Intra-arterial Thrombolytic Therapy Research Articles

P-017 time to treatment effect on visual recovery after intra-arterial thrombolysis for acute central retinal artery occlusion

Introduction Central retinal artery occlusion (CRAO) is considered an ophthalmologic emergency. The effectiveness of intra-arterial thrombolysis (IAT) remains controversial. Non-invasive standard therapies are often employed but their efficacy compared to no treatment is also controversial. Similar to emergent large vessel occlusion stroke, time to revascularization may be critically important with lower times possibly favoring improved visual outcomes. We performed a systematic review of the literature to determine whether evidence exists for improvement in vision after IAT and whether that improvement varied with time. Methods A comprehensive literature search was conducted in MEDLINE (1946–January 2015) for the following medical keywords: intra-arterial thrombolysis; retinal artery occlusion; intra-arterial fibrinolysis; and retinal artery. Additional articles were identified by review of the reference sections of each article. Inclusion criteria consisted of articles written in English, micro catheter directed infusion of thrombolytic (tPA, urokinase, streptokinase), individual patient data for visual outcomes and time from onset to IAT therapy. LogMAR scores were either abstracted directly from the data or converted from Snellen chart scores. The numerical scores for profound vision loss (counting fingers or worse) were substituted for logMAR scores as suggested by Lange et al . 1 Results Five studies met the inclusion criteria supplying individual data on 115 patients. 2–6 The mean and median time to IAT were 12.2 (SD 10.4) and 9 (IQR 6.9,12) hours respectively. Mean logMAR improvement was 0.61 (SD 0.68). A Shapiro-Wilk test of normality demonstrated non-parametric data and a paired-samples Wilcoxan Signed Rank test was performed on pre- and post-IAT treatment logMAR scores. This demonstrated a significant median improvement of 0.4 [IQR: 0, 1.06] (P Conclusions IAT therapy demonstrates a significant improvement in logMAR scores when comparing pre- and post-IAT therapy visual assessments. Time to treatment showed a trend towards superior improvement in patients treated in less than 4 h but this was not significant. References Lange C, Feltgen N, Junker B, et al . Graefes Arch Clin Exp Ophthalmol. 2009;247(1):137–42 Butz B. Acta Radiol . 2003;44(6):680–4 Mercier J. J Neurorad . Epub Ahead of Print 2014-Nov 15 Peterson J. Can J Neurol Sci . 2005;32:507–11 Richard G. Ophthalmology 1999;106(4):768–73 Schumacher M. Neuroradiology 1993;35:600–55 Disclosures P. Page: None. A. Cambon: None. R. James: 1; C; Microvention, Inc. Industry sponsored and Investigator-Initiated Research Support, Penumbra, Inc.; Investigator-Initiated Research Support. 2; C; Pulsar Vascular, Inc.; Clinical Events Committee Member, Covidien, Inc.; Clinical Events Committee Member. 4; C; Remedy Pharmaceuticals, Inc.

E-127 intra-arterial thrombolysis for central retinal artery occlusion: a systematic review and meta-analysis

