Intra-arterial Thrombolysis In Patients Research Articles

Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis.

There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT). We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT. A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons. Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.

Intra-Arterial Thrombolysis to Improve Final Thrombolysis in Cerebral Infarction Score after Thrombectomy: A Case-Series Analysis

Endovascular thrombectomy is the standard treatment in selected patients with acute ischemic stroke and large vessel occlusion, but continuous improvement in angiographic and clinical outcome is still needed. Intra-arterial thrombolysis has been tested as a possible rescue tool in unsuccessful thrombectomy, or as an adjuvant therapy after the endovascular procedure, to pursue complete recanalization. Here we present a case series analysis of intra-arterial alteplase administration (5 mg bolus, repeated up to 15 mg if Thrombolysis in Cerebral Infarction (TICI) scale ≥2c is not achieved) in 15 consecutive anterior circulation stroke patients after unsuccessful thrombectomy, defined as TICI score ≤2b after at least 3 passes or if unsuitable for further endovascular attempts, with the aim of improving recanalization. An improvement of final TICI score was achieved in 10 of 15 patients (66.7%). TICI score ≥2c was achieved after 5 mg intra-arterial tissue plasminogen activator (iaTPA) in 4 patients, and after 10 mg iaTPA in 5 cases. Six of 15 patients received 15 mg iaTPA: 1 of 6 showed angiographical improvement. A major effect of intra-arterial alteplase was observed for distally migrated emboli. None of the patients experienced any symptomatic hemorrhagic transformation or other major bleeding. Our report shows, in a very small cohort, a high rate of final TICI score improvement, encouraging the development of randomized controlled trials of rescue intra-arterial thrombolysis in patients with suboptimal angiographic results after mechanical thrombectomy.

Intravenous thrombolysis and mechanical recanalization for acute ischemic stroke in deep brain stimulation patients: a case series

BackgroundIntravenous thrombolysis (IVT) and endovascular mechanical thrombectomy therapy (MT) are well established in the treatment of acute ischemic stroke. It is currently unclear whether these treatments can be applied in patients with previous deep brain stimulation (DBS) surgery and how long the interval to the DBS operation should be.MethodsFour patients with ischemic stroke and IVT or MT were included in this retrospective case series. Data on demographics, genesis, severity and course of the stroke and the DBS indication were extracted and evaluated. Furthermore, a literature review was conducted. Outcomes and hemorrhagic complications after IVT, MT or intra-arterial thrombolysis in patients with prior deep brain stimulation surgery and intracranial surgery were analyzed.ResultsFour patients with acute ischaemic stroke and previous DBS surgery were treated with IVT (2 patients), MT (1) or a combined therapy of IVT and MT (1). The time interval to the previous DBS surgery was between 6 and 135 months. In these four patients, no bleeding complications occurred. The literature review revealed four publications with a total of 18 patients, who were treated with IVT, MT or intra-arterial thrombolysis. Of these 18 patients, only 1 had undergone deep brain stimulation surgery, the other 17 patients had received brain surgery for other reasons. Bleeding complications occurred in four of the 18 reported patients, but not in the DBS case. All four patients with bleeding complications were reported to have died as a result. In three of the four patients with fatal outcome, surgery was less than 90 days before the onset of stroke.ConclusionIVT and MT were tolerated by four patients with ischemic stroke more than 6 months after DBS surgery without bleeding complications.

Rescue thrombolysis for medium vessel occlusion (RESCUE-TNK): Rationale and design of a phase 2 randomized trial.

