Local Intra-arterial Thrombolysis Research Articles

On-Table Catheter-Based Neurosalvage Performed by Cardiologists for Embolic Complication during an Endovascular Procedure.

To report our experience and clinical results of neurosalvage techniques, performed by interventional cardiologists without moving the patient, to manage cerebral thromboembolic complications. Iatrogenic emboli may be released during an endovascular procedure, causing permanent neurological complications and catastrophic outcomes. Between July 2013 and December 2017, a total of eight patients suffered from embolic complications during endovascular procedures (two radiofrequency catheter ablation, five coronary angiogram/angioplasty, and one subclavian artery angioplasty). Catheter-based neurosalvage was attempted by experienced interventional cardiologists promptly in the same catheterization room. The embolized locations were the M1 segment of the middle cerebral artery in four patients, the M2/M3 segments in three, and the basilar artery in one. Access to the supra-aortic vessels was achieved. Local intra-arterial thrombolysis was given in five patients (63%) and balloon angioplasty in three (38%). Intra-arterial thrombectomy with a stent retriever was attempted in three patients but failed in one. A combination of different techniques was used in three patients (38%). Final thrombolysis in cerebral infarction grade 3 flow was achieved in seven patients (88%). Favorable clinical outcomes at 1-month follow-up (modified Rankin scale of 0-2) were observed in seven patients (88%), and none of the patients had died at 12 months. Our experience demonstrated that acute embolic complications during an endovascular procedure can be salvaged by interventional cardiologists with acceptable angiographic and clinical results.

Local Intra-arterial Thrombolysis during Mechanical Thrombectomy for Refractory Large-Vessel Occlusion: Adjunctive Chemical Enhancer of Thrombectomy.

Data on adjunctive intra-arterial thrombolysis during mechanical thrombectomy for refractory thrombus are sparse. The aim of this study was to evaluate the efficacy and safety of local intra-arterial urokinase as an adjunct to mechanical thrombectomy for refractory large-vessel occlusion. We retrospectively evaluated patients with acute ischemic stroke who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion between January 2016 and December 2019. Patients were divided into 2 groups based on the use of intra-arterial urokinase as an adjunctive therapy during mechanical thrombectomy for refractory thrombus: the urokinase and nonurokinase groups. Herein, refractory thrombus was defined as the target occlusion with minimal reperfusion (TICI 0 or 1) despite >3 attempts with conventional mechanical thrombectomy. The baseline characteristics, procedural outcomes, and clinical outcome were compared between the 2 groups. One hundred fourteen cases of refractory thrombus were identified. A total of 45 and 69 patients were in the urokinase and the nonurokinase groups, respectively. The urokinase group compared with the nonurokinase group showed a higher rate of successful reperfusion (82.2% versus 63.8%, P = .034), with lower procedural times (54 versus 69 minutes, P = .137). The rates of good clinical outcome, distal embolism, and symptomatic intracranial hemorrhage were similar between the 2 groups. The use of intra-arterial urokinase (OR = 3.682; 95% CI, 1.156-11.730; P = .027) was an independent predictor of successful reperfusion. The use of local intra-arterial urokinase as an adjunct to mechanical thrombectomy may be an effective and safe method that provides better recanalization than the conventional mechanical thrombectomy for refractory thrombus in patients with embolic large-vessel occlusion.

Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients

Background and PurposeTo determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation.MethodsRetrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT.ResultsPatients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups.ConclusionFailure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.

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.

Outcome after thrombolysis for occluded endoprosthesis, bypasses and native arteries in patients with lower limb ischemia

