at this point, the percentage resolution per lead was significantly less in the elderly than in the younger patients (51% versus 66%; P = 0.03), and the ST-segment elevation per lead remained higher in elderly patients (1.8 +/- 1.0 versus 1.2 +/- 0.6 mm; P = 0.0009). On day 2 post-thrombolytic therapy, although there was further resolution of ST-segment elevation in both groups, the percentage resolution per lead remained significantly less (68% versus 80%; P = 0.05) and ST-segment elevation per lead remained significantly higher in elderly patients (1.2 +/- 0.7 versus 0.7 +/- 0.4 mm; P = 0.0002). Resolution of ST-segment elevation after thrombolytic therapy was less marked in elderly patients, indicating a reduced response to thrombolytic therapy in this patient population.

Successful use of tissue plasminogen activator in catheter-related intracardiac thrombus of a premature infant

The incidence of clinically apparent neonatal thrombosis is about 0.1 to 0.2% in the neonatal intensive care unit (NICU). The optimal treatment modalities for neonates with thromboses are not known. We report on our experience with recombinant tissue type plasminogen activator (rt-PA) in a premature infant with an intracardiac thrombus.

Reduced brain infarct volume and improved neurological outcome by inhibition of the NR2B subunit of NMDA receptors by using CP101,606-27 alone and in combination with rt-PA in a thromboembolic stroke model in rats

OBJECT

A novel postsynaptic antagonist of N-methyl-D-aspartate (NMDA) receptors, CP-101,606-27 may attenuate the effects of focal ischemia. In current experiments, the authors investigated its neuroprotective effect alone and in combination with recombinant tissue plasminogen activator (rt-PA) in thromboembolic focal cerebral ischemia in rats.

METHODS

Forty-eight male Wistar rats underwent embolization of the right middle cerebral artery to produce focal cerebral ischemia. After random division into six groups (eight rats in each group), animals received: vehicle; low-dose (LD) CP-101, 606-27, 14.4 mg/kg; high-dose (HD) CP- 101,606-27, 28.8 mg/kg; rt-PA, 10 mg/kg; low-dose combination (LDC) CP- 101,606-27, 14.4 mg/kg plus rt-PA, 10 mg/kg; or high-dose combination (HDC) CP- 101,606-27, 28.8 mg/kg plus rt-PA, 10 mg/kg) 2 hours after induction of embolic stroke. Animals were killed 48 hours after the onset of focal ischemia. Brain infarction volume, neurobehavioral outcome, poststroke seizure activity, poststroke mortality, and intracranial hemorrhage incidence were observed and evaluated. Compared with vehicle-treated animals (39.4 +/- 8.6%) 2 hours posttreatment with CP-101,606-27 or rt-PA or in combination a significant reduction in the percentage of brain infarct volume was seen (LD CP-101,606-27: 20.8 +/- 14.3%, p < 0.05; HD CP-101,606-27: 10.9 +/- 3.2%, p < 0.001; rt-PA: 21.1 +/- 7.3%, p < 0.05; LDC, 18.6 +/- 11.5%, p < 0.05; and HDC: 15.2 +/- 10.1%, p < 0.05; compared with control: 39.4 +/- 8.6%). Combination of CP-101,606-27 with rt-PA did not show a significantly enhanced neuroprotective effect. Except for the control and LDC treatment groups, neurobehavioral outcome was significantly improved 24 hours after embolic stroke in animals in all other active therapeutic groups receiving CP-101,606-27 or rt-PA or in combination. The authors also observed that treatment with HD CP-101,606-27 decreased poststroke seizure activity.

CONCLUSIONS

The data in this study suggested that postischemia treatment with CP-101,606-27 is neuroprotective in the current stroke model; however, the authors also note that although rt-PA may offer modest protection when used alone, combination with CP-101,606-27 did not appear to enhance its effects.

[Intra-arterial thrombolysis for the treatment of restricted cochlear microcirculation disorder in guinea pigs]

OBJECTIVE

To ascertain a new treatment method for restricted cochlear microcirculation disorder.

METHODS

Photochemical reaction was utilized to induce localized microcirculation damage to the second cochlear turn of every guinea pig. The animals were divided into 5 groups. Group 1 was blank control. Group 2 and Group 3 were injected urokinase (UK) through left subclavian artery or left external jugular vein 30 minutes after photochemical reaction. Group 4 and Group 5 were two control groups. Instead of urokinase, saline injection was applied accordingly.

