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Pettersen JA, Hudon ME, Hill MD. Intra-arterial thrombolysis in acute ischemic stroke: a review of pharmacologic approaches. Expert Rev Cardiovasc Ther 2014; 2:285-99. [PMID: 15151476 DOI: 10.1586/14779072.2.2.285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke is a major public health problem worldwide. The potential to cure stroke patients with intravenous thrombolytic therapy has evolved to the use of intra-arterial thrombolytic agents. Fewer than 200 patients have been enrolled in randomized trials of intra-arterial therapy. In this article the authors have reviewed the literature listed in MEDLINE and EMBase, and searched relevant articles to examine the role of fibrinolytic agents in acute interventional stroke therapy. Only English language articles reporting five or more patients were included. Outcomes were defined at 90 days. Good outcome was defined on the modified Rankin Scale. Symtpomatic hemorrhage was defined as hemorrhage in the setting of clinical deterioration in the first 24 to 48 h. The search identified 57 studies of which 44 reported usable data. Only three randomized trials were reported. Of a total of 1140 patients, most (73%) were treated open-label with urokinase (Abbokinase, Abbott Laboratories). The best outcomes were reported in case series and slightly worse outcomes were reported in clinical trials. Overall, it was not possible to distinguish whether one agent was superior to the others. There is a paucity of published evidence on intra-arterial therapy for acute ischemic stroke. Alteplase (Activase, Genentech Inc.) is currently the drug of choice simply because it is available and it is the current intravenous standard. Further trials and developments are anticipated.
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Affiliation(s)
- Jacqueline A Pettersen
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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2
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Williams M, Patil S, Toledo EG, Vannemreddy P. Management of acute ischemic stroke: current status of pharmacological and mechanical endovascular methods. Neurol Res 2013; 31:807-15. [DOI: 10.1179/016164109x12445505689562] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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3
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Medical therapy for ischemic stroke: review of intravenous and intra-arterial treatment options. World Neurosurg 2012; 76:S9-15. [PMID: 22182278 DOI: 10.1016/j.wneu.2011.05.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 05/26/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Thrombolytic therapy is of proven and substantial benefit for select patients with acute cerebral ischemia. Diagnostic options and medical treatment options for acute stroke ischemia have undergone enormous changes in the past decades. Whereas initially stroke treatment was reduced to prevention, management of symptoms, and rehabilitation, nowadays a multitude of different fibrinolytic drugs are available. The wide availability of computed tomography in the late 1980s made thrombolysis a real therapeutic option because it allowed a fast and accurate differentiation between ischemic and hemorrhagic stroke. METHODS This study reviews these developments and how they have shaped our current use and understanding of thrombolytics in the treatment of acute ischemic stroke. RESULTS Patient selection remains a central aspect of thrombolytic treatment, and to date, the use of different fibrinolytics has been studied in over 20 large randomized trials for different clinical settings, time windows, and routes of administration. These studies included over 7000 patients, and led to our current understanding of the use of thrombolysis in acute stroke. CONCLUSIONS Intravenous fibrinolytic therapy within the first 3 hours of ischemic stroke onset offers substantial benefits for virtually all patients with potentially disabling deficits. In the 3- to 4.5-hour treatment window, intravenous fibrinolytic therapy has been shown to offer moderate net benefits when applied to all patients with potentially disabling deficits. Intra-arterial fibrinolytic therapy in the 3- to 6-hour window offers moderate net benefits when applied to all patients with potentially disabling deficits and large-artery cerebral thrombotic occlusions.
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Microbubbles improve sonothrombolysis in vitro and decrease hemorrhage in vivo in a rabbit stroke model. Invest Radiol 2011; 46:202-7. [PMID: 21150788 DOI: 10.1097/rli.0b013e318200757a] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Tissue plasminogen activator (tPA) is the thrombolytic standard of care for acute ischemic stroke, but intracerebral hemorrhage (ICH) remains a common and devastating complication. We investigated using ultrasound (US) and microbubble (MB) techniques to reduce required tPA doses and to decrease ICH. MATERIALS AND METHODS Fresh blood clots (3-5 hours) were exposed in vitro to tPA (0.02 or 0.1 mg/mL) plus pulsed 1 MHz US (0.1 W/cm²), with or without 1.12 × 10⁸/mL MBs (Definity or albumin/dextrose MBs [adMB]). Clot mass loss was measured to quantify thrombolysis. New Zealand white rabbits (n = 120) received one 3- to 5-hour clot angiographically delivered into the internal carotid artery. All had transcutaneous pulsed 1 MHz US (0.8 W/cm²) for 60 minutes and intravenous tPA (0.1-0.9 mg/kg) with or without Definity MBs (0.16 mL/mg/kg). After killing the animals, the brains were removed for histology 24 hours later. RESULTS In vitro, MBs (Definity or adMB) increased US-induced clot loss significantly, with or without tPA (P < 0.0001). At 0 and 0.02 mg/mL, tPA clot loss was greater with adMBs compared with Definity (P ≤ 0.05). With MB, the tPA dose was reduced 5-fold with good efficacy. In vivo, both Definity MB and tPA groups had less infarct volume compared with controls at P < 0.0183 and P = 0.0003, respectively. Definity MB+tPA reduces infarct volume compared with controls (P < 0.0001), and ICH incidence outside of strokes was significantly lower (P = 0.005) compared with no MB. However, infarct volume in Definity MB versus tPA was not different at P = 0.19. CONCLUSION Combining tPA and MB yielded effective loss of clot with very low dose or even no dose tPA, and infarct volumes and ICH were reduced in acute strokes in rabbits. The ability of MBs to reduce tPA requirements may lead to lower rates of hemorrhage in human stroke treatment.
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Recanalization therapy for acute ischemic stroke, part 1: surgical embolectomy and chemical thrombolysis. Neurosurg Rev 2010; 34:1-9. [DOI: 10.1007/s10143-010-0293-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Accepted: 08/29/2010] [Indexed: 10/18/2022]
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Yang FC, Lin CC, Hsueh CJ, Lee JT, Hsu CH, Lee KW, Peng GS. Local Intra-Arterial Thrombolysis With Urokinase for Acute Ischemic Stroke Before and After the Approval of Intravenous Tissue Plasminogen Activator Treatment in Taiwan. Ann Vasc Surg 2010; 24:1117-24. [PMID: 21035704 DOI: 10.1016/j.avsg.2010.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 03/03/2010] [Accepted: 07/09/2010] [Indexed: 11/26/2022]
Affiliation(s)
- Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Swarnkar AS, Jungreis CA, Wechsler LR, Wehner JJ. Combined intravenous and intraarterial thrombolytic therapy for treatment of an acute ischemic stroke: a case report. J Stroke Cerebrovasc Dis 2009; 8:264-7. [PMID: 17895175 DOI: 10.1016/s1052-3057(99)80077-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Acute cerebral ischemia resulting from the occlusion of a large or medium size intracranial artery is a known complication of antiphospholipid antibody syndrome (AAS). Usually these patients are treated by low dose aspirin and anticoagulants to prevent a stroke. We are reporting a case of acute stroke in a patient with AAS in whom combined intravenous and intraarterial thrombolytics were used emergently with an excellent outcome. A 32-year-old woman presented with a left hemispheric stroke of 2.5 hours duration. A computed tomography (CT) study of the brain was normal. The patient was treated with intravenous tissue plasminogen activator but remained aphasic and hemiplegic. Subsequently, the patient had a stable xenon CT cerebral blood flow study demonstrating low flow in the left middle cerebral artery (MCA) territory and an angiogram, which demonstrated occlusion of the left MCA. The patient was then treated with intraarterial urokinase with a rapid and marked improvement in her neurological deficit. The case suggests that stroke patients can be treated safely and effectively with combined thrombolytics.