The best reperfusion strategy for medium-sized vessel occlusion (MeVO) is not well established. Given the proven treatment effect of intra-arterial thrombolysis in patients with large vessel occlusion (LVO), we hypothesized that intra-arterial tenecteplase (TNK) could increase the recanalization rate of MeVO and thus improve clinical outcome. To explore the safety and efficacy of intra-arterial TNK in patients with MeVO. A maximum of 80 patients are required to test the superiority hypothesis, using power = 80% and α = 0.025 to conduct the one-sided test. Rescue treatment for mEdium veSsel oCclUsion by intra-artErial TNK (RESCUE-TNK) is a pilot, randomized, open-label, blinded end point, and multicenter trial. Eligible patients including primary MeVO as detected by the first DSA examination or secondary MeVO after endovascular treatment (EVT) for LVO will be assigned into the experimental group and control group as a ratio of 1:1. The experimental group will be treated with intra-arterial TNK (0.2-0.3 mg/min, for 20-30 min) via a microcatheter placed proximal to the site of occlusion, and the control group will be treated with routine therapy. Both groups of patients will be given standard stroke care based on the guidelines. The primary efficacy end point is successful recanalization of MeVO, defined as the expanded treatment in cerebral ischemia (eTICI) score 2b67-3 after the procedure, while the primary safety end point is symptomatic intracranial hemorrhage (sICH), defined as National Institutes of Health Stroke Scale score increase ≥4 caused by intracranial hemorrhage within 24 (-6/+24) hours after randomization. The results of RESCUE-TNK will provide evidence for the efficacy and safety of intra-arterial TNK in the recanalization of patients with MeVO.

Neurointerventional Advances in 2022

Neurointerventional Advances in 2022

Efficacy and safety of intra-arterial thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis.

To investigate the efficacy and safety of intra-arterial thrombolysis (IAT) in patients with central retinal artery occlusion (CRAO). PubMed and EMBASE were searched for potentially eligible studies that reported IAT in CRAO patients from inception to Nov 8, 2021. Standard mean difference (SMD) was pooled to compare visual acuity (VA) at baseline with final in IAT patients. The rates and odds ratios (OR) were meta-analyzed to compare VA improvement in IAT with non-IAT patients, stratified to different times from onset to procedure, different definitions of VA improvement, and three CRAO stages. Adverse effects were recorded. Fifteen studies were included, enrolling 507 CRAO patients who received IAT and 296 CRAO patients who did not. VA was significantly improved from baseline to final VA in IAT patients (SMD [LogMAR] 0.70, 95% CI [0.51, 0.90]). VA improvement rate was higher in IAT patients than that in non-IAT (56% vs 32%, OR 3.55, 95%CI [1.74, 7.24]), with greater OR in IAT within 6h from onset to procedure (OR 4.60, 95%CI [1.24, 16.99]) than that beyond 6h (OR 3.36, 95%CI [1.43, 7.85]). The benefit remained consistent when VA improvement was defined as ≥ 3 lines on the Snellen chart (OR 4.68, 95%CI [2.10, 10.41]) and was even greater when CRAO was incomplete. Five patients had a symptomatic intracranial hemorrhage and 21 patients had ischemic stroke or transient ischemic attack after IAT. IAT treatment has certain potential in ameliorating VA in CRAO patients, which should be balanced against cerebral complications.

Efficacy of Intra-Arterial Thrombolysis for Acute Central Retinal Artery Occlusion: A Meta-Analysis

Introduction: The best management strategy still remains strong controversy for acute nonarteritic central retinal artery occlusion (CRAO). We thus performed a meta-analysis to determine the efficacy of intra-arterial thrombolysis (IAT) for visual improvement according to different times from symptom onset. Methods: We searched EMBASE, PubMed, and Web of Science for relevant studies assessing efficiency of IAT in patients with CRAO compared with standard therapy. Fixed-effects and random-effects models were performed. Results: Five eligible studies including 459 patients with acute CRAO were pooled in the meta-analysis. In all, 219 (47.7%) received IAT, and the mean time from symptom onset to IAT was 13 h. The pooled analysis demonstrates odds ratio (OR) for the procedure of IAT and any visual improvement to be 1.520 (95% confidence intervals [CIs] 1.258–1.837; p < 0.001). Subgroup analyses further indicated that the CRAO patients who received IAT achieved any visual improvement more easily within 6 h from symptom onset (OR = 1.703, 95% CI 1.219–2.381; p = 0.002), but not those beyond 6 h (OR = 1.260, 95% CI 0.973–1.632; p = 0.080). Conclusion: Our meta-analysis of available published data supports IAT to be an alternative treatment option for CRAO patients within 6 h from symptom onset.