IntroductionTo report contemporary outcomes, and evaluate differences after thrombolysis for occluded endoprosthesis, bypasses and native artery occlusion in patients with lower limb ischemia. MethodsPatients undergoing local intra-arterial thrombolysis for lower limb ischemia between 2001 and 2010 were identified in the prospective database for endovascular intervention, and analysis was performed retrospectively. ResultsThere was an increase in thrombolysis for occluded endoprosthesis and a decrease in thrombolysis for occluded bypasses during the study period (p=0.001). The technical success rate for thrombolysis in occluded endoprosthesis, bypasses and native artery occlusion was 91%, 89% and 73%, respectively. The overall major amputation rate, mortality rate and amputation-free survival rate at 1year was 19%, 14% and 73%, respectively, without differences between groups. The major amputation rate at long-term was highest, 45%, for patients with occluded synthetic bypass grafts. Female gender (HR 1.7; 95% CI 1.1–2.7), ischemic heart disease (HR 1.8; 95% CI 1.1–2.8), anemia at admission (HR 1.9; 95% CI 1.2–3.0), foot ulcer (HR 4.4; 95% CI 2.4–8.0), motor deficit at admission (HR 2.5; 95% CI 1.4–4.3), occluded synthetic bypass graft (HR 3.3; 95% CI 1.9–5.7) and failure of thrombolysis (HR 4.8; 95% CI 2.9–7.7) were independently associated with an increased long-term risk of major amputation. ConclusionsThrombolysis for occluded endoprosthesis, bypasses and native artery occlusion was effective. Female gender, ischemic heart disease, anemia, foot ulcer, motor deficit, occluded synthetic bypass graft and failure of thrombolysis were independently associated with an increased risk of major amputation.

E-025 The use of intra-arterial rt-PA improves functional outcomes over mechanical thrombectomy alone in patients undergoing acute stroke therapy

BackgroundThe paradigm of endovascular stroke therapy, especially with the newer devices aimed at rapid revascularization, is shifting from local intra-arterial thrombolysis (IAT) to mechanical thrombectomy (MT). There is lack of...

Intra-Arterial Thrombolysis as an Ideal Treatment for Inflammatory Bowel Disease Related Thromboembolic Stroke: A Case Report and Review

ABSTRACTThromboembolism, both venous and arterial, is a well-known complication of inflammatory bowel disease, with the risk of stroke highest when patients are less than 50 years of age. Because inflammatory bowel disease patients often have gastrointestinal bleeding, it is a challenge to treat their thromboembolic events with systemic therapy. In this case, a 42-year-old woman with Crohn's disease developed a thromboembolism in her middle cerebral artery and was successfully treated with local intra-arterial thrombolysis. There is a growing trend to treat thromboembolic events in inflammatory bowel disease patients with local thrombolysis as it leads to better outcomes with regards to both the resolution of the thromboembolism and decreased secondary gastrointestinal bleeding.

Mechanical Thrombolysis and Stenting in Acute Ischemic Stroke

Acute ischemic stroke is one of the major sources of morbidity and mortality in the industrialized countries. The lifetime risk of stroke is estimated to be 1 in 5 for middle-aged women and 1 in 6 for men according to the Framingham Study.1 Outcome depends on the length of time between onset of symptoms and revascularization, the recanalization rate, and on whether or not intracranial hemorrhage occurs.2 A meta-analysis of 52 studies on thrombolysis outcome in 2066 patients showed that the chance of an independent life after stroke increases 4.4 times for patients with successful recanalization compared with patients without recanalization; mortality rate decreases 4-fold.2 Intravenously administered tissue plasminogen activator (IV tPA) and local intra-arterial thrombolysis (IAT) have both been shown to improve patient outcome. However, the time window for treatment and the recanalization rate of both approaches are limited,3–5 and the application of thrombolytic drugs increases the risk of symptomatic intracranial hemorrhage (sICH).6 The success of recanalization, furthermore, depends on the occlusion site; proximal occlusions of large vessels such as the internal carotid artery have a poor recanalization rate after either IV tPA or IAT.4,5 Recent studies have examined whether mechanical recanalization techniques can accelerate the process of recanalization, increase the recanalization rate, and even expand the window of opportunity. This article describes the evolution of the different mechanical thrombolysis and stenting techniques and their working principles for endovascular vessel recanalization and reviews the data on the outcome after acute stroke treatment. The various techniques and approaches for mechanical thrombolysis (MT) can be divided into 3 categories: thrombus disruption, immediate flow restoration with self-expandable stents, and thrombectomy. According to Pro-Urokinase for Acute Cerebral Thromboembolism-2 (PROACT II), IAT consists of local application of the fibrinolytic drug at the proximal surface …