Introduction Central retinal artery occlusion (CRAO) is considered an ophthalmologic emergency. Neurointerventionalists commonly treat emergent large vessel occlusion stroke with endovascular reperfusion procedures and, therefore, are well positioned to provide emergent endovascular treatment of CRAO with intra-arterial thrombolysis (IAT). The clinical benefit of IAT therapy for CRAO remains controversial. The most recent systematic review and meta-analysis on the topic was published in 2000 that evaluated five studies totaling 100 patients. Since that time additional studies have been performed with hundreds more patients available including a randomized controlled trial. Here we performed a systematic review of the literature and an exploratory meta-analysis. Methods A comprehensive literature search was conducted in MEDLINE (1946–January 2015) for the following medical keywords: intra-arterial thrombolysis; retinal artery occlusion; intra-arterial fibrinolysis; and retinal artery. Additional articles were identified by review of the reference sections of each article. Inclusion criteria consisted of articles written in English, microcatheter directed infusion of thrombolytic (tPA, urokinase, streptokinase), studies with control groups, and studies with more than five patients. An exploratory meta-analysis was conducted for studies of a similar level of evidence using the inverse variance method for weighting studies and the DerSimonian-Laird estimator for quantifying heterogeneity. A Forest plot was created using R (package meta) statistical software. Results Six studies were identified that met the inclusion criteria.1–6 There were five controlled retrospective cohort studies consisting of 409 patients and one randomized controlled trial (RCT) consisting of 82 patients (EAGLE Study). Pooled analysis was not performed on the RCT due to it having a significantly different level of evidence. The estimated pooled odds ratio for fixed effects analysis of the remaining five studies was 3.11 (95% CI, 2.02 to 4.78; P Conclusion IAT therapy for CRAO remains controversial. Pooled analysis of the retrospective studies supports IAT therapy whereas a single RCT does not support intervention. Other authors have suggested significant methodological concerns for the EAGLE study calling into question its conclusions that conflict with favorable studies of presumably lower levels of evidence.7 Additional study, potentially with stricter IAT time to treatment criteria may be warranted. References Ahn SJ. Invest Ophthalmol Vis Sci. 2013;54(12):7746–55 Aldrich EM. Stroke 2008;39:1746–50 Arnold M J. Neurol Neurosurg Psychiatry 2005;76:196–199 Schmidt DP. AJNR 2002;23:1301–7 Weber J. Stroke 1998;29:2076–79 Schumacher M. Ophthalmology 2010;117(7):1367–75 Hayreh SS. Graefe Arch Ophthal. 2007;245:464–66 Disclosures P. Page: None. A. Cambon: None. R. James: 1; C; Microvention, Penumbra. 2; C; Pulsar, Covidien. 4; C; Remedy Pharmaceuticals.

Intravenous versus intra-arterial thrombolysis in ischemic stroke: a systematic review and meta-analysis.

BackgroundReperfusion following ischemic stroke can be attained by either intravenous thrombolysis (IVT) or intra-arterial thrombolysis (IAT). Only a limited number of randomized prospective studies have compared the efficacy and safety of IVT and IAT. This meta-analysis investigated possible clinical benefits of IAT relative to IVT in patients with acute ischemic stroke.MethodsWe searched the PubMed, Cochrane, and Google Scholar databases through October 2013 for manuscripts that describe the findings of randomized controlled or prospective studies that evaluated the outcomes of patients with ischemic stroke who were treated with IVT or IAT. The clinical outcome measures were score on the modified Rankin scale (mRS) and mortality at 90 days. A favorable outcome was defined as an mRS score of 0 to 2.ResultsFor the mRS, the combined odds ratio (OR) of 3.28 (95% confidence interval (CI), 1.91 to 5.65, P < 0.001) indicated that patients who received IAT had a significantly higher chance for a favorable outcome than did those who received IVT. For mortality, the OR indicated that IAT therapy significantly reduced the proportion of patients who died within 90 days of the procedure (combined OR, 0.40; 95%CI, 0.17 to 0.92; P = 0.032).ConclusionThis meta-analysis determined that IAT conferred a significantly greater probability of achieving a favorable outcome compared with IVT. There was also a significant difference in mortality rates between IAT and IVT. The studies included in this analysis were small and heterogeneous; therefore, larger randomized prospective clinical studies are necessary to further investigate this issue.

Previous and Recent Evidence of Endovascular Therapy in Acute Ischemic Stroke.