RESULTS

Both intra-arterial thrombolysis and intravenous thrombolysis were effective to improve the hearing levels and the blood supply to the inner ear. 50 minutes after urokinase injection, animals with intra-arterial thrombolysis showed a lower action potential threshold than that with intravenous thrombolysis (P = 0.025). And this phenomenon lasted 30 minutes. Cochlear blood flow of the animals with intra-arterial thrombolysis began to decrease and action potential began to increase 80-90 minutes after UK injection.

CONCLUSION

Both intra-arterial thrombolysis and intravenous thrombolysis were effective to the restricted thrombosis in the stria vascularis, and intra-arterial thrombolysis showed a better improvement in the early stage of thrombolysis.

[New methods for the diagnosis of acute pulmonary embolism]

INTRODUCTION

Pulmonary embolism is a high mortality cardiovascular disease, which is difficult to diagnose even today.

AIM AND METHOD

In this study the symptoms and the results of diagnostic methods were analysed in 81 patients with acute pulmonary embolism, admitted during a one-year period to Kaposi Mór County Hospital. The patient records were examined with special emphasis on the diagnostic value of novel methods such as D-dimer assay and chest computed tomography scanning along with the routine techniques used in the management of pulmonary embolism.

RESULTS

In all patients ECG, in 88% of the cases chest X-ray, in 57% blood gas analysis and in 53% D-dimer assay results were evaluated. 14.8% of the patients died during hospitalisation. The following diagnostic imaging procedures were undertaken: in 80.2% of the cases lung scan, in 59.3% echocardiography and in 8.7% of the cases spiral computed tomography scan were prepared. In 12.3% of all cases thrombolysis proved necessary. The results were compared with data from International Cooperative Pulmonary Embolism Registry Study, which analyses 2454 patient cases.

CONCLUSION

It is foreseen that the increasing use of echocardiography, lower limb ultrasound and highly informative spiral computed tomography scanning as an additional means in pulmonary embolism diagnostics may in some cases spare the use of pulmonary scintigraphy.

[Endovascular thrombolysis and stent angioplasty for obliteration in cerebral venous sinuses]

OBJECTIVE

To summarize the experience of treating the obliteration of the cerebral venous sinus in 17 patients by using direct thrombolysis and stent angioplasty.

METHODS

All 17 patients with thrombosis and stenosis of the venous sinus were confirmed by digital subtraction angiography. Of these 3 patients had thrombosis in a single sinus and 14 had thrombosis in multiple sinuses. The circulating time was prolonged for over 13 seconds. The micro-catheter was preserved in the sinus for 5 days, followed by infusion of urokinase 1.5 million units and oral warfarin 3-5 mg each day. Stent angioplasty was done for 4 patients with obvious stenosis of the venous sinus detected by DSA after thrombosis.

RESULTS

After contact thrombosis and stent angioplasty in sinuses of the 17 patients, remarkable recanalization of obliterated sinuses was achieved. After treatment, intracranial hypertension pressure (ICP) returned to normal in 7 patients, and 8 thrombosis relapsed in different degree after 7 days. Anticoagulation was prescribed. Only 2 patients showed the ICP above 280 mm H(2)O. No obvious relapse was found in 15 patients during the follow-up for 3-60 months.

CONCLUSION

Our results demonstrated that successive thrombolysis and stent angioplasty for occlusion and thrombosis of the venous sinus are effective in promoting drainage of cerebral venous blood and rapidly decreasing ICP.

Procedural success and patency after percutaneous treatment of thrombosed autogenous arteriovenous dialysis fistulas

PURPOSE

To retrospectively evaluate success and midterm patency after percutaneous thrombectomy, lytic therapy, and angioplasty for thrombosed autogenous arteriovenous dialysis fistulas.

MATERIALS AND METHODS

From March 1996 to September 2001, 24 patients with 25 fistulas presented with 30 episodes of thrombosis of their autogenous fistulas, including 19 forearm radiocephalic fistulas in 18 patients and six upper arm brachiocephalic fistulas in six patients. Patients presented for percutaneous therapy within 48 hours of fistula thrombosis, with the exception of one patient who presented 7 days after thrombosis. Lytic therapy with urokinase or recombinant tissue plasminogen activator (rt-PA) was administered as a bolus into the fistula in 24 cases, with the exception of one case in which a 16-hour infusion of rt-PA was initiated. A mechanical thrombectomy device was used in a single case. Balloon thrombectomy was performed for residual clot. Angioplasty was performed at the arterial inflow, fistula, and outflow veins as required for identified areas of stenosis and/or maceration of thrombus.