Addition of aliskiren to angiotensin II receptor blockers ameliorates renal tubular injury and reduces intima media thickness of carotid artery in patients with diabetic nephropathy

ofmetachronous presentation the onset of either event urges immediate diagnosis and therapy without any delay. In both presented cases the primary manifestation was myocardial infarction and thus urgent coronary angiography was required as a first diagnostic step. The optimal therapeutic approach for subsequent basilar artery occlusion is less clear. Traditionally, patients have been treated with local intraarterial thrombolysis [2]. Nonetheless, its superiority to the technically simple intravenous thrombolysis has not been proven so far and both strategies seem to be equally effective [3]. We highlight that intravenous thrombolysis bears a significant risk of bleeding complications, notably in the setting of concomitant anticoagulation (Acetaylsalicylic acid, Clopidogrel, Heparin, Glycoprotein IIb/IIIA antagonists). In contrast, the endovasal procedure as performed in our patient allows detailed localization of the occluded vessel, assessment of collateral perfusion and efficient local thrombolysis with reduced risk of devastating bleeding complications.

Mechanical Thrombectomy Compared to Local-Intraarterial Thrombolysis in Carotid T and Middle Cerebral Artery Occlusions

The aim of the study was to examine the effects of mechanical thrombectomy using the Solitaire stent in patients with thromboembolic occlusions of the intracranial carotid artery bifurcation (carotid T) or middle cerebral artery (MCA) and to compare the results with a historical cohort treated with local intraarterial thrombolysis using urokinase. The time intervals from stroke onset to treatment, recanalization rates, occlusion sites, recanalization times and functional outcomes on the modified Rankin scale at 3 months in 25 patients treated with the Solitaire stent between 2010 and 2011 were evaluated. The data were compared with those of a historical cohort of 62 patients treated with local intraarterial thrombolysis between 1992 and 2001. A total of 15 out of 25 (60%) patients treated with mechanical thrombectomy and 25 out of 62 (40%) treated with local intraarterial thrombolysis achieved a modified Rankin score of ≤2 (p = 0.07). Occlusion sites, intervals from stroke onset to treatment and rates of parenchymal hematomas, 3 out of 25 (12%) versus 8 out of 62 (13%), were similar in both cohorts while the recanalization rate was significantly higher, 22 out of 25 (88%) versus 33 of 62 (53%), in the mechanical thrombectomy group (p ≤ 0.01). The data show that mechanical thrombectomy is superior to local intraarterial thrombolysis with respect to the recanalization rate in patients with thrombeoembolic carotid T or MCA occlusions.

Treatment of acute ischemic stroke: feasibility of primary or secondary use of a self-expanding stent (Neuroform) during local intra-arterial thrombolysis

We evaluated the feasibility of employing a self-expanding stent (Neuroform) in treatment of acute cerebral ischemia and compared the results of primary and secondary stenting. We analyzed the treatment results of 14 acute ischemic stroke patients (11 men and three women; median age, 65years) who were treated with Neuroform stents. Seven patients received stent placement for primary recanalization and a further seven for secondary recanalization. We performed between-group comparisons of all of overall procedure duration, recanalization rate immediately after stenting, need for additional measures after stenting, final recanalization rate, occurrence of hemorrhagic transformation, early re-occlusion rate after 24h, and 3-month functional recovery rate (mRS ≤2). The median interval from femoral puncture to stent placement was 61.5min and was significantly shorter in the primary than in the secondary group (55 vs. 95min, p = 0.004). The recanalization rate immediately after stenting was 42.9% and was greater in the primary than in the secondary group (71.4% vs. 14.3%, p = 0.1). Thirteen patients required various additional therapeutic measures. The final recanalization rate was 78.6%, attributable to improvements in the recanalization rate of the secondary group (71.4% vs. 85.7%). Early hemorrhagic transformation was noted in four patients, but only one patient became symptomatic (symptomatic hemorrhage, 7.1%). Good functional recovery was noted in eight patients (57.1%). Placement of a self-expanding stent during endovascular recanalization of acute ischemic stroke was both feasible and safe. Primary use of this method may enhance early recanalization.

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

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.