The ideal therapy of acute ischemic stroke is achieved by early recanalization that finally leads to good clinical outcome. The recombinant intravenous tissue plasminogen activator (rtPA) within 4.5 hours was approved as an important thrombolytic treatment. However, the recanalization rate was low in patients with a large artery occlusion. The efficacy of intravenous rtPA regarding recanalization of a large artery occlusion was limited. In several clinical trials, pharmacological and mechanical intra-arterial thrombolytic therapy showed improved recanalization rates, but the favorable outcome had not been achieved. Through those trials and errors, researchers have learned that speed of treatment initiation, patient selection by documentation of large artery occlusion and the use of effective devices could be crucial for good clinical outcomes. Finally, five recent randomized controlled trials of endovascular therapy compared to standard medical care have been published. The superiority of endovascular thrombolysis to standard medical care was proved. In this article, we reviewed previous and recent clinical evidence about endovascular thrombolytic therapy of acute ischemic stroke.

Increased globulin and its association with hemorrhagic transformation in patients receiving intra-arterial thrombolysis therapy.

Previous studies have identified a diverse set of predisposing factors for the occurrence of hemorrhagic transformation (HT), but the independent clinical predictors of HT after intraarterial thrombolysis have not been determined. In this retrospective study, we investigated the characteristics of patients with or without HT who had received intra-arterial thrombolysis therapy, using biochemical analysis, renal function test, routine blood test, blood lipid test, coagulation blood test, liver function test, random blood glucose test, time-window for intra-arterial thrombolysis, recanalization, National Institutes of Health Stroke Scale (NIHSS) score and systolic blood pressure before intra-arterial thrombolysis. The mortality rates were similar in the HT and non-HT groups (P = 0.944). In the single-factor analysis, patients with a higher globulin level (P <0.002), prothrombin time activity percentage (PTA; P = 0.026), and NIHSS score (P = 0.002), had a significantly increased risk of developing HT. In the multifactor logistic regression model involving globulin level, PTA, white blood cell count, and NIHSS score, the globulin level (P <0.001; OR, 1.185; 95% confidence interval [CI], 1.090-1.288), PTA (P = 0.018; OR, 1.016; 95% CI, 1.003-1.029), white blood cell count (P = 0.025; OR, 1.097; 95% CI, 1.012-1.190) and NIHSS score (P = 0.003; OR, 1.097; 95% CI, 1.031-1.166) were significantly increased in the HT group. The increase in globulin level is an independent risk factor for HT in patients receiving intra-arterial thrombolysis. The possible mechanisms may involve inflammatory cytokines, matrix metalloproteinase 9, and positive acute-phase reactants synthesized by the liver.

Predictive Factors for Early Clinical Improvement after Intra-arterial Thrombolytic Therapy in Acute Ischemic Stroke

In acute ischemic stroke, the speed of improvement after intra-arterial thrombolytic therapy (IAT)-mediated recanalization varies. This study aimed to identify clinical and radiological variables that are predictive of early improvement (EI) after IAT in acute ischemic stroke. This single-center retrospective cohort study included 141 consecutive patients who underwent IAT for terminal internal carotid and/or middle cerebral artery (MCA) occlusions. EI was defined as a National Institutes of Health Stroke Scale (NIHSS) score less than 3 or NIHSS score improvement of 8 points or more within 72 hours of IAT. The EI and non-EI groups were compared in terms of clinical and radiological findings before and after IAT. Forty-nine patients showed EI (34.8%). Multivariate analysis revealed that atrial fibrillation (odds ratio [OR] .35, 95% confidence interval [CI] .14-.89, P = .028) and hyperdense MCA sign (OR .39, CI .15-.97, P = .042) were related with lack of EI. The independent EI predictors were less extensive parenchymal lesion on baseline computed tomography (OR 4.92, CI 1.74-13.9, P = .003), intermediate to good collaterals (OR 3.28, CI 1.16-9.31, P = .026), and recanalization within 6 hours of symptom onset (OR 5.2, CI 1.81-14.94, P = .002). EI associated with favorable outcomes (modified Rankin scale score 0-2) at discharge (88% versus 7%; P < .001) and 3 months after discharge (92% versus 18%; P < .001). The clinical and radiological variables maybe useful for predicting EI and favorable long-term outcomes after IAT.