RESULTS

Clinical success was achieved in 73% of cases (22 of 30). All patients were followed for a maximum of 66 months (mean, 12 mo). Primary patency rates were 36% at 3 months (95% CI, 18%-54%), 28% at 6 months (95% CI, 12%-46%), and 24% at 1 year (95% CI, 10%-42%). The assisted primary patency rate was 40% (95% CI, 21%-58%) at 3 months and stabilized at 32% at 6 months (95% CI, 15%-50%). The secondary patency rate stabilized at 3 months at 44% (95% CI, 24%-62%) for 15 months. Patency rates after clot removal were not significantly different between upper and lower arm fistulas (P =.14). Total observation time of the cohort of 25 fistulas was 296 months. The complication rate was 7% (two of 30), with one major complication and one minor complication.

CONCLUSION

Salvage of function after percutaneous clot removal from autogenous fistulas involves a steep learning curve initially and is possible with 3-month patency rates that approximate Kidney Disease Outcomes Quality Initiative recommendations for clot removal from polytetrafluoroethylene grafts.

[Intravascular ultrasound thrombolysis for recanalization of peripheral arteries: evaluation of an in vitro model and results of a pilot-study]

OBJECTIVES

To evaluate the effectiveness of ultrasound thrombolysis in vitro in comparison with thrombectomy, and in vivo as a pilot-study for the treatment of thrombotic occlusions of peripheral arteries.

METHODS

Under standardized conditions, one-day-old and five-day-old thrombi of whole blood, thrombin-induced thrombi and old organized thrombi of human blood were treated with ultrasound thrombolysis and Amplatz thrombectomy device (ATD). Four patients with arterial occlusive disease of Fontaine stage IIb-III underwent intraarterial ultrasound-thrombolysis, applied to long segmental occlusions of the superficial femoral or iliac artery ranging in duration from three days to one year.

RESULTS

The weight of the thrombi after ultrasound thrombolysis was 1.5 g +/- 0.53 (ATD: 0 g) compared to 3.65 g +/- 0.34 without treatment, with more weight reduction in five-day-old thrombi than in one-day-old thrombi. In vivo, partial recanalization was achieved in a three-day-old femoral occlusion. There was no effect in the other three patients. Urokinase thrombolysis with subsequent PTA and stenting resulted in complete recanalization in three patients.

CONCLUSIONS

Ultrasound thrombolysis in vitro was significantly less effective than ATD. The results of ultrasound thrombolysis were influenced by the age of the thrombus and its in vitro formation. Intravascular ultrasound thrombolysis alone was insufficient to treat occluded peripheral arteries in vivo.

The clinical spectrum of acute renal infarction

BACKGROUND

Acute renal infarction is an oft-missed diagnosis. As a result, its true incidence, although presumed to be low, is actually unknown. Surprisingly, the medical literature on the subject, other than anecdotal case reports, is scarce.

OBJECTIVES

To increase physician awareness of the diagnosis and to identify predictive clinical and laboratory features of the entity.

METHOD

Between 1 November 1997 and 31 October 2000, 11 cases of acute renal infarction in 10 patients were diagnosed in our center by contrast-enhanced computerized tomography. The medical charts of these patients were reviewed regarding risk factors, clinical presentation, possible predictive laboratory examinations, and outcome.

RESULTS

During the 36 month observation period, the incidence of acute renal infarction was 0.007%. The mean age of the patients (5 men and 5 women) was 67.4 +/- 21.1 (range 30-87 years). In four cases the right and in five the left kidney was involved; in the other two cases bilateral involvement was seen. In 7/10 patients, an increased risk for thromboembolic events was found. Six had chronic atrial fibrillation and one had a combined activated protein C resistance and protein S deficiency. Three patients had suffered a previous thromboembolic event. Two cases were receiving anticoagulant therapy with an INR of 1.6 and 1.8, respectively. On admission, flank pain was recorded in 10/11, fever in 5 and nausea/vomiting in 4 cases. Hematuria was detected in urine reagent strips in all cases. Serum lactate dehydrogenase and white blood cell count were elevated in all cases (1,570 +/- 703 IU/L and 12,988 +/- 3,841/microliter, respectively). In no case was the diagnosis of acute renal infarction initially entertained. The working diagnoses were renal colic in 2, pyelonephritis in 3, renal carcinoma, digitalis intoxication, and suspected endocarditis in one patient each, and an acute abdomen in 3. Time from admission to definitive CT diagnosis ranged from 24 hours to 6 days. Three patients were treated with intravenous heparin and another with a combination of i.v. heparin and renal intra-arterial urokinase infusion with, in the latter case, no recovery of function of the affected kidney. With the exception of this one patient (with a contralateral contracted kidney) who required maintenance dialysis, in all other cases serum creatinine levels remained unchanged or reverted to the baseline mean of 1.1 mg/dl (0.9-1.2).

