Neurocritical Care

, Volume 11, Issue 2, pp 217–222 | Cite as

Intra-Arterial Thrombolysis Within Three Hours of Stroke Onset in Middle Cerebral Artery Strokes

  • Eric C. Bourekas
  • Andrew Slivka
  • Rajul Shah
  • Yousef Mohammad
  • H. Wayne Slone
  • Dimitris T. Kehagias
  • Jose Suarez
  • Jeffrey Sunshine
  • Osama O. Zaidat
  • Robert Tarr
  • Dennis M. Landis
  • M. Fareed K. Suri
  • Adnan I. Qureshi
Original Article

Abstract

Background and Purpose

The Prolyse in Acute Cerebral Thromboembolism II (PROACT II) trial showed improved outcomes in patients with proximal middle cerebral artery (MCA) occlusions treated with intra-arterial (IA) thrombolysis within 6 h of stroke onset. We analyzed outcomes of patients with proximal MCA occlusions treated within 3 h of stroke onset in order to determine the influence of time-to-treatment on clinical and angiographic outcomes in patients receiving IA thrombolysis.

Methods

Thirty-five patients from three academic institutions with angiographically demonstrated proximal MCA occlusions were treated with IA thrombolytics within 3 h of stroke onset. Outcome measures included outcomes at 30–90 day follow-up, recanalization rates, incidence of symptomatic intracranial hemorrhage, and mortality in the first 90 days. The endpoints were compared to the IA treated and control groups of the PROACT II trial.

Results

The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (range 4–24). The mean time to initiation of treatment was 106 min (range 10–180 min). Sixty-six percent of patients treated, had a modified Rankin Scale (mRS) score of 2 or less at 1–3 month follow-up compared to 40% in the PROACT II trial. The recanalization rate was 77% (versus 66% in PROACT II). The symptomatic intracranial hemorrhage rate was 11% (versus 10% in PROACT II) and the mortality rate was 23% (versus 25% in PROACT II).

Conclusion

Time-to-treatment is just as important in IA thrombolysis as it is in IV thrombolysis, both for improving clinical outcomes and recanalization rates as well.