Ophthalmic Artery Aneurysm: Potential Culprit of Central Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) is one of the most devastating ophthalmic emergencies, causing acute painless visual loss in the affected eye. We describe the first case of acute non-arteritic CRAO associated with peripheral ophthalmic artery aneurysm and its clinical course after intra-arterial thrombolysis therapy. This case suggests that ophthalmic artery aneurysm can be the cause of CRAO and should be included in the differential diagnosis of CRAO.

In-Room Assessment of Cerebral Blood Volume for Guidance during Intra-Arterial Thrombolytic Therapy

In acute ischemic stroke, the ability to estimate the penumbra and infarction core ratio helps to triage those who will potentially benefit from thrombolytic therapies. Flat-panel post-contrast DynaCT imaging can provide both vasculature and parenchymal blood volume within the angio room to monitor hemodynamic changes during the endovascular procedures. We report on an 80-year-old woman who suffered from an acute occlusion of the right distal cervical internal carotid artery. She was transferred to the angio room where in-room post-contrast flat-panel DynaCT imaging (syngo Neuro PBV IR) was performed to access the ischemic tissue, followed by successful mechanical thrombolytic therapy.

Acute bilateral hearing loss as a “worsening sign” in a patient with critical basilar artery stenosis

We report a patient who presented with an acute-onset transient vertigo and unsteady gait with bilateral hearing loss. Brain MRI revealed a critical basilar artery (BA) stenosis at the lower pons and infarction in various areas on both sides in the territories of the posterior inferior cerebellar arteries (PICA). Further, we could not visualize the right anterior inferior cerebellar artery (AICA). The bilateral hearing loss may be ascribed to stroke due to the critical BA stenosis, causing hypoperfusion injury extending from the PICA to the AICA on both sides. Local intra-arterial thrombolytic therapy with the administration of 1×106 IU of urokinase aided partial recanalization of the BA, after which the right AICA reappeared. The neurological function of the patient recovered to normal, and no hemorrhagic complications were observed. Therefore, practitioners should be alert when treating patients with acute bilateral hearing loss, which may be related to an underlying catastrophic stroke.

Efficacy and safety of intra-arterial thrombolytic therapy for ischemic stroke

Efficacy and safety of intra-arterial thrombolytic therapy for ischemic stroke

Thrombolytic therapy for ischaemic stroke in patients using warfarin: a systematic review and meta-analysis

BackgroundIt is uncertain whether thrombolytic therapy is safe in patients with acute ischaemic stroke who are treated with warfarin and have a subtherapeutic international normalised ratio (INR) at stroke onset.MethodsThe...

Abstract 3345: Does Acute Stroke Critical Pathway For Recanalization Therapy In Acute Ischemic Stroke Improve Short-term Clinical Outcome?

Background &amp; Objectives: The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent. However, in-hospital time delay is the most serious obstacle to achieve a goal for timely administration of intravenous tPA. Previous studies have been reported that critical pathway (CP) for acute stroke would reduce door-to-needle time, but there are few studies about the clinical efficiency. We aimed to elucidate the roll of CP for improving clinical outcomes among patients who underwent thrombolytic therapy. Method: Acute stroke CP has been implemented in our hospital since November 2010 for the purpose of reducing in-hospital delay, and applicated to the patients who were presented with focal neurologic signs within 24 hours after onset. To evaluate effectiveness of CP, we predefined time indicators as follows; arrival to consultation time by neurologist (door-to-doctor) time, arrival to tPA administration (door-to-needle) time, and arrival to intra-arterial thrombolysis (door-to-IA) time. We compared the performance of time indicators during 6 months with that of before implementation for the same months. The difference of NIH stroke scale (NIHSS) between administration and discharge was selected for comparing short-term clinical outcome between two groups. Results: A consecutive series of 282 patients with acute ischemic stroke were collected during the study period. Among them, 125 patients were assigned to ‘before CP ’ group and 157 to ‘after CP’ group. Median of Door-to-doctor time was significantly reduced after implementation of CP; 45 min (IQR, 25 to 69) vs. 17 (12 to 27) (P&lt;0.001). Median of door-to-needle time was also significantly reduced; 58 (49 to 99) vs. 47 (40 to 59) (P=0.003). However, median of door-to-IA time was failed to reduce; 2.0 h (1.4 to 3.1) vs. 1.9 (1.6 to 2.2) (P = 0.445). The number of patients who were treated with thrombolytic therapy slightly increased from 24.8% (31/125) to 25.4% (40/157) and especially, rate of intra-arterial thrombolytic therapy significantly increase from 8.8%(11/125) to 15.2%(24/157). The analyses about the difference of clinical outcome between two groups by generalized estimating equation (GEE) showed that there was no significant improvement (P = 0.09) in terms of short-term clinical outcome which was assessed by initial and discharge NIHSS. Conclusions: Our study suggests that the acute stroke CP might be effective in reducing door-to-doctor and door-to-needle time although it could not lead to improvement of clinical outcome. The study about relationship between CP and long-term outcome should be needed for the future direction.