CONCLUSIONS

Acute renal infarction is not as rare as previously assumed. The entity is often misdiagnosed. Unilateral flank pain in a patient with an increased risk for thromboembolism should raise the suspicion of renal infarction. In such a setting, hematuria, leucocytosis and an elevated LDH level are strongly supportive of the diagnosis.

Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy

PURPOSE

To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis.

MATERIALS AND METHODS

Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded.

RESULTS

Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours +/- 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U +/- 1.60 urokinase, 18.4 mg +/- 10.7 tissue plasminogen activator, and 13.8 U +/- 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% +/- 24.1) when using MT alone, compared with substantial thrombus removal (62.0% +/- 24.9) when using MT after pharmacologic thrombolytic agents had been administered (P =.006).

CONCLUSION

The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

[Treatment of massive pulmonary embolism with local thrombolysis]

BACKGROUND

The diagnosis and therapy of pulmonary embolism may still be difficult. Patients with massive central emboli have an unacceptable risk of treatment failure and death when treated with conventional anticoagulants.

PATIENTS AND RESULTS

Three patients with massive pulmonary embolism were treated with local catheter-directed thrombolysis and mechanical fragmentation. Nearly total thrombolysis was achieved, as estimated by angiography and spiral CT scan. Clinical improvement was confirmed by blood gas measurements, pulse oximetry, and echocardiographic assessment.

INTERPRETATION

Based on data from the literature, thrombolytic therapy is more efficient than conventional anticoagulation in patients with massive central pulmonary embolism affecting the systemic circulation. Local, catheter-directed thrombolysis with mechanical fragmentation and direct infusion into the thrombus produced very good results in our patients. Other published data confirm that this method is feasible, safe and effective. In selected patients, this therapy is a good alternative to systemic thrombolysis, although it remains to be established which method is best.

[Thrombolytic therapy in acute cerebral infarction]

BACKGROUND

The aim of this study was to assess the feasibility, safety, and clinical results in patients treated with intravenous thrombolysis in an acute stroke unit. Results from the first three years with thrombolysis as standard treatment procedure are presented.

MATERIAL AND METHODS

All patients admitted to our department within 3 hours after an acute ischaemic stroke were considered for thrombolysis. 33 patients with median age 71 years were treated.

RESULTS

16 patients demonstrated early clinical improvement. Six patients demonstrated a substantial but slow clinical improvement. 11 patients did not improve. One patient developed an intracerebral haematoma and two developed a haemorrhagic infarction without clinical deterioration. At follow-up after six months, 16 patients (49%) had achieved independence [modified Rankin Scale (mRS) 0-2], 12 (36%) had an unfavourable outcome (mRS 3-5). Five patients (15%) died, all within the first 3 months. None died due to a treatment complication.

INTERPRETATION

This study suggests that thrombolysis can be administered relatively safely in an acute stroke unit without intensive care facilities. The clinical results and safety were similar to those in large randomized studies and clinical series.

Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment

BACKGROUND AND PURPOSE

Local intraarterial fibrinolysis (LIF) is one of several methods used in treating central retinal artery occlusion (CRAO). We investigated whether LIF is more effective than conservative methods in the treatment of CRAO.

METHODS

In this retrospective study, a total of 178 patients (125 men and 53 women) with CRAO were treated at the Eye Hospital of the University of Freiburg from 1980 to 2000. The average age of the patients was 66.8 years (SD, 12 years). In group I, 116 patients were treated conservatively by anterior chamber paracentesis, massage of the globe, isovolemic hemodilution, acetazolamide, Pentoxifyllin, acetylsalicylic acid, and reduction of arterial hypertension. Some combination but not all of the mentioned conservative methods were used in the conservatively treated patients. In group II, 62 patients receiving LIF received local injection of urokinase or recombinant tissue plasminogen activator into the proximal part of the ophthalmic artery. In case of ipsilateral carotid artery occlusion or high grade stenosis (14 of 62 patients), the thrombolytic agent was administered into the internal maxillary artery.

RESULTS

Among 178 patients, the CRAO was subtotal in 130 (73.0%), incomplete in 39 (21.9%), and total in nine (5.1%). Statistical calculations showed a significantly better visual acuity in group II patients, who were treated with LIF, in comparison with group I patients, who were treated conservatively (P =.0022).