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Affiliation(s)
- A S Swarnkar
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bourekas EC, Slivka A, Shah R, Mohammad Y, Slone HW, Kehagias DT, Suarez J, Sunshine J, Zaidat OO, Tarr R, Landis DM, Suri MFK, Qureshi AI. Intra-arterial thrombolysis within three hours of stroke onset in middle cerebral artery strokes. Neurocrit Care 2009; 11:217-22. [PMID: 19225909 DOI: 10.1007/s12028-009-9198-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 01/28/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The Prolyse in Acute Cerebral Thromboembolism II (PROACT II) trial showed improved outcomes in patients with proximal middle cerebral artery (MCA) occlusions treated with intra-arterial (IA) thrombolysis within 6 h of stroke onset. We analyzed outcomes of patients with proximal MCA occlusions treated within 3 h of stroke onset in order to determine the influence of time-to-treatment on clinical and angiographic outcomes in patients receiving IA thrombolysis. METHODS Thirty-five patients from three academic institutions with angiographically demonstrated proximal MCA occlusions were treated with IA thrombolytics within 3 h of stroke onset. Outcome measures included outcomes at 30-90 day follow-up, recanalization rates, incidence of symptomatic intracranial hemorrhage, and mortality in the first 90 days. The endpoints were compared to the IA treated and control groups of the PROACT II trial. RESULTS The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (range 4-24). The mean time to initiation of treatment was 106 min (range 10-180 min). Sixty-six percent of patients treated, had a modified Rankin Scale (mRS) score of 2 or less at 1-3 month follow-up compared to 40% in the PROACT II trial. The recanalization rate was 77% (versus 66% in PROACT II). The symptomatic intracranial hemorrhage rate was 11% (versus 10% in PROACT II) and the mortality rate was 23% (versus 25% in PROACT II). CONCLUSION Time-to-treatment is just as important in IA thrombolysis as it is in IV thrombolysis, both for improving clinical outcomes and recanalization rates as well.
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Affiliation(s)
- Eric C Bourekas
- Department of Radiology and Neurology, College of Medicine, The Ohio State University Medical Center, 623 Means Hall, 1654 Upham Dr., Columbus, OH 43210, USA.
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Sugiura S, Iwaisako K, Toyota S, Takimoto H. Simultaneous treatment with intravenous recombinant tissue plasminogen activator and endovascular therapy for acute ischemic stroke within 3 hours of onset. AJNR Am J Neuroradiol 2008; 29:1061-6. [PMID: 18372418 DOI: 10.3174/ajnr.a1012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Because intravenous (IV) recombinant tissue plasminogen activator (rtPA) does not always lead to a good outcome in a considerable proportion of patients, combined IV rtPA and rescue endovascular therapy (ET) have been performed in several recent studies. However, rescue therapy after completion of IV rtPA often results in late ineffective recanalization. We examined the efficacy and safety of combined IV rtPA and simultaneous ET as primary rather than rescue therapy for hyperacute middle cerebral artery (MCA) occlusion. MATERIALS AND METHODS A total of 29 patients eligible for IV rtPA, who were diagnosed as having MCA (M1 or M2) occlusion within 3 hours of onset, underwent thrombolysis. In the combined group, patients were treated by IV rtPA (0.6 mg/kg for 60 minutes) and simultaneous ET (intra-arterial rtPA, mechanical thrombus disruption with microguidewire, and balloon angioplasty) initiated as soon as possible. In the IV group, patients were treated by IV rtPA only. RESULTS The improvement of the National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was 11 +/- 4.8 in the combined group versus 5 +/- 4.3 in the IV group (P < .001). In the combined group, successful recanalization was observed in 14 (88%) of 16 patients with no symptomatic intracranial hemorrhage, and 10 (63%) of 16 patients had favorable outcomes (modified Rankin Scale [mRS] 0, 1) at 3 months. CONCLUSIONS Aggressive combined therapy with IV rtPA and simultaneous ET markedly improved the clinical outcome of hyperacute MCA occlusion without significant adverse effect. Additional randomized study is needed to confirm our results.
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Affiliation(s)
- S Sugiura
- Department of Neurosurgery, Osaka Neurological Institute, Osaka, Japan.
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Sakai K, Nitta J, Horiuchi T, Ogiwara T, Kobayashi S, Tanaka Y, Hongo K. Emergency revascularization for acute main-trunk occlusion in the anterior circulation. Neurosurg Rev 2007; 31:69-76; discussion 76. [DOI: 10.1007/s10143-007-0116-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 08/20/2007] [Indexed: 10/22/2022]
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Li F, Liu Y, Zhu S, Wang X, Yang H, Liu C, Zhang Y, Zhang Z. Therapeutic time window and effect of intracarotid neural stem cells transplantation for intracerebral hemorrhage. Neuroreport 2007; 18:1019-23. [PMID: 17558288 DOI: 10.1097/wnr.0b013e328165d170] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This study investigated the therapeutic effect of neural stem cells transplanted via the carotid artery at different times after intracerebral hemorrhage. A great number of 5-bromo-2-deoxyuridine-positive cells were observed surviving and distributed evenly in the perihematoma areas. Phenotypes of grafted cells depended upon time of transplantation, and the later the cells were transplanted, the larger the percentage of cells that differentiated into neurons. Animals treated at 7 and 14 days after injury exhibited the most significant improvements in behavioral tests. Therefore,intracarotid injection allows efficient delivery of cells to the injured hemisphere, especially during the period 7-14 days after injury, and may potentially be applicable in humans.
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Affiliation(s)
- Feng Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, P.R. China
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12
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Higashida RT. Recent Advances in the Interventional Treatment of Acute Ischemic Stroke. Cerebrovasc Dis 2005; 20 Suppl 2:140-7. [PMID: 16327265 DOI: 10.1159/000089368] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute ischemic stroke is a major cause of morbidity and mortality in Europe, North America, and Asia. Recent advances over the past decade have been made in the interventional approach to patients with a stroke. These include intravenous (i.v.) trials, intra-arterial (i.a.) trials, combined i.v./i.a. trials, and newer devices undergoing current clinical evaluation to mechanically remove clot within the cerebral circulation. METHODS A summary of the latest interventional approaches to stroke, from the interventional neuroradiology perspective, is presented. Results of the major thrombolytic trials over the past decade are summarized. Newer devices and approaches for ischemic stroke patients, including the recently completed Phase 1/2 MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Trial are presented. RESULTS The Proact 1 and 2 trials involving i.a. thrombolytic therapy in patients who present with an acute middle cerebral artery stroke within 6 h from symptom onset have demonstrated significant benefit over the control group, for improved outcomes at 90 days. The MERCI trial has demonstrated, in 114 patients with moderate to severe strokes, that patients who are able to be recanalized have significant neurological improvement versus those who were not able to be recanalized. CONCLUSIONS Continued advances in the interventional approach to acute stroke treatment, with further clinical trials, are warranted. Early reports are encouraging regarding both combination thrombolytic drug trials and mechanical device trials for these patients.
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Affiliation(s)
- Randall T Higashida
- Division of Interventional Neurovascular Radiology, University of California, San Francisco Medical Center, San Francisco, Calif. 94143-0628, USA.
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Schonewille WJ, Algra A, Serena J, Molina CA, Kappelle LJ. Outcome in patients with basilar artery occlusion treated conventionally. J Neurol Neurosurg Psychiatry 2005; 76:1238-41. [PMID: 16107358 PMCID: PMC1739786 DOI: 10.1136/jnnp.2004.049924] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Most data on the outcome of basilar artery occlusion are from recent case series of patients treated with intra-arterial thrombolysis. The limited knowledge on the outcome after a conventional treatment approach comes from a few small case series of highly selected patients. OBJECTIVE To provide more data on the outcome of conventional treatment. METHODS Data were analysed on patients from three centres with symptomatic basilar artery occlusion treated conventionally. Conventional therapy was defined as treatment with antiplatelets, anticoagulation, or both. RESULTS Data were available on 82 patients. The case fatality was 40%. Among survivors, 65% remained dependent (Rankin score 4-5). Patients younger than 60 years (odds ratio = 3.1 (95% confidence interval, 1.0 to 9.5)) and those with a minor stroke (OR = 3.1 (1.0 to 9.6)) were more likely to have a good outcome (Rankin score 0-3). Patients with a progressive stroke were less likely to have a good outcome (OR = 0.3 (0.08 to 1.2)) than patients with a maximum deficit at onset or fluctuating symptoms at presentation. CONCLUSIONS Conventional treatment of symptomatic basilar artery occlusion is associated with a poor outcome in almost 80% of patients, which emphasises the importance of the search for a more effective treatment approach.
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Affiliation(s)
- W J Schonewille
- University Medical Centre Utrecht, Department of Neurology, HP G 03.228, PO Box 85500, 3508 GA Utrecht, Netherlands.