Abstract 3946: Determinants and Outcomes Associated with Withdrawal of Care following Endovascular Treatment in Acute Ischemic Stroke Patients.

Background: Withdrawal of care although frequently used may prematurely reduce the odds of recovery in patients with acute ischemic stroke. We performed this study to provide a better understanding of physician practices in withdrawal of care following endovascular treatment in acute ischemic stroke patients. Objective: Our goal was to identify frequency and factors associated with endovascular treatment that increase the odds of withdrawal of care in consecutive series of acute ischemic stroke patients. Methods: We reviewed consecutive acute ischemic stroke patients treated with endovascular treatment over a 5-year period. Demographics characteristics, National Institute of Health Stroke Scale (NIHSS) score before and after the procedure, and modified Rankin scale (mRS) at discharge were collected. The Qureshi grading scale was used to evaluate angiographic recanalization. We analyzed whether the presence of successful recanalization, or post-procedure intracerebral hemorrhage (ICH), was associated with withdrawal of care after age and 24 hr NIHSS score adjustment. The effect of withdrawal of care on poor outcome (mRS 3-6) at discharge was determined after adjusting for age and admission NIHSS score. Results: A total of 186 patients underwent endovascular treatment, mean age + SD: 65 (±17) years, 100 (54%) men, and mean NIHSS score ± SD: 15.5+ 7. Sixty four patients received intra-arterial thrombolytic only, 28 mechanical thrombectomy only, and 75 combined lytic/mechanical thrombectomy. Among all, 142 patients (77%) had vessel recanalization. Of these, 17 (9%) underwent withdrawal of care. 14% of the patients with recanalization versus 8% without recanalization underwent withdrawal of care (p=NS). Overall there were 37 patients who developed post-procedure ICH, but this occurrence was not associated with withdrawal of care status (p=NS). After adjusting for age and admission NIHSSS, there was no relationship between angiographic recanalization with withdrawal of care (OR=0.5, p=0.3). Patients who underwent mechanical thrombectomy during endovascular treatment had significant correlation with withdrawal of care compared to intra-arterial thrombolytic therapy alone (OR=10, p=0.02). Conclusion: Withdrawal of care, although infrequent, contributes to poor outcome at discharge in patients undergoing endovascular procedure for acute ischemic stroke. However, the choice of withdrawal of care is not related to angiographic recanalization or post-procedural ICH.

Successful intra-arterial thrombolytic therapy for a right middle cerebral artery stroke in a 2-year-old supported by a ventricular assist device

Embolic stroke is a common complication in patients on ventricular assist devices in both adults and children. The reported incidence of strokes in children supported by VAD's varies from 7 to 38%. The rapid increase in recent years in the availability of both adult and pediatric VADs will likely add to the overall prevalence of strokes in patients being bridged to heart transplant. Strokes in this population can be lethal as they frequently necessitate withdrawal of the extracorporeal device support and withdrawal from the organ transplant waiting list. We present a case of a fully anti-coagulated 29-month-old supported on a Berlin EXCOR LVAD (Berlin, Germany) with embolic stroke which was treated successfully with direct thrombolysis with recombinant tissue plasminogen activator. This is the first report which uses intra-arterial thrombolytics while on a ventricular assist device in a pediatric patient.