Safety and Efficacy of Selective Intra-arterial Thrombolysis for Central Retinal Artery Occlusion.

PurposeThe purpose of this study was to determine the efficacy and safety of selective intra-arterial thrombolysis in patients with central retinal artery occlusion (CRAO).MethodsMedical records for 44 eyes of 44 patients diagnosed with acute non-arteritic CRAO and thrombolysis between October 2010 and February 2019 were analyzed retrospectively. Based on visual acuity, fundoscopic findings, and fluorescein angiography, the patients were classified into three stages: incomplete, subtotal, and total. The perfusion state using the best-corrected visual acuity (BCVA), arm to retina time, and arteriovenous passage times, after 1 month, 6 months, and at the final visit after the procedure, were compared with baseline readings.ResultsImprovement of visual acuity was confirmed in 31 out of 44 patients (70.45%). The mean BCVA of 44 patients changed from 1.65 ± 0.78 logarithmic minimum angle of resolution (logMAR) at the first visit to 1.18 ± 0.91 logMAR at the last visit (p = 0.114). The BCVA according to CRAO stage was 0.08 ± 0.11 logMAR for the incomplete stage at the first visit, 0.06 ± 0.05 logMAR (p = 0.933) 1 month after the procedure, and 0.05 ± 0.07 logMAR (p = 0.933) at the last visit. In the subtotal stage, the results were 1.81 ± 0.54 logMAR at the first visit, 1.63 ± 0.76 logMAR (p = 0.035) 1 month after the procedure, and 1.36 ± 0.85 logMAR (p = 0.014) at the last visit. For the total stage of BCVA, the result at the first visit was 2.36 ± 0.25 logMAR, and it was 2.30 ± 0.30 logMAR (p = 0.510) 1 month after the procedure, and 2.42 ± 0.30 logMAR (p = 0.642) at the last visit. Reperfusion was observed in 40 patients out of the 44 (90.91%).ConclusionsSelective intra-arterial thrombolysis can be helpful in patients with subtotal CRAO in terms of visual improvement and retinal arterial reperfusion.

Outcome of intra-arterial thrombolysis in patients with diabetes and acute lower limb ischemia: a propensity score adjusted analysis

The presence of diabetes mellitus is rarely addressed in acute lower limb ischaemia (ALLI). The aim of this study was to evaluate the outcome of local intra-arterial thrombolysis for ALLI in patients with diabetes mellitus (DM). Outcome of all thrombolytic events performed in an endovascular first-strategy centre during a 13-year period between 2001 and 2013 in patients with ALLI were followed to January 2017. A propensity score adjusted analysis was performed to evaluate results in patients with (n = 83) versus without (n = 316) DM. Patients with DM were younger (p = 0.001), more often women (p = 0.014), more often had renal insufficiency (p = 0.041), foot ulcers (p < 0.001), and thrombosis (p = 0.032) than the patients without DM. At presentation, patients with DM had a lower degree of ischemia judged by the Rutherford classification, compared to those without DM (p = 0.023). None of the 83 diabetic patients had a popliteal artery aneurysm, compared to 25 (7.9%) of the 316 patients without DM (p = 0.008). The amount of tPA administered to patients with DM was higher than to patients without DM (p = 0.03). In the propensity score adjusted analysis, patients with DM had a higher rate of major amputation at 1 (OR 2.52; 95% CI 1.22–5.20) and 3 years (OR 2.52; 95% CI 1.26–5.04), and a lower amputation-free survival at 3 years (OR 0.46; 95% CI 0.25–0.85), than those without DM. Patients with DM presenting with ALLI differ in clinical characteristics, presentation, and aetiology compared to patients with DM, and have a higher rate of major amputation and lower amputation-free survival rate after intra-arterial thrombolysis.

