This Article Full Text Full Text (PDF) All Versions of this Article: 38/1/80    most recent 01.STR.0000251720.25337.b0v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shaltoni, H. M. Articles by Noser, E. A. Search for Related Content PubMed PubMed Citation Articles by Shaltoni, H. M. Articles by Noser, E. A. Pubmed/NCBI databases Substance via MeSH Medline Plus Health Information Stroke Related Collections Acute Cerebral Infarction Emergency treatment of Stroke Thrombolysis

(Stroke. 2007;38:80.)
© 2007 American Heart Association, Inc.

Original Contributions

Is Intra-Arterial Thrombolysis Safe After Full-Dose Intravenous Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke?

Hashem M. Shaltoni, MD; Karen C. Albright, DO, MPH; Nicole R. Gonzales, MD; Raymond U. Weir, MD; Aslam M. Khaja, MD; Rebecca M. Sugg, MD; Morgan S. Campbell, III, MD; Edwin D. Cacayorin, MD; James C. Grotta, MD Elizabeth A. Noser, MD

From the Departments of Neurology (H.M.S., K.C.A., N.R.G., A.M.K., R.M.S., J.C.G., E.A.N.) and Radiology (R.U.W., E.D.C.), University of Texas–Houston Medical School, Houston, Tex, and the Department of Neurology (M.S.C., III), Alabama Neurological Institute, Birmingham, Ala.

Correspondence to James C. Grotta, MD, Vascular Neurology Program, Department of Neurology, University of Texas Health Science Center–Houston, 6431 Fannin St, MSB 7.128, Houston, TX 77030. E-mail James.C.Grotta{at}uth.tmc.edu

Background and Purpose— The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA.

Methods— A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition.

Results— Sixty-nine patients (mean±SD age, 60±13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124±32 minutes (median, 120 minutes) and IAT, at 288±57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%).

Conclusions— IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.

Key Words: acute stroke • endovascular treatment • intracranial hemorrhage • t-PA • thrombolysis

This article has been cited by other articles:

				R.G. Nogueira, A.J. Yoo, F.S. Buonanno, and J.A. Hirsch Endovascular Approaches to Acute Stroke, Part 2: A Comprehensive Review of Studies and Trials AJNR Am. J. Neuroradiol., May 1, 2009; 30(5): 859 - 875. [Abstract] [Full Text] [PDF]

				H. Hallevi, A. D. Barreto, D. S. Liebeskind, M. M. Morales, S. B. Martin-Schild, A. T. Abraham, J. Gadia, J. L. Saver, the UCLA Intra-Arterial Therapy Investigators, J. C. Grotta, et al. Identifying Patients at High Risk for Poor Outcome After Intra-Arterial Therapy for Acute Ischemic Stroke Stroke, May 1, 2009; 40(5): 1780 - 1785. [Abstract] [Full Text] [PDF]

				T.C. Burns, G.J. Rodriguez, S. Patel, H.M. Hussein, A.L. Georgiadis, K. Lakshminarayan, and A.I. Qureshi Endovascular Interventions following Intravenous Thrombolysis May Improve Survival and Recovery in Patients with Acute Ischemic Stroke: A Case-Control Study AJNR Am. J. Neuroradiol., November 1, 2008; 29(10): 1918 - 1924. [Abstract] [Full Text] [PDF]

				J. De Keyser, Z. Gdovinova, M. Uyttenboogaart, P. C. Vroomen, and G. J. Luijckx Intravenous Alteplase for Stroke: Beyond the Guidelines and in Particular Clinical Situations Stroke, September 1, 2007; 38(9): 2612 - 2618. [Abstract] [Full Text] [PDF]

				H. P. Mattle Intravenous or Intra-Arterial Thrombolysis?: It's Time to Find the Right Approach for the Right Patient Stroke, July 1, 2007; 38(7): 2038 - 2040. [Full Text] [PDF]