Thrombolysis for acute occlusion of the superior mesenteric artery

This study evaluated the incidence, complications, and outcome of local intra-arterial thrombolytic therapy for acute superior mesenteric artery (SMA) occlusion in Sweden. Patients undergoing local intra-arterial thrombolytic therapy for acute SMA occlusion were identified in the Swedish Vascular Registry (SWEDVASC) between 1987 and 2009. Patient data were retrieved in a structured protocol by local vascular surgeons at each participating hospital. Included were 34 patients (20 women) from 12 hospitals. Median age was 78 years. The first patient was treated in 1997, and the annual number of patients undergoing thrombolysis increased continuously from 2004 to 2009. Twenty-eight patients (82%) had embolic occlusion. No patients (0%) had acute peritonitis, and one (3%) had bloody stools at admission. Thirty-two patients (94%) were diagnosed by computed tomography with intravenous contrast enhancement. The median dose of alteplase was 20 mg (interquartile range, 11.6-34.0). Successful thrombolysis was achieved in 30 patients (88%). Initial adjunctive aspiration thromboembolectomy was performed in 10 patients. There were six self-limiting bleeding complications; one from the gastrointestinal tract. Thirteen explorative laparotomies, 10 repeat laparotomies, and eight bowel resections were performed. The in-hospital mortality rate was 26% (9 of 34). Age was not associated with in-hospital death (P = .42). Successful thrombolysis was associated with decreased mortality (P = .048). Local thrombolysis for acute SMA occlusion is a minimally invasive and effective treatment alternative in a select group of patients without peritonitis. The few technique-related complications were mild.

Brain abscess following intra-arterial thrombolytic treatment for acute brain ischemia

Brain abscess formation is a rare complication of intracranial endovascular treatment. To our knowledge, all previous reports of brain abscess formation have been associated with treatments involving the introduction of foreign materials. A 75-year-old man was admitted to hospital for acute stroke. Cerebral angiography revealed occlusion of the left middle cerebral artery (MCA) at the origin of the M2 segment. Intra-arterial thrombolytic therapy was administered but a hemorrhagic event occurred during this process. A brain CT scan revealed a hematoma extending from the left basal ganglia to the left frontal lobe and expansion of the infarct in the left MCA territory. A brain abscess at the hemorrhagic site developed 3 months after symptom onset. This is the first report of a patient with brain abscess formation following intra-arterial thrombolytic treatment. It is important to ensure aseptic technique during endovascular procedures irrespective of the involvement of foreign materials.

Case of “Slow” Stroke from Carotid Artery Occlusion Treated by Delayed but Cautious Endovascular Intervention

In a challenging case of carotid occlusion with slowly evolving stroke, we used brain imaging to facilitate endovascular revascularization resulting in the relief of the patient's symptoms. Patients with carotid occlusion and continued neurological worsening or fluctuations present enormous treatment challenges. These patients may present “slow” strokes with subacute infarcts that present significant challenges and risks during attempts at revascularization of the occluded artery. We present such a case in which we used multimodal imaging techniques, including MR-perfusion, to facilitate endovascular revascularization. Our approach of delayed but cautious intra-arterial thrombolytic therapy, guided by brain imaging, and followed by stent placement across the residual stenosis, enabled revascularization of the occluded artery without overt in-hospital complications.