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Qureshi AI, Boulos AS, Hanel RA, Suri MFK, Yahia AM, Alberico RA, Hopkins LN. Randomized comparison of intra-arterial and intravenous thrombolysis in a canine model of acute basilar artery thrombosis. Neuroradiology 2004; 46:988-95. [PMID: 15580491 DOI: 10.1007/s00234-004-1180-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2003] [Accepted: 10/28/2003] [Indexed: 10/26/2022]
Abstract
We compared the rates of recanalization cerebral infarct and hemorrhage between intra-arterial (i.a.) reteplase and intravenous (i.v.) alteplase thrombolysis in a canine model of basilar artery thrombosis. Thrombosis was induced by injecting a clot in the basilar artery of 13 anesthetized dogs via superselective catheterization. The animals were randomized in a blinded fashion, 2 h after clot injection and verification of arterial occlusion, to receive i.v. alteplase 0.9 mg/kg over 60 min and i.a. placebo, or i.a. reteplase 0.09 units/kg over 20 min, equivalent to one-half the alteplase dose, and i.v. placebo. Recanalization was studied for 6 h after treatment with serial angiography; the images were later graded in a blinded fashion. Blinded interpretation of postmortem MRI was performed to assess the presence of brain infarcts and/or hemorrhage. At 3 h after initiation of treatment, partial or complete recanalization was observed in one of six dogs in the i.v. alteplase group and in five of seven in the i.a. reteplase group (P = 0.08). At 6 h, no significant difference in partial or complete recanalization was observed between the groups (two of six vs. five of seven; P = 0.20). Postmortem MRI revealed infarcts in four of six animals treated with i.v. alteplase and three of seven treated with i.a. reteplase (P = 0.4). Intracerebral hemorrhage was more common in the i.v. alteplase group (four of six vs. none of seven; P = 0.02). This study thus suggests that i.a. thrombolysis affords a recanalization rate similar to that of i.v. thrombolysis, but with a lower rate of intracerebral hemorrhage.
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Affiliation(s)
- A I Qureshi
- Zeenat Qureshi Stroke Research Center and Department of Neurology and Neurosciences, Neurological Institute of New Jersey, 90 Bergen Street, DOC-8100, Newark, NJ 07103, USA.
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Kanazawa R, Kominami S, Yoshida Y, Kobayashi S, Teramoto A. Middle cerebral artery thrombolysis through the contralateral internal carotid artery--case report. Neurol Med Chir (Tokyo) 2004; 44:372-5. [PMID: 15347215 DOI: 10.2176/nmc.44.372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 63-year-old male presented with sudden onset of right hemiplegia and global aphasia. On admission he was stuporous. Computed tomography (CT) revealed no abnormalities except for right intraventricular meningioma found incidentally. Emergency angiography confirmed complete occlusion of the left internal carotid artery (ICA) and left M1 trunk whereas the left ICA bifurcation remained patent. The ipsilateral ICA was permanently occluded with two detachable balloons to prevent thrombus migration into the distal ICA and middle cerebral artery (MCA), followed by thrombolysis of the clot in the ipsilateral M1 through the contralateral ICA with urokinase (total dose 420,000 U) under systemic heparinization. Partial recanalization of the ipsilateral MCA was accomplished. The time interval from onset to recanalization was about 3 hours. Postoperative CT showed no hemorrhagic transformation. Slight right paresis and mild motor aphasia persisted 2 months later and he was transferred to a rehabilitation facility. Thrombolysis of the MCA embolism can be performed through the contralateral ICA in the presence of ipsilateral ICA occlusion.
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Berlis A, Lutsep H, Barnwell S, Norbash A, Wechsler L, Jungreis CA, Woolfenden A, Redekop G, Hartmann M, Schumacher M. Mechanical Thrombolysis in Acute Ischemic Stroke With Endovascular Photoacoustic Recanalization. Stroke 2004; 35:1112-6. [PMID: 15017011 DOI: 10.1161/01.str.0000124126.17508.d3] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We present the results of endovascular photoacoustic recanalization (EPAR) treatment for acute ischemic stroke from the Safety and Performance Study at 6 centers in Europe and North America. The objectives of mechanical thrombolysis are rapid vessel recanalization and minimal use of chemical thrombolysis.
Methods—
This study was a prospective, nonrandomized study. The National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin Scale (mRS) score were recorded before treatment. The presence of recanalization was assessed by angiography. To measure outcome, follow-up examinations were performed at 24 hours, 7 days, and 30 days after stroke onset.
Results—
Thirty-four patients (median NIHSS 19) were enrolled. Ten patients had internal carotid artery occlusion, 12 patients had middle cerebral artery occlusion, 11 patients had vertebrobasilar occlusion, and 1 patient had posterior cerebral artery occlusion. The overall recanalization rate was 41.1% (14/34). Complete EPAR treatment was possible in 18 patients (median NIHSS 18), with vessel recanalization in 11 patients (61.1%) after EPAR. The average lasing time was 9.65 minutes. Incomplete EPAR treatment (16/34, median NIHSS 19) was defined as intention to treat with EPAR and that the EPAR microcatheter entered the patient. Additional treatment with intraarterial application of rTPA occurred in 13 patients. An adverse event associated with use of the device occurred in 1 patient. Symptomatic hemorrhages occurred in 2 patients (5.9%). The mortality rate was 38.2%.
Conclusions—
This study demonstrates the safety and technical feasibility of EPAR. This new technique may provide another treatment option in the therapeutic armamentarium for patients with acute ischemic stroke.
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Affiliation(s)
- Ansgar Berlis
- Department of Neuroradiology, University of Freiburg, Breisacherstr 64 D-79106, Freiburg, Germany.
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Ohmomo T, Kurata A, Suzuki S, Fujii K. Strategy for the Treatment of Acute Thromboembolic Stroke Involving an Internal Carotid Artery. Interv Neuroradiol 2004; 10 Suppl 1:77-82. [DOI: 10.1177/15910199040100s111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2004] [Accepted: 01/20/2004] [Indexed: 11/16/2022] Open
Abstract
With the recent improvement of endovascular techniques, intra-arterial local fibrinolytic therapy has become widely available for treatment of acute embolic stroke and there is some evidence that it could be superior to conventional approaches1–6. However, because of high mortality and morbidity, strokes involving the internal carotid artery (ICA) and featuring acute thromboembolic occlusion remain problematic7. We have successfully performed intra-arterial local fibrinolytic therapy via the anterior communicating artery through the contra-lateral ICA in two consecutive cases of thromboembolic occlusion of the ICA, anterior cerebral artery (ACA) and middle cerebral artery (MCA), and obtained satisfactory results. We here present details of this new technique applied for the two cases and discuss the efficacy of this method compared with conventional approaches.
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Affiliation(s)
| | - A. Kurata
- Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa; Japan
| | | | - K. Fujii
- Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa; Japan
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Bourekas EC, Slivka AP, Shah R, Sunshine J, Suarez JI. Intraarterial Thrombolytic Therapy within 3 Hours of the Onset of Stroke. Neurosurgery 2004; 54:39-44; discussion 44-6. [PMID: 14683539 DOI: 10.1227/01.neu.0000097197.61376.05] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2003] [Accepted: 07/23/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
The National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator Stroke Study Group showed that recombinant tissue plasminogen activator (rt-PA) administered intravenously within 3 hours of the onset of ischemic stroke can improve clinical outcome. Intraarterial (IA) thrombolysis has been shown to offer advantages over intravenous (IV) thrombolysis, but experience with this type of therapy within 3 hours of the onset of symptoms has not been reported previously. This study is the first retrospective analysis of a two-institution experience with IA thrombolysis within 3 hours of stroke onset.
METHODS
A total of 36 patients with angiographically demonstrated occlusions were treated with urokinase or rt-PA within 3 hours of stroke onset. Outcome measures included the percentage of patients with no or minimal neurological disability at 30 to 90 days as measured by the modified Rankin Scale, percentage recanalization, incidence of symptomatic intracranial hemorrhage, and mortality rate. The results were compared with those of the NINDS rt-PA study.
RESULTS
The median admission National Institutes of Health Stroke Scale score was 14. Fifty percent of treated patients had a modified Rankin Scale score of 0 or 1 indicating no or little disability at 1 to 3 months compared with 39% of treated patients in the NINDS trial. Recanalization was 75%, symptomatic intracranial hemorrhage was 11% (versus 6.4% with IV rt-PA in the NINDS trial), and the mortality rate was 22% (versus 17% with IV rt-PA in the NINDS trial).
CONCLUSION
The results suggest that IA thrombolysis administered within 3 hours of stroke onset is a feasible and viable alternative to IV rt-PA on the basis of improved clinical outcomes, high recanalization percentage, and comparable mortality rate and despite increased symptomatic intracranial hemorrhage. Whether IA thrombolysis is superior to IV therapy awaits further study.