CONCLUSION

For patients with CRAO, LIF is superior to conservative treatment.

[Superior vena cava syndrome]

Superior vena cava syndrome is due to an intrinsic or extrinsic caval obstruction that evolves in acute or subacute way with distinctive clinical feature such as respiratory symptoms and venous stasis. Since 1998 we have treated three cases of spontaneous superior vena cava thrombosis in neoplastic patients who underwent several infusion of chemotherapy, respectively for a breast, uterine and rectum cancer. All patients was female, 52, 58 and 70 years old. The first two cases was treated with locoregional thrombolysis by infusing Urokinase 50,000 UI/h during 24 hours and Urokinase 50,000 UI/h during 12 h the third one. After that, we have positioned a 16/9 wallstent: in the first two cases directly into the superior vena cava, in the third case in the subclavian-anonyma truncus. We had in all cases the complete opening of the stent within the first 48 hours without complications, enabling us to reach a free caval diameter of about 2 cm with resolution of the clinical signs. In patients with high surgical risk, the caval wall-stent is the first choice to solve the vein recanalization.

Local intraarterial urokinase thrombolysis of acute ischemic stroke with or without intravenous abciximab: a pilot study

PURPOSE

One of the most important prognostic factors in the thrombolytic treatment of acute ischemic stroke is the time to recanalization. To shorten the recanalization time, an antiplatelet agent, abciximab (platelet glycoprotein receptor IIb/IIIa antagonist), was administered intravenously before the initiation of local intraarterial urokinase thrombolysis. The purpose of this study was to evaluate the effectiveness and safety of this combined therapy.

MATERIALS AND METHODS

A total of 26 patients with acute ischemic stroke (National Institutes of Health Stroke Scale score >10) were enrolled in this study. In the earlier phase of this study, conventional local intraarterial urokinase thrombolysis was performed in 16 patients (urokinase group). In the later phase, combined use of intravenous abciximab and local intraarterial urokinase thrombolysis was performed in 10 patients (urokinase + abciximab group). Recanalization rate (Thrombolysis in Myocardial Infarction grade >or=2), total amount of urokinase used, incidence of symptomatic hemorrhage, and better functional outcome rate (modified Rankin scale <or=2) were compared between the two groups with use of the Fisher exact test or Mann-Whitney U test.

RESULTS

The recanalization rate in the urokinase + abciximab group (90%, nine of 10) was significantly higher than that in the urokinase group (43.8%, seven of 16) (P =.037). The mean amount of urokinase required for recanalization was significantly lower in the urokinase + abciximab group (828,000 IU vs 418,000 IU; P <.005). As for the incidence of symptomatic hemorrhage, no significant difference was noted between the two groups (four of 16 vs three of 10) (P = 1.0). The urokinase + abciximab group showed a trend of better functional outcome (50% vs 80%; P =.2).

CONCLUSIONS

Combined therapy employing intravenous abciximab and local intraarterial urokinase thrombolysis showed a marked improvement in recanalization rate and showed a trend of better functional outcome. The safety of this regimen still remains to be justified with modification of the indication and regimen dosage.

[Experience with intra-arterial thrombolysis in patients with acute stroke]

The authors report on their results with local intraarterial thrombolysis in four patients.

PATIENTS

Three patients suffered from vertebrobasilar artery occlusion, and one from carotid-T occlusion. All were treated with local intraarterial thrombolysis by a joint team of neurologist, neuroanaesthesist and interventional neuroradiologist in the stroke-department of St. Stephen Municipal Hospital in collaboration with National Institute of Neurosurgery. Selection of patients suitable for successful intraarterial thrombolysis has to be done in the neurological department with help of ultrasound and neurological examination and CT scan. Patients were transferred to the therapeutic angiosuit and interventional treatment was initiated immediately upon establishing the diagnosis. At least one million units of urokinase was infused directly into the embolus in each case.

RESULTS

Complete recanalisation was achieved in three of the four cases. That was associated with full recovery in two patients, in whom good collateral circulation and no signs of atherosclerotic lesions were found prior to treatment. Another patients has died despite of full recanalisation of the basilar artery. One patient survived after partial recanalisation of bilateral vertebral artery occlusion with mild residual tetraparesis.

CONCLUSION

Local intraarterial thrombolysis is effective and is associated with good clinical outcome in properly selected patients. Careful and accurate ultrasound diagnostics of the site of occlusion plays a significant role in proper patient selection. Although difficult, acute intraarterial thrombolysis can be organized in a timely fashion even utilizing the required facilities in two different institutions, providing that all efforts is being made by each party for the fast diagnosis and treatment initiation.