Keywords

Stroke Intra-arterial Thrombolysis Treatment Middle cerebral artery TPA 

References

  1. 1.
    Sussman BJ, Fitch TSP. Thrombolysis with fibrinolysis in cerebral arterial occlusion. JAMA. 1958;167:1705–9.Google Scholar
  2. 2.
    del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M, et al. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. Stroke. 1998;29(1):4–11.PubMedGoogle Scholar
  3. 3.
    Furlan A, Higashida RT, Wechsler L, et al. for the PROACT Investigators: Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. JAMA. 1999;282(21):2003–11. doi:10.1001/jama.282.21.2003.
  4. 4.
    The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–8. doi:10.1056/NEJM199512143332401.CrossRefGoogle Scholar
  5. 5.
    Marler J, Tilley BC, Lu M, et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology. 2000;55(11):1649–55.PubMedGoogle Scholar
  6. 6.
    Bourekas EC, Slivka AP, Shah R, Tarr RW, Sunshine J, Suarez J. Intra-arterial thrombolytic therapy within 3 hours of the onset of stroke. Neurosurgery. 2004;4(1):39–46. doi:10.1227/01.NEU.0000097197.61376.05.CrossRefGoogle Scholar
  7. 7.
    Lisboa RC, Jovanovic BD, Alberts MJ. Analysis of the safety and efficacy of intra-arterial thrombolytic therapy in ischemic stroke. Stroke. 2002;33:2866–71. doi:10.1161/01.STR.0000038987.62325.14.PubMedCrossRefGoogle Scholar
  8. 8.
    del Zoppo G, Ferbert A, Otis S, et al. Local intra-arterial fibrinolytic therapy in acute carotid territory stroke. A pilot study. Stroke. 1988;19(3):307–13.PubMedGoogle Scholar
  9. 9.
    Hacke W, Zeumer H, Ferbert A, Bruckman H, del Zoppo G. Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988;19(10):1216–22.PubMedGoogle Scholar
  10. 10.
    Mori E, Tabuchi M, Yoshida T, Yamadori A. Intracarotid urokinase with thromboembolic occlusion of the middle cerebral artery. Stroke. 1988;9(7):802–12.Google Scholar
  11. 11.
    Sasaki O, Takeuchi S, Koike T, Koizumi T, Tanaka R. Fibrinolytic therapy for acute embolic stroke: intravenous, intracarotid, and intra-arterial local approaches. Neurosurgery. 1995;36(2):246–52. doi:10.1097/00006123-199502000-00002.PubMedCrossRefGoogle Scholar
  12. 12.
    Theron J, Courtheoux P, Casasco A, et al. Local intraarterial fibrinolysis in the carotid territory. AJNR Am J Neuroradiol. 1989;10(4):753–65.PubMedGoogle Scholar
  13. 13.
    Suarez JI, Sunshine JL, Tarr R, et al. Predictors of clinical improvement, angiographic recanalization, and intracranial hemorrhage after intra-arterial thrombolysis for acute ischemic stroke. Stroke. 1999;30(10):2094–100.PubMedGoogle Scholar
  14. 14.
    Gonner F, Remonda L, Mattle H, et al. Local intra-arterial thrombolysis in acute stroke. Stroke. 1998;29:1894–900.PubMedGoogle Scholar
  15. 15.
    Qureshi AI, Suri M, Nasar A, et al. Thrombolysis for ischemic stroke in the united states: data from national hospital discharge survey 1999–2001. Neurosurgery. 2005;57(4):647–54. doi:10.1227/01.NEU.0000175546.62088.D6.PubMedCrossRefGoogle Scholar
  16. 16.
    Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. for the ATLANTIS Study Investigators. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS study: a randomized controlled trial. JAMA. 1999;82(21):2019–26. doi:10.1001/jama.282.21.2019.Google Scholar
  17. 17.
    Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with reconmbinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995;274:1017–25. doi:10.1001/jama.274.13.1017.PubMedCrossRefGoogle Scholar
  18. 18.
    Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998;352:1245–51. doi:10.1016/S0140-6736(98)08020-9.PubMedCrossRefGoogle Scholar
  19. 19.
    Wardlaw J, del Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke (Cochrane review). Cochrane Database of Syst Rev. 2003;(3). doi:10.1002/14651858.CD000213.
  20. 20.
    Kanter D, Kothari R, Panioloi A, et al. The greater Cincinnati tPA experience after the NINDS trial: does a longer time to treatment within the current 3-hour window reduce efficacy? (Abstract). Presented at 24th Annual American Heart Association International Conference on Stroke and Cerebral Circulation, February 5, 1999; Nashville, TN.Google Scholar
  21. 21.
    Endo S, Kuwayama N, Hirashima Y, Takuya A, Nishijima M, Takaku A. Results of urgent thrombolysis in patients with major stroke and atherothrombotic occlusion of the cervical internal carotid artery. AJNR Am J Neuroradiol. 1998;19:1169–75.PubMedGoogle Scholar
  22. 22.
    Arnold M, Schroth G, Nedeltchev K, et al. Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke. 2002;33:1828–33. doi:10.1161/01.STR.0000020713.89227.B7.PubMedCrossRefGoogle Scholar
  23. 23.
    Jahan R, Duckwiler GR, Kidwell CS, et al. Intraarterial thrombolysis for treatment of acute stroke: experience in 26 patients with long-term follow-up. AJNR Am J Neuroradiol. 1999;20:1291–9.PubMedGoogle Scholar
  24. 24.
    Tomsick T, Brott T, Barsan W, et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. AJNR Am J Neuroradiol. 1996;17:79–85.PubMedGoogle Scholar
  25. 25.
    del Zoppo GJ, Poeck K, Pessin MS, et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992;32:78–86. doi:10.1002/ana.410320113.PubMedCrossRefGoogle Scholar
  26. 26.
    Wolpert SM, Bruckmann H, Greenlee R, Wechsler L, Pessin, del Zoppo GJ, et al. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. AJNR Am J Neuroradiol. 1993;14:3–13.PubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • Eric C. Bourekas
    • 1
  • Andrew Slivka
    • 1
  • Rajul Shah
    • 1
    • 4
  • Yousef Mohammad
    • 1
  • H. Wayne Slone
    • 1
  • Dimitris T. Kehagias
    • 1
    • 5
  • Jose Suarez
    • 2
    • 6
  • Jeffrey Sunshine
    • 2
  • Osama O. Zaidat
    • 2
    • 7
  • Robert Tarr
    • 2
  • Dennis M. Landis
    • 2
    • 6
  • M. Fareed K. Suri
    • 3
    • 8
  • Adnan I. Qureshi
    • 3
    • 8
  1. 1.Departments of Radiology and Neurology, College of MedicineThe Ohio State University Medical CenterColumbusUSA
  2. 2.Cerebrovascular Center and Neurosciences Critical Care, Departments of Neurology and RadiologyThe University Hospitals of Cleveland and Case Western Reserve UniversityClevelandUSA
  3. 3.Department of Neurosurgery, School of Medicine and Biomedical SciencesState University of New YorkBuffaloUSA
  4. 4.Department of RadiologySt. Mary’s HospitalTuscanUSA
  5. 5.Department of RadiologyHygeia HospitalAthensGreece
  6. 6.Department of NeurologyBaylor College of MedicineHoustonUSA
  7. 7.Departments of Neurology and NeurosurgeryMedical College of WisconsinMilwaukeeUSA
  8. 8.Departments of Neurology, Neurosurgery and RadiologyUniversity of MinnesotaMinneapolisUSA

Personalised recommendations