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Affiliation(s)
- Eric C Bourekas
- Department of Radiology, College of Medicine and Public Health, The Ohio State University, Columbus, Ohio 43210, USA.
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Agarwal P, Borden N, Tan WA, Sen S. Rescue angioplasty after failed intra-arterial thrombolysis in acute middle cerebral artery stroke: A case report. Catheter Cardiovasc Interv 2004; 62:396-400. [PMID: 15224312 DOI: 10.1002/ccd.20092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intra-arterial thrombolysis is increasingly being used in the treatment of acute ischemic stroke with a failure rate of recanalization as high as 66%. We describe a case of acute ischemic stroke secondary to occlusion of the middle cerebral artery that failed intra-arterial thrombolytic therapy but responded to rescue balloon angioplasty.
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Ng PP, Higashida RT, Cullen SP, Malek R, Dowd CF, Halbach VV. Intraarterial Thrombolysis Trials in Acute Ischemic Stroke. J Vasc Interv Radiol 2004; 15:S77-85. [PMID: 15101517 DOI: 10.1097/01.rvi.0000107490.61085.10] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Stroke is a common cause of death and disability in industrialized nations. Technical advances and the increased availability of noninvasive brain imaging techniques have permitted precise and early diagnosis of acute cerebral ischemia. This has made emergent thrombolytic therapy for rapid restoration of cerebral perfusion increasingly possible. Herein, the authors present a review of the clinical trials investigating acute stroke treatment with intraarterial thrombolysis.
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Affiliation(s)
- Perry P Ng
- Division of Interventional Neuroradiology, Room L352, University of California at San Francisco Medical Center, 505 Parnassus Avenue, San Francisco, California 94143-0628, USA
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21
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Arnold M, Nedeltchev K, Mattle HP, Loher TJ, Stepper F, Schroth G, Brekenfeld C, Sturzenegger M, Remonda L. Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions. J Neurol Neurosurg Psychiatry 2003; 74:739-42. [PMID: 12754342 PMCID: PMC1738509 DOI: 10.1136/jnnp.74.6.739] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- M Arnold
- Department of Neurology, University Hospital of Berne, Switzerland
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22
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Wechsler LR, Roberts R, Furlan AJ, Higashida RT, Dillon W, Roberts H, Rowley HA, Pettigrew LC, Callahan AS, Bruno A, Fayad P, Smith WS, Firszt CM, Schulz GA. Factors influencing outcome and treatment effect in PROACT II. Stroke 2003; 34:1224-9. [PMID: 12677011 DOI: 10.1161/01.str.0000068782.15297.28] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The PROACT II study demonstrated a significant benefit from treatment with intra-arterial pro-urokinase (r-proUK) in patients with middle cerebral artery occlusion treated within 6 hours of stroke onset. The purpose of the current study was to examine baseline factors to determine predictors of good outcome and response to treatment. METHODS We selected from the baseline clinical, radiologic, and angiographic data variables that considered possibly related to outcome. A univariate analysis was performed to examine the association between these baseline factors and good outcome, defined as a modified Rankin scale score <or=2. A multivariate model then selected the most important variables independently influencing prognosis. A risk score for each patient was constructed on the basis of the patient's individual values for each independent variable. Patients were stratified into risk quartiles based on their risk scores, and an odds ratio for each risk quartile was calculated. The treatment effects of each quartile were compared. RESULTS In the univariate analysis, screening National Institutes of Health stroke scale (NIHSS) score and age were strongly associated with good outcome. The multivariate model selected age, NIHSS score, and CT hypodensity as the most important prognostic variables. Dividing patients into quartiles based on risk scores achieved a uniform gradient of probability of good outcomes. A trend toward benefit of r-proUK treatment was seen in all risk quartiles, and no differential treatment effect was observed across risk groups. CONCLUSIONS There was no evidence of differential effect of r-proUK across subgroups of patients stratified by risk.
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Lisboa RC, Jovanovic BD, Alberts MJ. Analysis of the safety and efficacy of intra-arterial thrombolytic therapy in ischemic stroke. Stroke 2002; 33:2866-71. [PMID: 12468783 DOI: 10.1161/01.str.0000038987.62325.14] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intra-arterial thrombolytic therapy (IAT) may be a treatment option for patients with ischemic stroke. We analyzed the safety and efficacy of IAT on the basis of published data. METHODS We searched computerized databases for studies using IAT in >/=10 patients with ischemic stroke. Some studies had control patients for comparison. Data were collected on age, stroke territory, time to treatment, medication, site of arterial occlusion and recanalization on angiogram, outcomes, and symptomatic intracranial hemorrhage (SICH). RESULTS The analysis included 27 studies with 852 patients who received IAT and 100 control subjects. There were more favorable outcomes in the IAT than in the control group (41.5% versus 23%, P=0.002), with a lower mortality rate for IAT (IAT, 27.2%; control group, 40%, P=0.004). The IAT group had an odds ratio of 2.4 (95% CI, 1.45 to 3.85) for favorable outcome. SICH was more frequent in the IAT group compared with the control group (9.5% versus 3%, P=0.046). The subgroup of patients receiving a combination of intravenous thrombolytic therapy and IAT had more favorable outcomes than the IAT alone subgroup, but this trend did not reach statistical significance (53.6% versus 41.5%, P=0.1). Among the patients treated with IAT, those who had supratentorial strokes were more likely to have favorable outcomes than those with infratentorial strokes (42.2% versus 25.6%; P=0.001; odds ratio, 2.0; 95% CI, 1.33 to 3.0). CONCLUSIONS IAT for ischemic stroke appears efficacious but carries an increased risk of SICH. Further prospective studies are needed to prove the safety and efficacy of IAT in stroke.
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Affiliation(s)
- Rejane C Lisboa
- Departments of Neurology, Northwestern University Medical School, Chicago, Illinois, USA
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24
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Lee DH, Jo KD, Kim HG, Choi SJ, Jung SM, Ryu DS, Park MS. Local intraarterial urokinase thrombolysis of acute ischemic stroke with or without intravenous abciximab: a pilot study. J Vasc Interv Radiol 2002; 13:769-74. [PMID: 12171979 DOI: 10.1016/s1051-0443(07)61984-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Deok Hee Lee
- Department of Diagnostic Radiology, Kangnung Hospital, College of Medicine, University of Ulsan, 415 Bandong-ri, Sacheon-myon, Kangnung-si, Kangwon-do 210-711, Korea.
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25
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Arnold M, Schroth G, Nedeltchev K, Loher T, Remonda L, Stepper F, Sturzenegger M, Mattle HP. Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke 2002; 33:1828-33. [PMID: 12105361 DOI: 10.1161/01.str.0000020713.89227.b7] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to evaluate the safety and efficacy of local intra-arterial thrombolysis (LIT) using urokinase in patients with acute stroke due to middle cerebral artery (MCA) occlusion. METHODS We analyzed clinical and radiological findings and functional outcome 3 months after LIT with urokinase of 100 consecutive patients. To measure outcome, the modified Rankin scale (mRs) score was used. RESULTS Angiography showed occlusion of the M1 segment of the MCA in 57 patients, of the M2 segment in 21, and of the M3 or M4 segment in 22. The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 14, and, on average, 236 minutes elapsed from symptom onset to LIT. Forty-seven patients (47%) had an excellent outcome (mRs score 0 to 1), 21 (21%) a good outcome (mRs score 2), and 22 (22%) a poor outcome (mRs score 3 to 5). Ten patients (10%) died. Excellent or good outcome (mRs score < or =2) was seen in 59% of patients with M1 or M2 and 95% of those with M(3) or M(4) MCA occlusions. Recanalization as seen on angiography was complete (thrombolysis in myocardial infarction [TIMI] grade 3) in 20% of patients and partial (TIMI grade 2) in 56% of patients. Age <60 years (P<0.05), low NIHSS score at admission (P<0.00001), and vessel recanalization (P=0.0004) were independently associated with excellent or good outcome and diabetes with poor outcome (P=0.002). Symptomatic cerebral hemorrhage occurred in 7 patients (7%). CONCLUSIONS LIT with urokinase that is administered by a single organized stroke team is safe and can be as efficacious as thrombolysis has been in large multicenter clinical trials.