[Management in preretinal macular hemorrhage. Case report]

The report presents a method of management in case of clotted premacular haemorrhage in a 46 year-old woman. The used method of treatment proceeded in 2 stages: 1) pars plana, intravitreal injection of 50 mg tissue plasminogen activator (tPA-Actilise), 2) after 24 hours intravitreal 0.5 cc SF6 with air mixture (1:5). Fibrinolytic tPA action and mechanic action of expanding gas caused after argon laser puncture intravitreal haemorrhage dislocation and following its resorption. The almost full visual acuity persisted for over 2 years.

[Thrombolytic therapy in acute ischemic stroke with streptokinase]

AIM AND METHODS

In an open, observational study, 40 consecutive ischemic stroke patients eligible for thrombolytic therapy using the combined ECASS/NINDS inclusion criteria have been treated intravenously with 1.5 M units of streptokinase. The therapeutic window was 3 hours or shorter.

RESULTS

The safety analysis documented a low rate (5%) of intracerebral hemorrhages, and an additional 13% rate of hemorrhagic transformation of the initial infarction. Two patients died due to intracerebral bleeding. The efficacy of the SK thrombolysis was significant in 53% of the patients (the mean of the improvement on the NIH stroke scale was 15 points), while an other 42% of the patients achieved only the mean of 4 points improvement on their NIHSS score.

DISCUSSION

These results are of the same magnitude, as those documented in the NINDS trial with rt-PA. Time window rather than the thrombolytic agent itself seems to be the decisive factor for successful thrombolysis.

CONCLUSION

The good safety profile of SK in acute stroke using the ECASS/NINDS criteria, and the cost-effectiveness of the drug underline the necessity of a new SK trial with the recently accepted inclusion and exclusion criteria.

New grading system for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke

OBJECTIVE

The Thrombolysis in Myocardial Infarction (TIMI) grading scheme and other classification systems are limited because they do not account for occlusion location or collateral circulation. A new scheme for angiographic classification of arterial occlusion and recanalization response to intra-arterial thrombolysis in acute ischemic stroke was designed because of limitations in existing grading systems.

METHODS

The proposed scheme assigns a score from 0 to 5 on the basis of occlusion site and collateral supply. The pre- and post-thrombolysis angiograms of 15 patients with acute ischemic stroke were independently graded by three neurointerventionists according to TIMI perfusion grade (0-3), a grading scheme developed by Mori et al. (Mori E, Tabuchi M, Yoshida T, Yamadori A: Intracarotid urokinase with thromboembolic occlusion of the middle cerebral artery. Stroke 19:802-812, 1988) (0-4), and the proposed scheme (0-5); and interobserver agreement was assessed. The effect of severity of initial arterial occlusion on outcomes of good recovery (National Institutes of Health Stroke Scale score of < or =4) or death at 7 days after thrombolysis according to the proposed and TIMI grading schemes was also assessed in 60 patients with acute ischemic stroke. Multivariate analyses were performed to assess these relationships after adjusting for patient age, sex, time interval between symptom onset and treatment, and thrombolytic agent used.

RESULTS

Interobserver agreement was higher for pre- and posttreatment grading of angiographic images using the new classification scheme (kappa = 0.73) than with either TIMI perfusion grade (kappa = 0.68) or Mori et al. grade (kappa = 0.68). The proposed grading scheme was inversely associated with good recovery at 7 days (odds ratio, 0.4; 95% confidence interval, 0.2-0.9) and directly associated with 7-day mortality (odds ratio, 2.0; 95% confidence interval, 1.1-3.6) after treatment. Initial TIMI grade did not correlate with either good recovery or death at 7 days. An inverse trend was observed between initial severity of angiographic occlusion as determined by the proposed scheme and complete recanalization after treatment (odds ratio, 0.6; 95% confidence interval, 0.4-1.02).

CONCLUSION

Application of the new classification scheme for assessing pretreatment occlusion and response to intra-arterial thrombolysis resulted in high interobserver agreement and correlated with 7-day outcomes. The six grades used in this scheme allowed precise angiographic evaluation of perfusion changes.

Early dramatic recovery during intravenous tissue plasminogen activator infusion: clinical pattern and outcome in acute middle cerebral artery stroke

BACKGROUND AND PURPOSE

Acute-stroke patients receiving standard intravenous tissue plasminogen activator (tPA) have been noted to experience early dramatic recoveries. The prevalence, clinical characteristics, and outcome of patients experiencing dramatic recovery is not well described.

