Local Intra-Arterial Thrombolysis With Urokinase for Acute Ischemic Stroke Before and After the Approval of Intravenous Tissue Plasminogen Activator Treatment in Taiwan

Abstract

Local intra-arterial thrombolysis (LIT) has been previously suggested as an effective therapy for acute ischemic stroke. In this study, we describe our experience of using LIT for the treatment of Taiwanese patients with ischemic stroke at different vascular locations, before and after Alteplase was approved as a first-line treatment in Taiwan. The criteria required for the initiation of LIT have become more stringent after the approval of Alteplase (AA). A retrospective analysis of medical records was conducted for 20 ischemic stroke patients treated with LIT; including 10 patients treated before and 10 patients treated after AA (we did not treat any of the patients in this study with AA). Urokinase was used for LIT treatment. Outcome measures included patient demographics, clinical characteristics, and clinical outcomes before and after LIT. Clinical outcomes were evaluated using four different stroke scales. The median National Institutes of Health stroke scale score (NIHSS) before treatment was reported to be 19.2 (range: 8-30). After AA, only one patient who had an occluded internal carotid artery (ICA) was treated with LIT. Among the 20 patients, 11 (55%) (five before AA and six after AA) reported having favorable or good clinical outcomes within 3 months of treatment, whereas five reported having poor outcomes (three before AA and two after AA), and the rest four patients died following treatment (two before AA and two after AA). Arterial recanalization was reported as complete in 10 patients (50%; seven middle cerebral artery [MCA] and three basilar artery; six before AA and four after AA), as incomplete in four patients (20%; one MCA and three basilar artery; one before AA and three after AA), and it failed in the remaining six patients (30%; two MCA and four ICA; three before AA and three after AA). Five patients (one MCA and four ICA) in whom recanalization had failed reported having poor outcomes, including one ICA patient who subsequently succumbed to the illness. Intracranial hemorrhagic and intraventricular hemorrhage transformation occurred in three and two patients, respectively. A case of intraventricular hemorrhage transformation after AA was also reported. On the basis of our experience, we found that LIT was of limited value in patients with ICA occlusion before AA approval. After AA, the outcomes in acute stroke patients, who were receiving urokinase therapy and who were carefully selected on the basis of the site of occlusion, were improved.