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Affiliation(s)
- Marcel Arnold
- Department of Neurology, Inselspital, University of Berne, Switzerland
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26
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Sonobe M, Nakai Y, Matsumaru Y, Sugita K. Revascularization Using an Extracorporeal Pump for the Treatment of Cerebral Embolism in the Acute Stage. For Protection of the Brain Tissue from Irreversible Change due to Cerebral Embolism. Interv Neuroradiol 2001; 7:315-8. [PMID: 20663363 DOI: 10.1177/159101990100700406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2001] [Accepted: 10/25/2001] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Object. For patients with cerebral embolism, we are using an extracorporeal pump to rev ascularize the more peripheral brain tissues far from the thrombus, proceeding the microcatheter beyond the thrombus, and dissolving the thrombus during a satisfactory time as required. Methods. As the critical cerebral blood flow is thought to be below 30 mlllOOglmin, in the case of middle cerebral artery occlusion at the Ml portion, over 15mllmin. of arterial blood is necessary to protect the brain tissue from irreversible change. One thousand and eight hundred mmHg (about 2 atoms) of pump pressure is necessary to send l5mllmin. of blood through the microcatheter (110 cm, FastTrucker 18, Boston). It was confirmed by laboratory and clinical data that hemolysis of the pump action is not sufficient to aggravate kidney function. Conclusion. This method enables the protection of brain tissues from irreversible change after cerebral embolism, and extends the time sufficiently for thrombolysis.
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Affiliation(s)
- M Sonobe
- Department of Neurosurgery; Mito National Hospital, Mito, Ibaraki, Japan -
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27
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Schellinger PD, Fiebach JB, Mohr A, Ringleb PA, Jansen O, Hacke W. Thrombolytic therapy for ischemic stroke--a review. Part II--Intra-arterial thrombolysis, vertebrobasilar stroke, phase IV trials, and stroke imaging. Crit Care Med 2001; 29:1819-25. [PMID: 11546994 DOI: 10.1097/00003246-200109000-00028] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Intra-arterial thrombolytic therapy for carotid and vertebrobasilar stroke may result in a more rapid clot lysis and higher recanalization rates than can be achieved with intravenous thrombolysis and thus may warrant the more invasive and time-consuming therapeutic approach. We present an overview of all hitherto completed trials of intra-arterial thrombolytic therapy for carotid and vertebrobasilar artery stroke including recommendations for therapy and a meta-analysis. Furthermore, new imaging techniques such as diffusion- and perfusion-weighted magnetic resonance imaging and their impact on patient selection are discussed. Finally, phase IV trials of thrombolysis in general and cost efficacy analyses are presented. DATA SOURCES We performed an extensive literature search not only to identify the larger and well-known randomized trials but also to identify smaller pilot studies and case series. Trials included in this review, among others, are the PROACT I and PROACT II studies and the Cochrane Library report. CONCLUSION Intra-arterial thrombolytic therapy of acute M1 and M2 occlusions with 9 mg/2 hrs pro-urokinase significantly improves outcome if administered within 6 hrs after stroke onset. Seven patients need to be treated to prevent one patient from death or dependence. Vertebrobasilar occlusion has a grim prognosis and intra-arterial thrombolytic therapy to date is the only life-saving therapy that has demonstrated benefit with regard to mortality and outcome, albeit not in a randomized trial. New magnetic resonance imaging techniques may facilitate and improve the selection of patients for thrombolytic therapy. Presently, thrombolytic therapy is still underutilized because of problems with clinical and time criteria, and lack of public and professional education to regard stroke as a treatable emergency. If applied more widely, thrombolytic therapy may result in profound cost savings in health care and reduction of long-term disability of stroke patients.
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Affiliation(s)
- P D Schellinger
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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28
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Abstract
Over the past decade, there has been an explosion in data related to the treatment of patients with acute ischemic stroke. Thrombolytic therapy with intravenous tissue plasminogen activator has revolutionized the approach to stroke treatment. Intra-arterial administration of thrombolytic agents is also being investigated and is now being used on a compassionate basis. Medical management can have a large impact on stroke-related outcomes, even in patients who do not receive thrombolytic therapy.
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Affiliation(s)
- L B Goldstein
- Duke Center for Cerebrovascular Disease, Stroke Policy Program, Center for Clinical Health Policy Research, Duke University Medical Center, Box 3651, Durham, NC 27710, USA.
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29
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Matsumaru Y, Sonobe M, Mashiko R, Sugimori M, Takahashi S, Nose T. Utilization of Extracorporeal Pump during Local Intra-arterial Fibrinolysis in the Treatment of Acute Cerebral Arterial Occlusion. A Case Report. Interv Neuroradiol 2001; 6 Suppl 1:217-21. [PMID: 20667252 DOI: 10.1177/15910199000060s136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2000] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Local intra-arterial fibrinolysis may improve the outcome of patients with ischemic cerebrovascular disease. A favorable prognosis is thought to be related to early re-establishment of blood flow into the affected brain. To minimize the time to revascularization during local intraarterial fibrinolysis, we employed an extracorporeal pump to deliver oxygenated blood into the affected brain through a microcatheter. The patient, a 57-year-old man, showed disturbance of consciousness with left hemiparesis and was admitted to our hospital one hour after onset of symptoms. Cerebral angiography demonstrated an acute occlusion of the right middle cerebral artery, and the patient underwent local intra-arterial fibrinolysis with an extracorporeal pump. Oxygenated blood was successfully delivered through a microcatheter into the affected brain before recanalization. Subsequently, recanalization was obtained by intra-arterial fibrinolysis with a tissue plasminogen activator. The outcome of this patient was excellent. Thus, local intra- arterial thrombolysis with extracorporeal pump may be an effective method by which to increase the residual blood flow and widen the therapeutic window for fibrinolysis.
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Affiliation(s)
- Y Matsumaru
- Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba; Tsukuba, Japan -
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30
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Matsumaru Y, Hyodo A, Okazaki M, Nose T. A pitfall of fibrinolysis. Aneurysms found after attempted fibrinolytic therapy of occluded arteries. Interv Neuroradiol 2001; 4:165-9. [PMID: 20673405 DOI: 10.1177/159101999800400209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/1998] [Accepted: 03/20/1998] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Three patients with angiographically invisible aneurysms found after attempted fibrinolytic therapy are presented. One aneurysm bled during the procedure with a tragic result. All of aneurysms were located distal to the occluded arteries. Aneurysms were preexisting and invisible distal to the occluded artery, or they developed rapidly after the fibrinolysis. These aneurysms were at a risk for rupture during and after fibrinolytic therapy.
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Affiliation(s)
- Y Matsumaru
- Department of Neurosurgery, Mito National Hospital; Ibaraki, Japan
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Dubey N, Bakshi R, Wasay M, Dmochowski J. Early computed tomography hypodensity predicts hemorrhage after intravenous tissue plasminogen activator in acute ischemic stroke. J Neuroimaging 2001; 11:184-8. [PMID: 11296590 DOI: 10.1111/j.1552-6569.2001.tb00031.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Parenchymal hypodensity is a proposed risk factor for hemorrhage after recombinant tissue plasminogen activator (TPA) thrombolysis for ischemic stroke. In Buffalo, NY, and Houston, TX, the authors reviewed 70 patients who were treated with intravenous TPA for acute middle cerebral artery (MCA) stroke. Two observers blinded to clinical outcome analyzed initial noncontrast head computed tomography (CT) scans. Basal ganglia CT hypodensity was quantitated in Hounsfield units (HUs). Contralateral-ipsilateral difference in density was calculated using the asymptomatic side as a control. Ictus time to TPA averaged 2.5 hours. Six patients developed symptomatic intraparenchymal hematomas (2 fatal). The hemorrhage group had more severe basal ganglia hypodensity (mean 7.5 +/- 1.4, range 6-10 HU) than the nonhemorrhage group (2.2 +/- 1.4, range 0-9 HU) (P < .0001). The hemorrhage group had hypodensity of > 5 HU; the nonhemorrhage group had hypodensity of < or = 4 HU, except 1 patient with hypodensity of 9 HU. In predicting hemorrhage, the positive predictive value of hypodensity > 5 HU was 86%; the negative predictive value was 100%. Prethrombolysis NIH Stroke Scale (NIHSS) deficit (P = .0007) and blood glucose (P = .005) were also higher in the hemorrhage group. Age, gender, smoking, hypertension, and ictus time to TPA infusion did not differ between the 2 groups. Logistic regression indicated that basal ganglia hypodensity was the best single predictor of hemorrhage. Hypodensity and NIHSS score together predicted all cases of hemorrhage. The authors conclude that basal ganglia hypodensity quantified by CT may be a useful method of risk stratification to select acute MCA stroke patients for thrombolytic therapy.
