Intra-arterial thrombolysis within three hours of stroke onset in middle cerebral artery strokes.
ABSTRACT 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.
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.
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).
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.
- SourceAvailable from: Michael D Hill[Show abstract] [Hide abstract]
ABSTRACT: BACKGROUND: There is an increasing trend to treating proximal vessel occlusions with intravenous-inter-arterial (IV-IA) thrombolysis. The best dose of IV tissue plasminogen activator (tPA) remains undetermined. We compared the combination of full-dose IV recombinant tissue plasminogen activator (rtPA) and IA thrombolytic therapy to IA therapy. METHODS: Between 2002 and 2009, we reviewed our computed tomographic angiography database for patients who received full-dose intravenous rtPA and endovascular therapy or endovascular therapy alone for acute ischaemic stroke treatment. Details of demographics, risk factors, endovascular procedure, and symptomatic intracranial haemorrhage were noted. Modified Rankin Scale ≤2 at three-months was used as good outcome. Recanalization was defined as Thrombolysis in Myocardial Ischaemia 2-3 flow on angiography. RESULTS: Among 157 patients, 104 patients received IV-IA treatment and 53 patients underwent direct IA therapy. There was a higher recanalization rate with IV-IA therapy compared with IA alone (71% vs. 60%, P < 0·21) which was driven by early recanalization after IV rtPA. Mortality and independent outcome were comparable between the two groups. Symptomatic intracranial haemorrhage occurred in 8% of patients (12% in the IA group, 7% in the IV-IA group) but was more frequent as the intensity of intervention increased from device alone to thrombolytic drug alone to device plus thrombolytic drug(s). Recanalization was a strong predictor of reduced mortality risk ratio (RR) 0·48 confidence interval(95) 0·27-0·84) and favourable outcome (RR 2·14 confidence interval(95) 1·3-3·5). CONCLUSIONS: Combined IV-IA therapy with full-dose intravenous rtPA was safe and results in good recanalization rates without excess symptomatic intracranial haemorrhage. Testing of full-dose IV tPA followed by endovascular treatment in the IMS3 trial is justified.International Journal of Stroke 09/2012; 9(8). DOI:10.1111/j.1747-4949.2012.00890.x · 4.03 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Reperfusion of the ischemic territory forms the basis of most acute stroke treatments. This overview of the literature relating to reperfusion in acute ischemic stroke published within the last year provides a snapshot of a rapidly evolving aspect of cerebrovascular disease. Arterial revascularization from systemic thrombolysis to combination endovascular procedures to achieve recanalization has proliferated. Stroke imaging continues to discern features of critical pathophysiology that may influence tissue fate and clinical outcome. Balancing the risk of hemorrhagic transformation against the therapeutic aim to salvage the ischemic penumbra remains a formidable challenge. Collateral therapeutics that enhance perfusion outside the ischemic core present novel dimension to acute stroke therapy, focused on ischemia and not just the clot or plaque. These timely findings illustrate the essential role of reperfusion in acute stroke, delineating aspects of arterial revascularization and collateral therapeutics to be refined in coming years.Current opinion in neurology 11/2009; 23(1):36-45. DOI:10.1097/WCO.0b013e328334da32 · 5.73 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Ischemic stroke remains one of the leading cause of adult death and disability in the United States. Reperfusion of the occluded vessel is the standard of care in the setting of acute ischemic stroke according to established guidelines. Since the introduction of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) in the late 1990s, significant advances have been made in methods to deliver thrombolytic agents and in devices for mechanical recanalization of occluded vessels. Furthermore, improvements in patient selection contribute to achievement of good clinical outcomes after endovascular therapy. This article summarizes findings from recent clinical trials and presents evidence-based guidelines for endovascular interventions in the treatment of ischemic stroke.Current Atherosclerosis Reports 07/2010; 12(4):244-50. DOI:10.1007/s11883-010-0115-6 · 3.06 Impact Factor