Risk factors for haemorrhage during local intra-arterial thrombolysis for lower limb ischaemia

Assessment of clinical risk factors for haemorrhagic complications in patients undergoing intra-arterial thrombolysis for lower limb ischaemia. Retrospective reviews of consecutive patients subjected to intra-arterial thrombolysis due to lower limb ischemia at the Vascular Center, Malmö University Hospital, during a 5-year period from 2001 to 2005. Two hundred and twenty intra-arterial thrombolytic procedures were carried out in 195 patients (46% women), median age 73 years. Haemorrhagic complications were recorded in 72 procedures (33%), of which 13 were discontinued. Haemorrhage at the introducer and distant sites occurred in 53 and 32 procedures, respectively. Thrombolysis for occluded synthetic grafts was associated with higher risk of haemorrhage (P = 0.043). The platelet count was lower (P = 0.017) and the dose of alteplas higher (P = 0.041) in bleeders than in non-bleeders. Age was not associated with haemorrhage (P = 0.30). Two patients died during thrombolysis, one of them due to intracerebral haemorrhage. The grade of thrombolysis was an independent predictor of both in-hospital amputation (P < 0.001; OR 3.5 [95% CI 2.1-5.8]) and mortality (P = 0.021; OR 3.0 [95% CI 1.2-7.9]). The in-hospital amputation-free survival rate was 85% (188/220). Haemorrhage associated with thrombolysis is common, but does seldom require discontinuation of treatment. Insertion of introducers for local thrombolysis through synthetic grafts, lower platelet count and higher alteplas dose were found to be risk factors for haemorrhage. An algorithm for clinical management of haemorrhage has been proposed.

Combined interventional stroke therapy using intracranial stent and local intraarterial thrombolysis (LIT)

Supported by results of the ECASS III study, intravenous rt-PA thrombolysis is considered a standard therapy for acute stroke within 4.5h. Still under debate is the use of a more aggressive treatment as that of local intraarterial thrombolysis (LIT) or combining intravenous administration of recombinant tissue plasminogen activator (rt-PA) followed by LIT (bridging concept). Mechanical thrombus removal devices and effective flow achievement by stenting are reported to increase the recanalization rate and patient outcome. Newer reports showed the use of intracranial stents as the latest trend-setting technique. A combined approach hereby appears to achieve the best results consisting of pharmacologic thrombolysis, manual aspiration devices and stenting. We employed a novel removable stent as a new approach in acute stroke, aiming to make the intraarterial thrombolysis through an enhanced thrombus contact surface more effective and to reduce the effective revascularisation time with the possibility of stent removal after re-opening the occluded vessel. We describe four cases with acute stroke in the anterior and posterior circulation using a newer self-expandable removable stent (Solitaire™ AB) combined with LIT performed in the 'bridging technique', occasionally supported by additional thrombus aspiration. In all cases, we directly achieved after stenting an effective revascularization with fast recanalization time when using stent implantation first. Stenting was always technically successful without complications. The easy handling of a removable stent in stent-assisted revascularization combined with thrombolysis (i.v./i.a.) is a newly described technique for acute stroke treatment, which join immediate mechanical recanalization, postulated improved thrombolysis and the possibility of stent removing.

Treatment of Acute Cerebral Artery Occlusion With a Fully Recoverable Intracranial Stent

A 42-year-old woman was referred to our institution with sudden onset of ataxia, facial paresis, horizontal gaze palsy, and progressive dysarthria. The patient worsened within a few minutes, with appearance of left hemiparesis. The National Institutes of Health Stroke Scale Score was 13. On computer tomography scan 2 hours after stroke onset, no brain stem lesion or intracranial bleeding was visible. Computed tomographic angiography revealed a mid basilar vessel occlusion, which suggested embolic basilar artery occlusion. A 4-vessel angiogram with a 5F diagnostic catheter confirmed the basilar artery occlusion and depicted more precisely the location of the thrombus (Figure 1A). Figure 1. A, Digital subtraction angiography after vertebral injection demonstrates a mid basilar vessel occlusion. B, The angiogram after placement of the stent from the left P1 segment (white arrow) into the basilar artery showed flow restoration of the basilar artery with a narrowing in the middle part of the vessel due to compression of the thrombus into the arterial wall (black arrows). C, …

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.

Containing a Clot in the Mid-Basilar Artery Using a Self-Expandable Stent to Prevent Distal Clot Migration during Intra-Arterial Thrombolysis

During local intra-arterial thrombolysis (LIT), management of the secondary embolization of a fragmented or dislodged clot can be cumbersome. The fate could be dismal if without pursuit and lysis of the migrated clot. Recently, we successfully managed a patient with acute ischemia due to a large clot impinged in the mid basilar trunk while avoiding distal migration of the clot by containing the impinged clot using a self-expandable stent during LIT.