METHODS

We prospectively studied all patients presenting with acute middle cerebral artery (MCA) stroke syndromes and transcranial Doppler (TCD) evidence of an MCA obstruction. All patients received intravenous tPA per the National Institute of Neurological and Communicative Disorders and Stroke protocol, with serial National Institutes of Health Stroke Scale (NIHSS) scores and continuous TCD monitoring. Dramatic recovery was defined as an improvement of > or =10 NIHSS points or a decrease to an NIHSS score of < or =3 by the end of infusion. Outcome at the end of infusion, at 24 hours, and at long-term follow-up were obtained. The timing and pattern of deficit recovery during dramatic recovery was also studied.

RESULTS

Dramatic recovery occurred in 22% of all patients. Compared with patients who did not experience dramatic recovery, those patients who did had significantly lower end-infusion NIHSS (median 2 and range 0 to 16 for dramatic-recovery patients versus median 17 and range 6 to 35 for non-dramatic-recovery patients, P<0.01) and 24-hour NIHSS (median 2 and range 0 to 16 for dramatic-recovery patients versus median 13 and range 2 to 35 for non-dramatic-recovery patients, P<0.01). A long-term modified Rankin Score benefit was noted (median 1 and range 0 to 6 for dramatic-recovery patients versus median 4 and range 0 to 6 for non-dramatic-recovery patients, P<0.01). Baseline clinical characteristics were similar. The only difference was improved TCD-determined flow values at the end of infusion (normal restoration of flow was 58% in dramatic-recovery patients versus 14% in non-dramatic-recovery patients, P<0.01). A characteristic pattern of recovery of deficit was noted.

CONCLUSIONS

Early dramatic recovery in acute MCA stroke patients treated with intravenous tPA is relatively frequent. The benefit of dramatic recovery is maintained at 24 hours and over the long term. TCD monitoring suggests that dramatic recovery is a result of early restoration of MCA flow during the tPA infusion. The consistent pattern of early clinical recovery may help explain the mechanisms by which thrombolysis improves outcome and could suggest targets for enhancing the therapeutic effect of intravenous tPA.

Can transcranial ultrasonication increase recanalization flow with tissue plasminogen activator?

BACKGROUND AND PURPOSE

In thrombolytic therapy for acute ischemic stroke, it is essential to obtain rapid thrombolysis before ischemic neuronal injury occurs. To develop a new technique of thrombolysis for acute ischemic stroke, the effect of transcranially applied ultrasound (TUS) on thrombolysis was examined.

METHODS

An occlusion model of rabbit femoral artery was produced with thrombin after establishment of stenotic flow and endothelial damage. After stable occlusion was confirmed, monteplase (mtPA) was administered intravenously, and ultrasound (490 kHz, 0.13 W/cm2) was applied through a piece of temporal bone (TUS group; n=9). The control group received mtPA alone (tissue plasminogen activator [tPA] group; n=12). To verify the efficacy of TUS, femoral artery flow was measured during the procedure.

RESULTS

The recanalization ratio was 16.7% (2 of 12) in the tPA group and 66.7% (6 of 9) in the TUS group. The recanalization ratio in the TUS group was higher than that in the tPA group (P=0.03). Patency flow ratio, which was defined as recanalization flow divided by baseline flow, of the TUS group (44.6+/-13.9%) was significantly greater than that of the tPA group (9.9+/-6.8%) at 60 minutes (P=0.025). Patency flow ratio became higher in the TUS group than in the tPA group between 20 and 30 minutes from the start of thrombolysis.

CONCLUSIONS

Low-frequency and low-intensity TUS enhanced thrombolysis by mtPA in a rabbit femoral artery occlusion model. This technique should be clinically useful for thrombolysis in acute ischemic stroke.

Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature

BACKGROUND

Results of recently published studies suggest that intravenous thrombolysis (IVT) and local intra-arterial thrombolysis (LIT) are feasible procedures in acute stroke after cervical artery dissection (CAD).

OBJECTIVES

To describe 9 patients with acute stroke caused by CAD who were treated by LIT (n = 7) or IVT (n = 2) and to review the literature.

METHODS

Retrospective analysis of clinical and neuroradiological findings; literature review from 1980 to present.

MAIN OUTCOME MEASURE

Modified Rankin Scale (mRS) score.