Carotid stenting in acute ischemic stroke patients with intraluminal thrombus

Carotid stenosis with intraluminal thrombus is associated with a high risk of early recurrent stroke. We evaluated the feasibility and outcome of carotid stenting in acute ischemic stroke patients with carotid stenosis and intraluminal thrombus. Among 295 consecutive acute ischemic stroke patients who were referred for intra-arterial thrombolytic (IAT) therapy, six patients with carotid stenosis and intraluminal thrombus were treated by stent assisted angioplasty. The clinical characteristics, feasibility, and clinical outcomes were assessed. All patients had severe stenosis of the underlying carotid bulb (mean, 86.8%; range, 71-99%) with adjacent intraluminal thrombus. Stent assisted angioplasty resulted in successful recanalization in all six patients. Thrombus was captured with the filter device in four patients. Three patients with tandem occlusion of the ipsilateral proximal middle cerebral artery were successfully recanalized with intra-arterial urokinase. No patients suffered procedure related complications or symptomatic hemorrhage. Four patients showed good long-term outcome (3 month mRS; 0-2). Stent assisted angioplasty is a feasible treatment option for acute ischemic stroke patients caused by carotid stenosis with intraluminal thrombus and may be effective in preventing early recurrent stroke.

Intra-arterial thrombolytic therapy for acute intracranial large artery occlusive disease in patients selected by magnetic resonance image

Background and purpose We reported an experience of intra-arterial thrombolysis (IAT) study triaged by emergent MRI. Methods Patients were recruited if vascular occlusions were identified by emergent MRA. Urokinase was infused hyperselectively within 6 h after onset to a maximum dose of 900,000 IU or recanalization achieved with mechanical thrombus disruption. Heparin infusion was discontinued after 2 hemorrhage in the first 7 patients. TIMI grade 2 and 3 recanalization was recognized as successful. Favorable outcomes were mRS 0–3 at 3 months. Results Among 4225 ischemic stroke patients during the 29 months study period, 52 patients met the inclusion criteria with 49 screened by MRA and 3 screened by CT, 30 patients were enrolled and 25 were treated. Three patients (10%) were unable for the MRI examination due to time or equipment limit. There were 5 ICA, 13 MCA, and 7 VBA occlusions. Among 27 patients screened from MRA, 25 patients had the same occluded vessels and 2 patients had compatible occluded vessels confirmed by cerebral angiography. The median NIHSS was 26 and median time from symptom onset to IAT was 283 min. Successful recanalization was achieved in 68% (17/25). Intracerebral hemorrhage was recognized as symptomatic in 3 (12%) and asymptomatic in 8 (32%) at 3 months. Mortality was 32%. 36% patients had a mRS of 0–3 at 3 months. Patients with lower initial NIHSS score (20.9 vs. 28.4, P = 0.02) and MCA occlusions (69.3%, 9/13, P < 0.001) tend to have favorable outcomes. Conclusions Though the incidence was low, IAT triage with emergent MRI appeared to be feasible. MRI screening might be incorporated in the future IAT studies. Mechanical thrombus disruption and heparin infusion in IAT might need further investigation in this area.

Tratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudo

Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. DESIGN AND AREA: An observational prospective study in the Intensive Care Unit.16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by modified Rankin scale (obtained by telephone survey) were collected.Ten male patients with a mean age of 59 years (29-74) were included. The mean stay in the ICU was 6 days (1-33). Seven patients required mechanical ventilation. Treatment indications were: intravenous thrombolysis failure in 4 patients, major vessel occlusion in 5, outside of the therapeutic window in 2, posterior circulation occlusion in 3, outside of the therapeutic window plus major vessel occlusion in 1 and intravenous thrombolysis contraindication in 1. The occlusion site was on posterior circulation in 3 and on carotid territories and branches in 13. Thrombolytic treatment used was Urokinase at a dose of 100,000-600,000IU. Four patients required mechanical embolectomy and 10 stent implantation. Complete recanalization was observed in 11 (69%) and partial in 4 (25%). Three evolved to brain death. Six patients (46%) had a favorable outcome (modified Rankin scale score ≤ 2). Technical complication was 1 femoral artery pseudoaneurysm.With the intra-arterial treatment, high rates of recanalization and favorable outcome are obtained with few complications. It could be indicated in patients with severe neurological injury (NIHSS ≥ 10), evolution time between 3-6h, intravenous thrombolysis contraindication and proximal arterial occlusion.