Validation of FLAIR Hyperintense Lesions as Imaging Biomarkers to Predict the Outcome of Acute Stroke after Intra-Arterial Thrombolysis following Intravenous Tissue Plasminogen Activator

Background: Intravenous tissue plasminogen activator (tPA) given within 4.5 h of symptom onset is accepted as the standard treatment of ischemic stroke. Persistent occlusion of cerebral arteries despite intravenous thrombolysis and unremitting neurologic deficits lead us to consider additional intra-arterial approaches. The aim of this study was to elucidate the potential of fluid-attenuated inversion recovery (FLAIR) MRI performed during or immediately after intravenous thrombolysis for predicting clinical outcomes of subsequent intra-arterial thrombolysis. Methods: With a prospective stroke registry database of patients hospitalized in our institution from January 2004 to February 2010, we identified ischemic stroke patients with the following conditions: (1) presentation within 2.5 h of onset, (2) treated with intravenous tPA based on brain CT, (3) persistent occlusion on subsequent MRI/MR angiography, including a FLAIR sequence, and (4) eventually treated with intra-arterial thrombolysis. Demographic, clinical and laboratory findings including initial National Institutes of Health Stroke Scale (NIHSS), follow-up NIHSS at the 7th day or discharge, modified Rankin scale (mRS) score at 3 months, and symptomatic hemorrhagic transformation were captured. FLAIR images were reviewed by 2 investigators blinded to clinical information independently and dichotomized into the absence and presence of FLAIR change within the diffusion-restriction lesions. Results: Of the 57 patients who met these conditions, FLAIR-hyperintense lesions (FHL) were observed in 32 (56.1%). The FHL-negative group was 69.1 ± 12.1 years old on average and the FHL-positive group 67.3 ± 11.0 years old. In both groups, hypertension was the most common vascular risk factor, cardioembolic stroke was the most common subtype, and distal middle cerebral artery was the most common site of occlusion. The incidence of symptomatic hemorrhagic transformation was 4.0% in the FHL-negative group and 9.4% in the FHL-positive group (p = 0.62). NIHSS scores of 0-1 on the 7th day of hospitalization or at discharge were observed in 36% of the FHL-negative group and in 9.4% of the FHL-positive group; mRS scores of 0-1 at 3 months was 32% in the FHL-negative group and 21% in the FHL-positive group. An ordinal logistic regression analysis showed that the presence of FHL was associated with higher 7-day NIHSS scores (adjusted for relevant covariates) but not with higher 3-month mRS scores. Conclusions: This study suggests that the FHL might be used as imaging biomarker to predict outcomes for additional intra-arterial thrombolysis in patients treated with intravenous tPA.

Assessment of Recanalization after Intra-Arterial Thrombolysis in Patients with Acute Ischemic Stroke : Proposed Modification of the Qureshi Grading System

ObjectiveWe aimed to investigate the correlation between the success of recanalization and a modified version of the Qureshi grading system in acute ischemic stroke patients.MethodsWe retrospectively analyzed the intra-arterial thrombolysis (IAT) records of 37 patients who were evaluated by Thrombolysis in Myocardial Infarction (TIMI) and a modified version of the Qureshi grading systems as follows : 1) post-IAT Qureshi grade, 2) modified Δ Qureshi grade : pre-IAT group grade - post-IAT group grade (grade 1 : Qureshi grades 0-2 and grade 2 : Qureshi grade 3-5) and 3) Δ Qureshi grade (post-IAT Qureshi grade - pre-IAT Qureshi grade). Successful recanalization was defined as follows : 1) post-IAT TIMI grades 2 and 3, 2) post-IAT Qureshi grade 0-2, 3) modified Δ Qureshi grade=1, and 4) Δ Qureshi grade of ≥2 and/or post-IAT Qureshi grade=0. We investigated the correlation between the post-IAT TIMI grade and the modified Qureshi grade and also compared the various grading systems with modified Rankin Scale scores for evaluating the clinical outcome at 3 months.ResultsThe post-IAT Qureshi grade and Δ Qureshi grade and/or post-IAT Qureshi grade were significantly correlated with the TIMI grade (γ=0.976 and, 0.942, respectively). Further, post-IAT Qureshi grade and Δ Qureshi grade and/or post-IAT Qureshi grade showed a significantly stronger association with clinical outcome than did the post-IAT TIMI grade (p=0.001 and, 0.000 vs. 0.083, respectively).ConclusionOur preliminary results suggest that the modified Qureshi grading system is a useful tool for assessing the success of recanalization after IAT.