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Affiliation(s)
- N Dubey
- Department of Neurology, University of Texas at Houston, Texas, USA
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Wechsler LR, Jungreis CA, Massaro LM, Yonas H, Barch CA, Kassam A, Aston C, Johnson DW. Long-term follow-up of patients treated with intra-arterial urokinase for acute stroke. J Stroke Cerebrovasc Dis 2000. [DOI: 10.1053/jscd.2000.16189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Tamatani S, Sasaki O, Koizumi T, Nishimaki K, Ito Y, Koike T, Takeuchi S, Tanaka R. Evaluation of local intra-arterial fibrinolytic therapy for acute middle cerebral artery occlusion. Interv Neuroradiol 2000; 6:125-33. [PMID: 20667190 DOI: 10.1177/159101990000600206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2000] [Accepted: 03/30/2000] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Fibrinolytic therapy for acute ischaemic stroke has been investigated in several clinical trials, with various protocols. This retrospective study was undertaken to evaluate the efficacy and limitation of local intra-arterial fibrinolytic therapy using urokinase (UK) in patients with acute middle cerebral artery occlusion. Fifty patients were treated with local intra-arterial fibrinolytic therapy within six hours after onset of symptoms. The median National Institutes of Health Stroke Scale (NIHSS) score was 17 (range, 6 to 28).Two hundred and forty thousand IU of UK was administered through a microcatheter for 20 minutes. When arterial recanalization was not achieved, a second or third infusion was performed. Maximum dosage of UK was 0.96 x 106 IU. Recanalization efficacy was evaluated at the end of fibrinolytic therapy and intracranial haemorrhage was assessed within 24 hours. Clinical outcome was evaluated three months after ictus with modified Rankin scale (RS). Thirty-nine patients (78%) obtained recanalization. Twenty-nine of 39 (74%) showed clinical improvement just after treatment. On the other hand, only 18% patients (2/11) who did not recanalize demonstrated improvement. Twenty-five of 50 (50%) patients recovered to RS score 0 or 1, however, only 28% of patients (5/18) with proximal M1 occlusion obtained good outcome and 39% of them (7/18) died. The mean time interval from onset to treatment did not affect outcome. The overall incidence of haemorrhagic event (HE) within 24 hours was 36%, however, 78% of patients with proximal M1 occlusion showed HE. Only one patient with HE clinically deteriorated. In conclusion, local intra-arterial fibrinolytic therapy could be a safe and effective method for acute middle cerebral artery occlusion, however, indication of this therapy for patients with proximal M1 occlusion should be carefully decided.
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Affiliation(s)
- S Tamatani
- Department of Neurosurgery, Brain Research Institute, Niigata University; Niigata, Japan -
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Mericle RA, Lopes DK, Fronckowiak MD, Wakhloo AK, Guterman LR, Hopkins LN. A grading scale to predict outcomes after intra-arterial thrombolysis for stroke complicated by contrast extravasation. Neurosurgery 2000; 46:1307-14; discussion 1314-5. [PMID: 10834636 DOI: 10.1097/00006123-200006000-00005] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Contrast extravasation after intra-arterial thrombolysis for stroke occurs frequently and is identifiable on a computed tomographic (CT) scan, but it is often unrecognized or misdiagnosed. Few articles describing this phenomenon have been published. The clinical outcomes of patients after contrast extravasation are poorly understood. We designed a grading system to predict outcomes after contrast extravasation and tested the grading scale prospectively. METHODS We studied 27 patients who had contrast extravasation exhibited on a CT scan immediately after intra-arterial thrombolysis. The National Institutes of Health Stroke Scale was used to quantify neurological examinations preoperatively, postoperatively, and at follow-up an average of 3 months later. A grading scale from 0 to 10 was developed from a retrospective analysis of the first 18 patients using odds ratios and Fisher's exact test. The grading system was then applied prospectively to the next 9 consecutive patients. RESULTS Six components of the grading system were weighted approximately proportional to corresponding odds ratios: 1) incomplete recanalization (3 points), 2) prolonged angiographic blush (2 points), 3) hyperdensity greater than 150 Hounsfield units (2 points), 4) lesion volume greater than 50 cc exhibited on a CT scan (1 point), 5) lesion in eloquent parenchyma (1 point), and 6) hypodensity demonstrated on an immediate postoperative CT scan (1 point). The contrast extravasation grades for each outcome category (excellent, fair, poor, died) increased in stepwise fashion. There was a direct linear correlation between the assigned grade and National Institutes of Health Stroke Scale score improvement at follow-up. CONCLUSION This grading system should prove useful as a preliminary guide for predicting outcomes of patients with contrast extravasation after intra-arterial thrombolysis for stroke. Further analysis in a large cohort of prospective patients is necessary to ensure extensibility.
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Affiliation(s)
- R A Mericle
- Department of Neurological Surgery (RAM), The University of Florida Brain Institute, College of Medicine, University of Florida, Gainesville, USA.
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35
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Abstract
Acute ischemic stroke is a medical emergency that requires rapid evaluation and treatment. Prehospital and emergency department care can be streamlined to meet those goals. Intravenous rt-PA therapy improves outcome in selected patients with ischemic stroke if given within 3 hours of stroke onset, but offers no benefit beyond that time window. Intra-arterial thrombolytic therapy and intravenous defibrogenating agents may also be beneficial in selected patients. Newer thrombolytic agents such as aspirin and heparin in acute ischemic stroke treatment have been clarified by recent trials.
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Affiliation(s)
- S L Hickenbottom
- Clinical Assistant Professor, Department of Neurology, University of Michigan Medical Center, Ann Arbor, MI 48109, USA
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36
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IA Stroke Therapy: The Brain Plumbing How-to Guide. J Vasc Interv Radiol 2000. [DOI: 10.1016/s1051-0443(00)70140-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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37
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Ueda T, Sakaki S, Kumon Y, Ohta S. Multivariable analysis of predictive factors related to outcome at 6 months after intra-arterial thrombolysis for acute ischemic stroke. Stroke 1999; 30:2360-5. [PMID: 10548671 DOI: 10.1161/01.str.30.11.2360] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Recent reports have suggested that a rapid assessment of pretreatment residual cerebral blood flow (CBF) could be used to optimize selection criteria for thrombolysis in patients with acute ischemic stroke to improve clinical outcome. We investigated retrospectively residual CBF and other clinical factors related to outcome at 6 months after intra-arterial thrombolysis by using multivariable analysis. METHODS Seventy-six patients received intra-arterial thrombolysis within 6 hours of symptom onset. The multiple regression method was used to analyze associations between the modified Rankin scale (MRS) at 6 months after treatment and clinical factors including age, infarction type, duration of ischemia, dose of urokinase, degree of recanalization, hemorrhage, National Institutes of Health Stroke Scale score (NIHSSS), and residual CBF evaluated by pretreatment single-photon emission-computed tomography; these values were assessed with the use of the regional-to-cerebellar activity (R/CE) ratio of ischemic region to cerebellum and asymmetry index. RESULTS MRS at 6 months was good (0 to 3) in 65% and poor (4 to 6) in 35%. Factors significantly related to MRS at 6 months were R/CE ratio (P<0.0001), NIHSSS at baseline and the following day (P<0.0001), cardioembolic infarction (P=0.0014), age (P=0.0074), and recanalization grade (P=0. 007). NIHSSS of >20, R/CE ratio of <0.35, cardioembolic infarction, incomplete recanalization (grade <3), and older age (>75 years) were determined to be significant independent predictors of poor outcome. CONCLUSIONS The residual CBF, neurological score at baseline and the following day, age, and recanalization grade correlated significantly with long-term outcome. The NIHSSS of >20 and R/CE ratio of <0.35 were determined to be significant independent predictors of poor outcome by multivariable analysis.
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Affiliation(s)
- T Ueda
- Department of Neurological Surgery, Ehime University School of Medicine, Ehime, Japan.
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38
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Angiographic Classification of Cerebral Embolism. Interv Neuroradiol 1999; 5 Suppl 1:145-50. [DOI: 10.1177/15910199990050s126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/1999] [Accepted: 09/30/1999] [Indexed: 11/15/2022] Open
Abstract
Since 1994, we have treated 62 cases with hyperacute cerebral embolism with local intraarterial thrombolysis (LIT), but not all cases showed recanalization. We tried to classify these cases by angiographic results. Angiographically they could be classified into four types; tapering type, fading type, stump type, and edge type. The tapering and fading type had a significantly higher tendency to recanalize than the stump and edge type. We think these classifications indicate the dissolubility of the cerebral emboli; the former two types dissoluble, the latter two types indissoluble. The tapering and fading type are the good indicators for LIT, but the stump and edge type may not be.