RESULTS

Of 7 patients treated with LIT, 3 had good outcomes (mRS score of 0-2) and 4 had bad outcomes (mRS score of 3-6) at 3 months. The 2 patients who had received IVT recovered to mRS scores of 0 and 3. Twenty-one patients were identified in the literature. Overall (N = 30), in the IVT group (n = 19), the outcome was good in 8 patients (42%) and bad in 11 (58%); in the LIT group (n = 11), 6 patients (55%) had a good outcome and 5 (45%) had a bad outcome. Overall, 47% (14/30) of the patients (IVT and LIT groups) had a good outcome. Total mortality was 13% (4/30). There were no secondary complications due to extension of wall hematoma or angiography. One symptomatic hemorrhage occurred.

CONCLUSIONS

Thrombolysis is feasible in acute stroke caused by CAD. Local complications from extension of wall hematoma did not occur. Further prospective studies are needed to determine the safety and efficacy of thrombolysis in the special circumstance of acute stroke caused by CAD.

Prophylaxis with urokinase in pediatric oncology patients with central venous catheters

This study evaluated the effects of urokinase in the prevention of central venous catheter (CVC)-related complications in children with malignancy. Fifteen patients with 16 CVCs (study group A) received an intraluminal application of urokinase (10,000 IU in each catheter lumen for 4 h) once a week. They were monitored prospectively with quantitative blood cultures and ultrasonography (color Doppler ultrasound of the great veins and echocardiography). The rate of complications was compared with that of 15 children with 19 CVCs without thromboprophylaxis, treated the previous significantly lower incidence of CVC dysfunction year (control group B). The authors found a wer incidence of CVC dysfunction (3/16 versus 13/19), no major thrombosis, fewer CVC-related bacteremias (2/16 versus 8/19), and a higher salvage of CVCs (1/16 versus 5/19 CVC removals due to persistent bacteremia) in the thromboprophylaxis group. Asymptomatic thrombosis rate was also lower (7/16 cases in group A versus 9/11 in group B when sonography was performed). No hemorrhagic complications were noted. Thromboprophylaxis with urokinase seems a safe and effective measure for reducing the rate of CVC-related complications.

[Surgical procedures in the treatment of age-related macular degeneration]

The surgical techniques for removal of a subretinal membrane associated with age-related macular degeneration will be discussed and compared on the basis of published data. The so-called simple subretinal membrane extraction will be compared with pigment epithelium cell transplantation and with the various techniques for macular translocation. The pars plana gas injection with tissue plasminogen activator procedure will also be mentioned. Because a controlled trial with a sufficient number of patients and follow-up has not been carried out for any of these techniques, the results of published case series will be used for this review.

Combined direct percutaneous transluminal angioplasty and low-dose native tissue plasminogen activator therapy for acute embolic middle cerebral artery trunk occlusion

BACKGROUND AND PURPOSE

In embolic middle cerebral artery (MCA) trunk occlusion, recanalization with direct percutaneous transluminal angioplasty (PTA) may be preferable to time-consuming thrombolysis. However, distal embolization with small crushed fragments is a complication of direct PTA. We prospectively evaluated combined direct PTA and low-dose native tissue plasminogen activator (t-PA) therapy for acute embolic MCA trunk occlusion.

METHODS

Fifteen patients underwent direct PTA. The embolus was successfully crushed in 12, who received subsequent native t-PA infusion. Direct PTA was performed with a balloon catheter, which was advanced into the occlusion site and inflated several times until recanalization was established. After PTA, 7.2 mg of native t-PA in 100 mL of isotonic sodium chloride solution was infused for 30 minutes. Neurologic status was evaluated at admission and immediately and 1 month after treatment. In all patients, follow-up CT was performed within 24 hours and 3-7 days after onset, and follow-up MR imaging, 1 month after onset.

RESULTS

Direct PTA failed to crush the embolus in three of 15 patients; these three had no clinical improvement. In 11 of 12 patients, combined therapy was successful, with no technical complication. Although no symptomatic intracerebral hemorrhage occurred, one patient had a small hematoma. All patients with successful recanalization had marked clinical improvement. Although angiograms showed distal embolizations in 10, cortical infarctions were confirmed in only three at follow-up.

CONCLUSION

Combined direct PTA and IV low-dose native t-PA therapy may be a safe alternative to thrombolytic therapy in some patients with embolic MCA trunk occlusion.

[Long-term follow-up of patients with acute myocardial infarction treated with primary angioplasty or thrombolysis. Results of the MITRA trial]

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p < 0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p < 0.001) or statins (24.5% versus 16.5%, p < 0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.