Journal of Neurology

, Volume 253, Issue 12, pp 1552–1556 | Cite as

Reasons to withhold intra-arterial thrombolysis in clinical practice

  • J. Isenegger
  • K. Nedeltchev
  • M. Arnold
  • U. Fischer
  • G. Schroth
  • L. Remonda
  • H.P. MattleEmail author



In selected stroke centers intra-arterial thrombolysis (IAT) is used for the treatment of acute stroke patients presenting within 6 hours of symptom onset. However, data about eligibility of acute stroke patients for IAT in clinical practice are very scarce.


We collected prospectively data on indications advising for or against IAT of 230 consecutive stroke patients in a tertiary stroke center.


76 patients (33.0%) presented within 3 hours, 69 (30%) between 3 and 6 hours of symptom onset and 85 (37%) later than 6 hours. Arteriography was performed in 71 patients (31%) and IAT in 46 (20%). In 11 patients no or only peripheral branch occlusions were seen on arteriography and therefore IAT was not performed. In 9 patients the ICA was occluded and barred IAT and in five anatomical or technical difficulties made IAT impossible. 72 patients presenting within 6 hours did not undergo arteriography and thrombolysis, mostly because of mild (n = 44) or rapidly improving neurological deficits (n = 13). Other reasons to withhold IAT were CT and/or clinical findings suggesting lacunar stroke due to small vessel occlusion (n = 7), limiting comorbidty (n = 7) and baseline international normalized ratio > 1.7 (n = 1).


A third of the patients underwent diagnostic arteriography and one fifth received IAT. The most important reasons to withhold thrombolysis were presentation beyond the 6 hours time window and mild or rapidly improving symptoms.


stroke acute stroke management thrombolytic therapy 


Acknowledgments and Funding

We thank Pietro Ballinari, PhD, for statistical advice. This study was supported in part by a grant of “Stiftung zur Förderung der wissenschaftlichen Forschung an der Universität Bern”