Intra-arterial thrombolysis for acute central retinal artery occlusion

Objective: In this study, we aimed at exploring the effect and safety of local intra-arterial thrombolysis on acute central retinal artery occlusion.Methods: Retrospective data analysis of 49 consecutive acute central retinal occlusion patients was performed. All the patients were treated with urokinase perfusion through the ophthalmology artery within the first 6 hours after central retinal artery occlusion attack. Conventional treatments including intra-ocular pressure decreasing, microcirculation improvement, neuroprotection and antiplatelet aggregation were conducted. The visual acuity (with International Snellen Chart) and field of vision were detected after thrombolysis. The complications and adverse events were observed.Results: Recanalization was found in 71% of patients. The visual acuity improvement was greater in the recanalization group (n=35) than in the non-recanalization group (n=14). The averaged visual acuity was 0.15±0.02, 0.25±0.03 and 0.4±0.05 after 2, 28 days and 6 months, respectively. Of the patients, 24.5% regained >0.6 of visual acuity, and the visual field deficit was less than 30% in 34.7% of patients after 28 days. Six months later, 36.7% patients regained visual acuity of >0.6, and the field deficit was less than 30% in 44.9% of patients. The difference between visual acuity in recanalization (0.6±0.04) and non-recanalization (0.002±0.0012) patients after 6 months after thrombolysis was significant (p>0.05).Conclusions: Intra-arterial thrombolysis could obviously improve the short- and long-term visual function for patients with acute central retinal artery occlusion within 6 hours of symptom onset.

Acute Stroke Therapy 1981–2009*

This article includes a review of major intravenous and endovascular stroke trials, treatment options, and future aspects of acute stroke treatment in hemispheric and vertebrobasilar stroke. Since the invention of local intraarterial thrombolysis by Hermann Zeumer in 1981, acute stroke diagnostics and treatment have undergone dramatic improvement. This article addresses major topics in recent stroke treatment debates: optimization of patient selection, intravenous versus endovascular therapy, time window limitations, combined treatment with intravenous/intraarterial bridging therapies (intravenous/intraarterial recombinant tissue plasminogen activator [rtPA] bridging and intravenous glycoprotein IIb/IIIa inhibitor/intraarterial rtPA bridging) and modern endovascular treatment modes like percutaneous transluminal angioplasty (PTA)/stenting and mechanical thrombectomy devices. Modern acute stroke therapy networks should optimize their noninvasive diagnostic capacity to early identify candidates for endovascular therapy with rapid access to specialized neuroendovascular centers using standard protocols. The most promising approach in acute stroke treatment seems to be a combination of intravenous and endovascular revascularization procedure, combining early treatment initiation with direct clot manipulation and PTA/stenting in underlying stenosis with atherothrombotic occlusions. Further randomized studies comparing intravenous and endovascular treatment, mainly in the anterior circulation, have to be expected and need wide support of the neurologic and neuroradiologic stroke community.

Local intra‐arterial thrombolysis in a 4‐year‐old male with vertebrobasilar artery thrombosis

We report the case of a 4-year-old male with vertebrobasilar artery thrombosis for which he was treated with local intra-arterial urokinase 60 hours after onset of symptoms. Initially the patient had dysarthria and dysphagia. Brain magnetic resonance imaging (MRI) in a community hospital showed abnormalities in the pons, and vertebrobasilar artery thrombosis was suspected. The patient was transferred to the university hospital because of neurological deterioration. Just before thrombolysis, his physical examination revealed a downward ocular deviation, stretching of the arms, and spontaneous movements of the legs. Brain MRI showed recent ischaemia in the pons and caudal part of the mesencephalon, and magnetic resonance angiography showed occlusion of the basilar artery. Intra-arterial thrombolysis with urokinase (total dose 36 000U/kg) was performed 60 hours after onset of symptoms. After thrombolysis he was treated with heparin for 10 days, followed by aspirin. The patient recovered well. After 1 year he had only minor ataxia and performed all activities at school. Local vasculitis due to an infection with Borrelia burgdorferi was thought to be the cause of the local thrombosis. A review of the literature revealed 11 other case reports of successful local intra-arterial thrombolysis in children and adolescents with ischaemic stroke. This suggests that intra-arterial thrombolysis is feasible and safe in selected paediatric patients with ischaemic stroke.