Emergent stent placement following intra-arterial thrombolysis for the treatment of acute basilar artery occlusion

Acute basilar artery occlusion (BAO) is a condition producing high rates of morbidity and mortality. Intravenous thrombolysis or intra-arterial thrombolysis are therapeutic options; however, the clinical outcomes remain poor. The purpose of the present study was to evaluate feasibility, safety, and efficacy of emergency stent placement following intra-arterial thrombolysis for patients with acute BAO. Thirty-six consecutive patients were treated for acute BAO using intra-arterial therapy from September 2004 to October 2009. Nine patients, with a Glasgow Coma Scale (GCS) score ranging from 8 to 12, underwent emergency stent placement following inadequate revascularization after thrombolysis. Neurological status prior to treatment was evaluated using the GCS score. Modified Rankin Scale (mRS) scores at 90 days post-treatment were used to assess functional outcome and we reviewed clinical records for frequency of procedure-related complications. Stents were deployed at the target lesion in all patients. Successful revascularization was achieved in eight of nine (88.9%) patients (residual stenosis <50%). The median GCS score prior to thrombolysis was 9 (range: 6–12) and prior to stent placement was 10 (range: 8–12). Four patients (44.4%) achieved good outcomes as determined by the mRS scale (0–2 at 90 days). Mortality was 33.3% in all procedures with one patient (11.1%) experiencing acute intrastent thrombus formation. No patient developed symptomatic intracerebral hemorrhage. Data from our small case series demonstrates that emergency stent placement following intra-arterial thrombolysis is a feasible treatment for patients with acute BAO and may reduce mortality and prevent re-occlusion of the basilar artery.

Rescue therapy with local intra‐arterial urokinase after poor clinical response with intravenous recombinant tissue plasminogen activator in acute ischaemic stroke

We report a case of combined intravenous and intra-arterial thrombolysis in a patient presenting with acute ischaemic stroke. Progression to intra-arterial thrombolysis in patients who fail to show clinical improvement within 6 h of symptom onset might be a safe treatment option at centres with access to stroke specialist and endovascular services. The purpose of this report is to demonstrate the efficacy and potential benefits of this rescue therapy.

The Alberta Stroke Program Early CT Score in Clinical Practice: What have We Learned?

The introduction of brain imaging with computed tomography revolutionised the treatment of patients with acute ischaemic stroke. With the visual differentiation of haemorrhagic stroke from ischaemic stroke, thrombolytic therapy became feasible. The Alberta Stroke Program Early CT Score was devised to quantify the extent of early ischaemic changes in the middle cerebral artery territory on noncontrast computed tomography. With its systematic approach, the score is simple and reliable. However, the assessment of early ischaemic changes and Alberta Stroke Program Early CT scoring require training. The Alberta Stroke Program Early CT Score is a strong predictor of functional outcome. Furthermore, the effectiveness of intraarterial thrombolysis in patients with middle cerebral artery occlusion shows effect modification by the Alberta Stroke Program Early CT Score. This review summarises the Alberta Stroke Program Early CT Score methodology. We illustrate current knowledge regarding Alberta Stroke Program Early CT Score applied to clinical trials and comment on how Alberta Stroke Program Early CT Score may facilitate clinical treatment decision making and future trial design. Moreover, we introduce a modification of the Alberta Stroke Program Early CT Score methodology that disregards isolated cortical swelling, i.e. focal brain swelling without associated parenchymal hypoattenuation, as early ischaemic changes in the Alberta Stroke Program Early CT Score system.