  1. 1.
    Arnold M, Nedeltchev K, Mattle HP, Loher TJ, Stepper F, Schroth G, Brekenfeld C, Sturzenegger M, Remonda L (2003) Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions. J Neurol Neurosurg Psychiatry 74:739–742PubMedCrossRefGoogle Scholar
  2. 2.
    Arnold M, Nedeltchev K, Brekenfeld C, Fischer U, Remonda L, Schroth G, Mattle H (2004) Outcome of acute stroke patients without visible occlusion on early arteriography. Stroke 35:1135–1140PubMedCrossRefGoogle Scholar
  3. 3.
    Arnold M, Nedeltchev K, Schroth G, Baumgartner RW, Remonda L, Loher TJ, Stepper F, Sturzenegger M, Schuknecht B, Mattle HP (2004) Clinical and radiological predictors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis. J Neurol Neurosurg Psychiatry 75:857–862PubMedCrossRefGoogle Scholar
  4. 4.
    Arnold M, Schroth G, Nedeltchev K, Loher T, Remonda L, Stepper F, Sturzenegger M, Mattle HP (2002) Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke 33:1828–1833PubMedCrossRefGoogle Scholar
  5. 5.
    Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM (2001) Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology 56:1015–1020PubMedGoogle Scholar
  6. 6.
    Brott T, Adams HP Jr., Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20:864–870PubMedGoogle Scholar
  7. 7.
    Buchan AM, Barber PA, Newcommon N, Karbalai HG, Demchuk AM, Hoyte KM, Klein GM, Feasby TE (2000) Effectiveness of t-PA in acute ischemic stroke: outcome relates to appropriateness. Neurology 54:679–684PubMedGoogle Scholar
  8. 8.
    Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F (1999) Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 282:2003–2011PubMedCrossRefGoogle Scholar
  9. 9.
    Grond M, Stenzel C, Schmulling S, Rudolf J, Neveling M, Lechleuthner A, Schneweis S, Heiss WD (1998) Early intravenous thrombolysis for acute ischemic stroke in a community-based approach. Stroke 29:1544–1549PubMedGoogle Scholar
  10. 10.
    Grotta JC, Burgin WS, El-Mitwalli A, Long M, Campbell M, Morgenstern LB, Malkoff M, Alexandrov AV (2001) Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000. Arch Neurol 58:2009–2013PubMedCrossRefGoogle Scholar
  11. 11.
    Hacke W, Albers G, Al-Rawi Y, Bogousslavsky J, Davalos A, Eliasziw M, Fischer M, Furlan A, Kaste M, Lees KR, Soehngen M, Warach S; DIAS Study Group (2005) The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke 36:66–73PubMedCrossRefGoogle Scholar
  12. 12.
    Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, Brott T, Frankel M, Grotta JC, Haley EC Jr, Kwiatkowski T, Levine SR, Lewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC, Albers G, Bluhmki E, Wilhelm M, Hamilton S, ATLANTIS Trials Investigators; ECASS Trials Investigators, NINDS rt-PA Study Group Investigators (2004) Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 363:768–774PubMedCrossRefGoogle Scholar
  13. 13.
    Heuschmann PU, Berger K, Misselwitz B, Hermanek P, Leffmann C, Adelmann M, Buecker-Nott HJ, Rother J, Neundoerfer B, Kolominsky-Rabas PL (2003) Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality: the German Stroke Registers Study Group. Stroke 34:1106–1113PubMedCrossRefGoogle Scholar
  14. 14.
    Katzan IL, Graber TM, Furlan AJ, Sundararajan S, Sila CA, Houser G, Landis DM. Cuyahoga (2003) County Operation Stroke Speed of Emergency Department Evaluation and Compliance With National Institutes of Neurological Disorders and Stroke Time Targets. Stroke 36:6Google Scholar
  15. 15.
    Lindsberg PJ, Soinne L, Roine RO, Salonen O, Tatlisumak T, Kallela M, Happola O, Tiainen M, Haapaniemi E, Kuisma M, Kaste M (2003) Community-based thrombolytic therapy of acute ischemic stroke in Helsinki. Stroke 34:1443–1449PubMedCrossRefGoogle Scholar
  16. 16.
    Nedeltchev K, Arnold M, Brekenfeld C, Isenegger J, Remonda L, Schroth G, Mattle HP (2003) Pre- and in-hospital delays from stroke onset to intra-arterial thrombolysis. Stroke 34:1230–1234PubMedCrossRefGoogle Scholar
  17. 17.
    Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba CH, Do D, Arnold M, Mattle HP, Schroth G. Stenting Of The Internal Carotid Artery in Acute Stroke: Preliminary Results Of 25 Patients. Radiology, in pressGoogle Scholar
  18. 18.
    Macleod MR, Davis SM, Mitchell PJ, Gerraty RP, Fitt G, Hankey GJ, Stewart-Wynne EG, Rosen D, McNeil JJ, Bladin CF, Chambers BR, Herkes GK, Young D, Donnan GA (2005) Results of a Multicentre, Randomised Controlled Trial of Intra-Arterial Urokinase in the Treatment of Acute Posterior Circulation Ischaemic Stroke.Cerebrovasc Dis. 20(1):12–17PubMedCrossRefGoogle Scholar
  19. 19.
    Mattle HP, Kappeler L, Arnold M, Fischer U, Nedeltchev K, Remonda L, Jakob SM, Schroth G (2005) Blood pressure and vessel recanalization in the first hours after ischemic stroke. Stroke 36:264–268PubMedCrossRefGoogle Scholar
  20. 20.
    Reed SD, Cramer SC, Blough DK, Meyer K, Jarvik JG (2001) Treatment with tissue plasminogen activator and inpatient mortality rates for patients with ischemic stroke treated in community hospitals. Stroke 32:1832–1840PubMedGoogle Scholar
  21. 21.
    Schmulling S, Grond M, Rudolf J, Heiss WD (2000) One-year follow-Up in acute stroke patients treated with rtPA in clinical routine. Stroke 31:1552–1554PubMedGoogle Scholar
  22. 22.
    The National Institute of Neurological Disorders, Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587CrossRefGoogle Scholar
  23. 23.
    van Swieten JC, Koudstaal PJ, Visser MC, Schouten JH, von Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:604–607PubMedGoogle Scholar
  24. 24.
    Wang DZ, Rose JA, Honings DS, Garwacki DJ, Milbrandt JC (2000) Treating acute stroke patients with intravenous tPA. The OSF stroke network experience. Stroke 31:77–81Google Scholar
  25. 25.
    Weber J, Remonda L, Mattle HP, Koerner U, Baumgartner RW, Sturzenegger M, Ozdoba C, Koerner F, Schroth G (1998) Selective intra-arterial fibrinolysis of acute central retinal artery occlusion. Stroke 29:2076–2079PubMedGoogle Scholar

Copyright information

© Steinkopff Verlag Darmstadt 2006

Authors and Affiliations

  • J. Isenegger
    • 1
  • K. Nedeltchev
    • 2
  • M. Arnold
    • 2
  • U. Fischer
    • 1
  • G. Schroth
    • 3
  • L. Remonda
    • 3
  • H.P. Mattle
    • 2
    Email author
  1. 1.Dept. of Internal MedicineUniversity of BernBernBernSwitzerland
  2. 2.Dept. of NeurologyUniversity of BernInselspitalSwitzerland
  3. 3.Dept. of NeuroradiologyUniversity of BernInselspitalSwitzerland

Personalised recommendations