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39
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Abstract
Recanalization of acutely occluded arteries in the carotid territory, particularly the middle cerebral artery, by intra-arterial delivery of thrombolytic drugs, has advanced dramatically over the last decade. Randomized prospective studies have begun to show the potential impact of this form of intervention. Still, patient selection, therapeutic window, critical care support, and experience of the management team are clearly the determining features for the success of intra-arterial thrombolysis. The use of thrombolytic agents currently available, and research involving the next generation of these agents, open a field that shows promise for the improvement of outcomes of patients whose typical prognosis is poor.
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Affiliation(s)
- L R Wechsler
- Department of Neurology, University of Pittsburgh Medical School, Pennsylvania, USA
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40
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Abstract
BACKGROUND Improved recognition of stroke signs and symptoms has paralleled the development of pharmacological strategies that may be examined to reduce stroke mortality and morbidity. Presently, tissue plasminogen activator is the only therapy that significantly improves outcome in acute stroke, with no agent demonstrating a significant reduction in mortality. SUMMARY OF REVIEW Antiplatelet agents are a heterogenous class of drugs that have been successfully used for more than 2 decades in secondary stroke prevention. These agents include aspirin, with or without dipyridamole, and more recently, the adenosine antagonists ticlopidine and clopidogrel. However, studies of the use of antiplatelet agents within 48 hours of the ictus have examined only aspirin. Only 1 study, the Multicentre Acute Stroke Trial-Italy (MAST-I), entered patients within 6 hours of the ictus. These data suggest that an improvement in mortality may be related to the speed of administration. No significant adverse events were noted with early antiplatelet monotherapy. However, MAST-I did note a significant increase in early mortality in patients receiving aspirin plus streptokinase, a finding not adequately explained by an increase in the intracranial hemorrhage rate. CONCLUSIONS The use of antiplatelet therapy in acute stroke, clinical or experimental, has only recently received attention. It is likely that the use of antiplatelet agents for acute stroke therapy will be less restrictive than that currently seen for thrombolytics. Future studies should include an examination of those agents that have previously demonstrated efficacy in secondary stroke prevention, most notably, aspirin. The recognition that all platelet stimuli share a final common pathway that is dependent on the surface glycoprotein IIb/IIIa (fibrinogen) receptor has resulted in the development of various agents which block this receptor and are currently the focus for clinical trials. The role of nitric oxide in stroke therapy will depend on minimizing the hypotensive side effects of this agent. Stroke models are needed to provide preliminary data on the efficacy of antiplatelet therapy, especially as relates to the interaction of antiplatelet agents with thrombolytics.
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Affiliation(s)
- M M Bednar
- Division of Neurosurgery, University of Vermont, Burlington, VT 05405,
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41
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Mäurer M, Müllges W, Becker G. Diagnosis of MCA-occlusion and monitoring of systemic thrombolytic therapy with contrast enhanced transcranial duplex-sonography. J Neuroimaging 1999; 9:99-101. [PMID: 10208107 DOI: 10.1111/jon19999299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
A case of a successful systemic thrombolysis of an acute middle carotid artery occlusion is reported. The case underlines the role of contrast-enhanced transcranial color-coded duplex sonography as a noninvasive technique for rapid diagnosis of vessel occlusion in acute stroke. The diagnostic potential of transcranial color-coded duplex sonography for indication and monitoring of intravenous systemic thrombolytic therapy is demonstrated.
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Affiliation(s)
- M Mäurer
- Department of Neurology, University of Würzburg, Germany
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Kakinuma K, Ezuka I, Takai N, Yamamoto K, Sasaki O. The simple indicator for revascularization of acute middle cerebral artery occlusion using angiogram and ultra-early embolectomy. SURGICAL NEUROLOGY 1999; 51:332-41. [PMID: 10086500 DOI: 10.1016/s0090-3019(98)00041-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of the study was: (1) to find a clinical indicator for revascularization of acute middle cerebral artery (MCA) occlusion using angiograms of 100 patients examined immediately after onset and treated medically and (2) to investigate 10 ultra-early MCA embolectomies. METHODS Quantity of collateral circulation, based on time required for conduction of contrast media to the insular portion of the MCA from the anterior cerebral artery, MCA conduction time (MCT) was graded as: Grade 1: In the arterial phase, there was conduction not only to the insular portion of the MCA but also to proximal M2; Grade 2: Conduction to the insular portion was present in late arterial phase; Grade 3: Conduction was present in capillary phase; Grade 4: Conduction was present in venous phase; Grade 5: No conduction was seen. The results of embolectomy are discussed. RESULTS MCT can predict the extent of resultant low-density area on computed tomographic scan. For Grades 3, 4, or 5, embolectomy could be considered superior to medical treatment, if the low-density area was localized in the basal ganglia or centrum semiovale after surgery. Consequently, embolectomy was effective in four cases recanalized within 6 hours of onset. Except for one Grade 5 case, the remaining nine cases showed neither lethal hemorrhagic infarction nor brain edema. Overall outcome was significantly better than cases treated medically (p < 0.05), but some cases did not recover from hemiparesis due to infarcts in the area of the lenticulostriate arteries. CONCLUSIONS MCT helps to predict the applicability of revascularization of acute MCA occlusion. Efficacy of embolectomy depends on revascularization within 6 hours of onset. Even after complete MCA flow restoration, infarcts in the area of the lenticulostriate arteries cannot always be prevented.
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Affiliation(s)
- K Kakinuma
- Department of Neurosurgery, Niigata Rosai Hospital, Japan
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43
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Rubin G, Firlik AD, Pindzola RR, Levy EI, Yonas H. The effect of reperfusion therapy on cerebral blood flow in acute stroke. J Stroke Cerebrovasc Dis 1999; 8:9-16. [PMID: 17895131 DOI: 10.1016/s1052-3057(99)80033-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/1998] [Accepted: 07/24/1998] [Indexed: 11/18/2022] Open
Abstract
The effect of reperfusion therapy on cerebral blood flow (CBF) in acute cerebral ischemia was studied using xenon-enhanced computed tomography (XeCT). The XeCT CBF studies of 10 patients were evaluated before and after thrombolytic therapy. CBF evidence of reperfusion was evaluated in relation to the angiographic results and the clinical outcomes. Six patients had occlusions of the middle cerebral artery and four of the internal carotid artery. The mean CBF of the ischemic areas before attempted reperfusion was 9 +/- 3 mL/100g/min compared with 34 +/- 9 mL/100g/min in the contralateral asymptomatic region (P<.001). Intra-arterial-thrombolysis was performed in nine patients, and in one patient the intravenous route was used. Reperfusion of the ischemic region was shown in 9 of 10 patients, both angiographically and with the XeCT CBF studies (the mean CBF increased from 9 +/- 3 mL/100g/min to 32 +/- 10 mL/100g/min, P<.001). Among the nine successfully reperfused patients, seven were neurologically improved, one was unchanged, and one died. The mean National Institutes of Health stroke scale in the eight reperfused survivors was 12 on admission and decreased to 6 on discharge. XeCT CBF measurements are correlated with the angiographic results and can assist in the understanding of the effects of thrombolytic therapy on CBF in acute stroke. Re-establishment of CBF is associated with an improved clinical outcome but exceptions can be found. Reperfusion can occur in ischemic brain regions even with very low CBF (approaching 0 mL/100g/min) although it is not associated with prevention of infarction.
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Ueda T, Sakaki S, Yuh WT, Nochide I, Ohta S. Outcome in acute stroke with successful intra-arterial thrombolysis and predictive value of initial single-photon emission-computed tomography. J Cereb Blood Flow Metab 1999; 19:99-108. [PMID: 9886360 DOI: 10.1097/00004647-199901000-00011] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study investigates retrospectively, in selected patients, the ischemic outcome (reversible ischemia, infarction, and hemorrhage) and neurologic outcome of acute stroke treated with intra-arterial thrombolysis and the predictive value of pretreatment single-photon emission-computed tomography (SPECT). Thirty patients with complete recanalization within 12 hours were analyzed. The extent of ischemia was outlined on SPECT, and two CBF parameters were calculated: the ratio of ischemic regional activity to CBF in the cerebellum and the asymmetry index. Reversible ischemia, infarction, and hemorrhage were identified by comparing SPECT and follow-up computed tomography. Nine patients (30%) had no or small infarction, 14 (47%) had medium or large infarction, and seven (23%) had hemorrhage. Forty-two lesions were identified (22 reversible ischemia, 13 infarction, and 7 hemorrhage). Duration of ischemia, urokinase dose, disease type, and occlusion site were nonsignificant factors, whereas neurologic outcome and CBF parameters were significant among the three patient groups and three types of ischemic lesions. Ischemic tissue with CBF greater than 55% of cerebellar flow still may be salvageable, even with treatment initiated 6 hours after onset of symptoms. Ischemic tissue with CBF greater than 35% of cerebellar flow still may be salvageable with early treatment (less than 5 hours). Ischemic tissue with with CBF less than 35% of cerebellar flow may be at risk for hemorrhage within the critical time window. Pretreatment SPECT can provide useful parameters to increase the efficacy of thrombolysis by reducing hemorrhagic complications and improving neurologic outcome.