The MERCI Retrieval System for the Management of Acute Ischaemic Stroke – The NNI Singapore Experience

Systemic and local intra-arterial thrombolysis in patients with large vessel ischaemic stroke is hampered by poor re-canalisation rates and risk of haemorrhage. The Merci Retrieval System is an endovascular device for removal of acute intracranial thrombus. We present our initial experience using this device in conjunction with existing thrombolytic therapy already in place in our institute. Prospective data in all patients presenting with large vessel ischaemic stroke treated using the Merci Retrieval System from July 2007 to March 2009 were analysed. Selection criteria for patients were similar to the multi- Merci trial of 2008. We compared re-canalisation rate, National Institutes of Health Stroke Score (NIHSS) and modified Rankin score (mRS) outcomes to the published trial results. Seventeen patients were reviewed; none suffered immediate post-procedural complications. Fifteen underwent successful thrombus retrieval but in 2 cases the device failed due to technical considerations. Sites of vascular occlusion included: ICA/ICA-'T' junctions 27%, middle cerebral artery 13% and vertebrobasilar artery 60%. Of the 15 patients treated by MERCI with or without adjuvant thrombolytic therapy, complete re-canalisation was achieved in 60%, partial re-canalisation in 20%, partial re-canalisation with persistent distal vessel occlusion in 6% and failure of re-canalisation in 14%. Asymptomatic haemorrhage occurred in 33% and there was 1 death (6%) from symptomatic haemorrhage. Pre-treatment median NIHSS was 17.88 and 9.5 immediately post-treatment. Median mRS at 30 days was 2.6 for patients who achieved complete re-canalisation and 4.5 in failure or partial re-canalisation with or without persistent distal vessel occlusion. Re-canalisation rates using the Merci Retrieval System was comparable to the multi-Merci trial. Haemorrhagic complications and safety were also found to be satisfactory. Importantly, treatment success with eventual good clinical outcome hinges strongly on the ability of the device to achieve complete re-canalisation.

Intra-arterial Thrombolysis of Acute Iatrogenic Intracranial Arterial Occlusion Attributable to Neuroendovascular Procedures or Coronary Angiography

For selected stroke patients, intra-arterial thrombolysis (IAT) has been shown to be an effective treatment option. However, knowledge of safety and efficacy of IAT in patients with acute stroke as a complication of arterial catheter interventions is limited. We analyzed clinical radiological findings and functional outcomes in consecutive patients 3 months after treatment with IAT for peri-procedural strokes occurring during neuroendovascular or cardiac catheter interventions. To measure outcome, the modified Rankin scale score was used. Of a total of 432 patients treated with IAT, 12 (4 women and 8 men; mean age, 60 years) were treated because of an ischemic stroke after a neuro-endovascular procedure (n=6) or coronary angiography (n=6). The median baseline National Institutes of Health Stroke Scale score was 15. Recanalization was complete (thrombolysis in myocardial infarction grade 3) in 6, partial (thrombolysis in myocardial infarction 2) in 5, and minimal (thrombolysis in myocardial infarction 1) in 1. Nine patients (75%) had a favorable outcome (modified Rankin scale score, 0 to 2), and 3 had a poor outcome (modified Rankin scale score, 3 or 4). All patients with complete recanalization had a favorable outcome, whereas only 3 of 6 patients with partial or minimal recanalization (P=0.18) had a favorable outcome. Follow-up brain imaging was normal in 2 and showed new ischemic lesions in 10 patients. Two patients (17%) had a symptomatic intracerebral hemorrhage. In acute stroke attributable to arterial catheter interventions, IAT is feasible and has the potential to improve outcome in these patients. A high recanalization rate could be achieved.

Vertebral artery dissection complicated by basilar artery occlusion successfully treated with intra-arterial thrombolysis: three case reports

Cervical artery dissection is an important cause of stroke in young patients and accounts of 10%-20% of stroke or TIA in patients aged less than 50 years. Basilar artery occlusion (BAO) is an infrequent cause of acute stroke, which invariably leads to death or long-term disability if not recanalized. We describe three patients with BAO caused by vertebral dissection, successfully treated with intra-arterial thrombolysis. The lysis of the occluding embolus was obtained by injection of the thrombolytic drug directly or near the thrombus without haemorrhagic complications. Our cases confirm the safety and efficacy of intra-arterial thrombolysis in patients with BAO due to a vertebral artery dissection.