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Affiliation(s)
- T Ueda
- Department of Neurological Surgery, Ehime University School of Medicine, Japan
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45
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Demchuk AM, Morgenstern LB, Krieger DW, Linda Chi T, Hu W, Wein TH, Hardy RJ, Grotta JC, Buchan AM. Serum glucose level and diabetes predict tissue plasminogen activator-related intracerebral hemorrhage in acute ischemic stroke. Stroke 1999; 30:34-9. [PMID: 9880385 DOI: 10.1161/01.str.30.1.34] [Citation(s) in RCA: 206] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Five pretreatment variables (P<0.1 univariate analysis), including serum glucose (>300 mg/dL), predicted symptomatic intracerebral hemorrhage (ICH) in the National Institute of Neurological Disorders and Stroke rtPA trial. We retrospectively studied stroke patients treated <3 hours from onset with intravenous rtPA at 2 institutions to evaluate the role of these variables in predicting ICH. METHODS Baseline characteristics, including 5 prespecified variables (age, baseline glucose, smoking status, National Institutes of Health Stroke Scale [NIHSS] score, and CT changes [>33% middle cerebral artery territory hypodensity]), were reviewed in 138 consecutive patients. Variables were evaluated by logistic regression as predictors of all hemorrhage (including hemorrhagic transformation) and symptomatic hemorrhage on follow-up CT scan. Variables significant at P<0.25 level were included in a multivariate analysis. Diabetes was substituted for glucose in a repeat analysis. RESULTS Symptomatic hemorrhage rate was 9% (13 of 138). Any hemorrhage rate was 30% (42 of 138). Baseline serum glucose (5.5-mmol/L increments) was the only independent predictor of both symptomatic hemorrhage [OR, 2.26 (CI, 1.05 to 4.83), P=0.03] and all hemorrhage [OR, 2.26 (CI, 1.07 to 4.69), P=0.04]. Serum glucose >11.1 mmol/L was associated with a 25% symptomatic hemorrhage rate. Baseline NIHSS (5-point increments) was an independent predictor of all hemorrhage only [OR, 12.42 (CI, 1.64 to 94.3), P=0.01]. Univariate analysis demonstrated a trend for nonsmoking as a predictor of all hemorrhage [OR, 0.45 (CI, 0.19 to 1. 08), P=0.07]. Diabetes was also an independent predictor of ICH when substituted for glucose in repeat analysis. CONCLUSIONS Serum glucose and diabetes were predictors of ICH in rtPA-treated patients. This novel association requires confirmation in a larger cohort.
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Affiliation(s)
- A M Demchuk
- University of Texas-Houston, Department of Neurology, Stroke Program, 77030, USA
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Ueda T, Sakaki S, Nochide I, Kumon Y, Kohno K, Ohta S. Angioplasty after intra-arterial thrombolysis for acute occlusion of intracranial arteries. Stroke 1998; 29:2568-74. [PMID: 9836769 DOI: 10.1161/01.str.29.12.2568] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to report our experience with percutaneous transluminal angioplasty (PTA) of intracranial arteries in acute stroke patients who were resistant to intra-arterial thrombolysis alone. METHODS PTA was performed within 6 hours from symptom onset in 13 acute stroke patients in whom no hypodensity areas were observed on initial CT. PTA was classified into 3 categories: immediate (3 patients), delayed (3 patients), and rescue (7 patients) angioplasty. Treatment results in the PTA group for 9 cases of middle cerebral artery (MCA) occlusion were compared with those in the thrombolysis alone group for 12 cases of thrombotic MCA occlusion. RESULTS Technical success rates for immediate, delayed, and rescue angioplasty were 100%, 100%, and 71%, respectively, and that of angioplasty for the MCA was 100%. Ten patients (77%) showed improvement in the National Institutes of Health (NIH) stroke score after treatment. Improvement in NIH stroke scores in the PTA group for MCA occlusion was greater than that in the thrombolysis alone group (P<0.01). Nine patients (69%) had an excellent, good, or fair outcome 3 months after treatment. In 9 patients who had follow-up angiography 1 month after treatment, no restenosis or reocclusion was demonstrated. There were no symptomatic complications during or after treatment. CONCLUSIONS This limited study demonstrates the technical feasibility of angioplasty for intracranial arteries in acute ischemic stroke and suggests that angioplasty may be an effective option for improving the success rate of recanalization and preventing reocclusion of the MCA. The present results encourage us to perform further clinical trials in a larger number of patients to assess the efficacy of this procedure.
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Affiliation(s)
- T Ueda
- Department of Neurological Surgery, Ehime University School of Medicine, Ehime, Japan.
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47
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Smith TP. Cerebral thrombolysis in the patient suffering from acute stroke. Tech Vasc Interv Radiol 1998. [DOI: 10.1016/s1089-2516(98)80301-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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48
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Albers GW, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 1998; 114:683S-698S. [PMID: 9822071 DOI: 10.1378/chest.114.5_supplement.683s] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- G W Albers
- Stanford University Medical Center, Stanford Stroke Center, Palo Alto, CA 94304-1705, USA
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49
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Gönner F, Remonda L, Mattle H, Sturzenegger M, Ozdoba C, Lövblad KO, Baumgartner R, Bassetti C, Schroth G. Local intra-arterial thrombolysis in acute ischemic stroke. Stroke 1998; 29:1894-900. [PMID: 9731615 DOI: 10.1161/01.str.29.9.1894] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE We performed a retrospective analysis of the prognostic factors in patients treated with local intra-arterial thrombolysis (LIT). The purpose of this study was to evaluate the safety and efficacy of LIT using urokinase in patients with acute ischemic stroke of the anterior or posterior circulation and to determine the influence of clinical and radiological parameters on outcome. METHODS Forty-three patients were treated with LIT using urokinase (median dose, 0.75x10(6) IU). The median National Institutes of Health Stroke Scale (NIHSS) score at hospital admission was 18 (range, 9 to 36). Nine patients had occlusions of the internal carotid artery (ICA), 23 of the middle cerebral artery (MCA), 1 of the anterior cerebral artery, and 10 of the basilar artery (BA). Outcome was assessed after 3 months and classified as good for Rankin Scale (RS) scores of 0 to 3 and poor for RS scores of 4 or 5 and death. RESULTS Nine patients (21%) recovered to RS scores 0 or 1, 17 (40%) to scores of 2 or 3, and 7 (16%) to scores of 4 or 5. Ten patients (23%) died. Outcome was good in 17 patients (80%) with MCA occlusions, in 3 patients (33%) with ICA, and in 5 patients (50%) with BA occlusions. Good outcome was associated with an initial NIHSS score of <20 (P<0.001), improvement by 4 or more points on NIHSS score within 24 hours (P=0.001), and vessel recanalization (P=0.02). Recanalization was more likely if LIT was started within 4 hours (P=0.01). Symptomatic cerebral hemorrhage occurred in 2 patients (4.7%). CONCLUSIONS LIT was most efficacious in patients with MCA and BA occlusions when the initial NIHSS score was less than 20 and when treated within 4 hours. It is of limited value in patients with distal ICA occlusions.
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Affiliation(s)
- F Gönner
- Department of Neuroradiology, Inselspital, University of Berne, Switzerland
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50
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Abstract
Acute ischemic stroke is a neurological emergency that requires ultra-rapid intervention. Stroke teams and stroke protocols can be devised to expediate evaluation and treatment. In carefully selected patients, thrombolytic therapy offers a significant benefit but must be initialized within 3 hours of stroke onset. Emerging alternative strategies for reperfusion and neuroprotection must also be initiated during the hyperacute period. The role of more traditional therapies, such as antiplatelet agents and anticoagulants, have been better defined through several recent major clinical trials.
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Affiliation(s)
- S E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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