Reduced Pretreatment Ipsilateral Middle Cerebral Artery Cerebral Blood Flow Is Predictive of Symptomatic Hemorrhage Post–Intra-Arterial Thrombolysis in Patients With Middle Cerebral Artery Occlusion

Intracerebral hemorrhage (ICH) can be a devastating complication associated with thrombolytic therapy for acute ischemic stroke. We hypothesized that patients with lower prethrombolysis cerebral blood flow (CBF) were at a higher risk of symptomatic ICH (sICH). Twenty-three patients who underwent quantitative CBF assessment with Xenon CT studies for acute stroke before intra-arterial (IA) thrombolysis for a middle cerebral artery (MCA) or internal carotid artery terminus occlusion within 6 hours of symptom onset were studied. Univariate and multivariate analysis were carried out to determine predictors of sICH post-IA thrombolysis. Receiver operating characteristic curves were generated to determine the association between mean ipsilateral CBF and the occurrence of sICH. The mean age of our cohort was 68+/-12 years and a mean National Institutes of Health Stroke Scale (NIHSS) score of 18+/-3. In univariate analysis, patients with higher percent of core infarct, hyperglycemia, and reduced mean ipsilateral CBF were at risk of sICH. In multivariate analysis only mean ipsilateral CBF was associated with higher rates of sICH (odds ratio 1.58; 95% CI, 1.01 to 2.51; P<0.04). The area under the receiver operating characteristic curve was 0.87 (95% CI, 0.76 to 0.97; P<0.005). Patients with lower pre-IA thrombolysis mean ipsilateral MCA CBF are at significantly higher risk for sICH in the setting of a MCA or carotid terminus occlusion. The threshold identified in this study may be useful for selection of patients with acute MCA occlusions for acute stroke thrombolysis.

Sulcal Hyperintensity on Fluid-Attenuated Inversion Recovery Imaging in Acute Ischemic Stroke Patients Treated With Intra-Arterial Thrombolysis

To investigate the effect of iodinated contrast medium on sulcal hyperintensity on fluid-attenuated inversion recovery (FLAIR) imaging immediately after intra-arterial thrombolysis in patients with acute ischemic stroke and to determine whether it may be associated with subsequent hemorrhagic transformation (HT). Fourteen consecutive patients with acute ischemic stroke who were treated with intra-arterial thrombolysis were enrolled. All patients underwent noncontrast computed tomography (NCT) and diffusion-weighted (DWI), perfusion-weighted, gradient-recalled echo (GRE), and gadolinium-enhanced T1-weighted magnetic resonance imaging (MRI). Immediate follow-up NCT and MRI (T2-weighted, FLAIR, GRE, DWI, perfusion-weighted, T1-weighted, and gadolinium-enhanced T1-weighted) were obtained and evaluated to determine the presence of sulcal hyperintensity or subarachnoid hemorrhage (SAH). The same follow-up images were obtained on days 1, 3, and 7 and evaluated to determine HT. Sulcal hyperintensity was found in 8 (57.1%) of 14 patients and was seen as hyperattenuation on immediate follow-up NCT and as hyperintensity on T1-weighted images in 4 (50%) of 8 patients. It may be suggested that the sulcal hyperattenuation was responsible for the sulcal hyperintensity, considering signal intensity and follow-up imaging. All patients with sulcal hyperintensity showed enhancement in the corresponding gyri on gadolinium-enhanced T1-weighted imaging. Hemorrhagic transformation developed in 5 of 8 patients with sulcal hyperintensity and in 1 of 4 patients without (P = 0.031). In acute ischemic patients treated with intra-arterial thrombolysis, sulcal hyperintensity on FLAIR imaging may be caused by iodinated contrast medium, which should not be considered SAH. Sulcal hyperintensity is significantly associated with subsequent HT.

Recanalizing therapies in acute stroke

Systemic thrombolysis with rt-PA within 3 hours after symptom onset has developed into a standard therapy for acute stroke patients. Recombinant t-PA is now licensed in Europe for this indication. Within 3 to 6 hours, no general therapeutic standard has been established yet. Currently, the available data are in favor of intra-arterial thrombolysis for patients with proximal occlusions of the middle cerebral artery. Systemic thrombolysis is not generally recommended in this time window, but is used in some centers for selected patients. In addition to thrombolysis and new strategies to improve thrombolysis (including patient selection with MRI), several interventional and surgical recanalization techniques are discussed.