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(Stroke. 1998;29:2568-2574.)
© 1998 American Heart Association, Inc.
Original Contributions |
Angioplasty after Intra-Arterial Thrombolysis for Acute Occlusion of Intracranial Arteries
From the Department of Neurological Surgery, Ehime University School of Medicine, Ehime, Japan.
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Abstract |
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Background and Purpose—The purpose of this study was to report our experience with percutaneous transluminal angioplasty (PTA) of intracranial arteries in acute stroke patients who were resistant to intra-arterial thrombolysis alone.
Methods—PTA was performed within 6 hours from symptom onset in 13 acute stroke patients in whom no hypodensity areas were observed on initial CT. PTA was classified into 3 categories: immediate (3 patients), delayed (3 patients), and rescue (7 patients) angioplasty. Treatment results in the PTA group for 9 cases of middle cerebral artery (MCA) occlusion were compared with those in the thrombolysis alone group for 12 cases of thrombotic MCA occlusion.
Results—Technical success rates for immediate, delayed, and rescue angioplasty were 100%, 100%, and 71%, respectively, and that of angioplasty for the MCA was 100%. Ten patients (77%) showed improvement in the National Institutes of Health (NIH) stroke score after treatment. Improvement in NIH stroke scores in the PTA group for MCA occlusion was greater than that in the thrombolysis alone group (P<0.01). Nine patients (69%) had an excellent, good, or fair outcome 3 months after treatment. In 9 patients who had follow-up angiography 1 month after treatment, no restenosis or reocclusion was demonstrated. There were no symptomatic complications during or after treatment.
Conclusions—This limited study demonstrates the technical feasibility of angioplasty for intracranial arteries in acute ischemic stroke and suggests that angioplasty may be an effective option for improving the success rate of recanalization and preventing reocclusion of the MCA. The present results encourage us to perform further clinical trials in a larger number of patients to assess the efficacy of this procedure.
Key Words: angioplasty • cerebral thrombosis • stroke, ischemic • thrombolytic therapy
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Introduction |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Although the efficacy of intra-arterial thrombolytic therapy for acute ischemic stroke has been reported in several clinical studies,1 2 3 4 5 there is no established protocol for dealing with this therapy, and there are some limitations to this technique.6 7 It is extremely difficult to recanalize an occluded vessel with a thrombolytic agent alone when the embolus is large and/or hard, particularly if there are atherosclerotic changes in the occluded vessel. Furthermore, in acute thrombotic stroke, reocclusion by rethrombosis after successful thrombolysis often occurs. Because recent advances in endovascular treatment techniques for stroke patients have made it possible to perform percutaneous transluminal angioplasty (PTA) of the intracranial artery, a few reports on the usefulness of angioplasty as an adjuvant to intra-arterial thrombolysis have been published.8 9
In a previous study, we reported on intra-arterial thrombolysis combined with PTA for acute thrombotic occlusion of the middle cerebral artery (MCA).9 Percutaneous transluminal coronary angioplasty in acute myocardial infarction has been classified into 4 categories10 : (1) immediate angioplasty, to be performed as soon as possible after thrombolysis; (2) delayed angioplasty, to be performed within several hours or a few days after thrombolysis; (3) rescue angioplasty, to be performed after failed thrombolysis; and (4) primary (direct) angioplasty, to be performed instead of thrombolysis. In this study, we report our experience with immediate, delayed, and rescue angioplasty of intracranial arteries for acute stroke patients who were resistant to intra-arterial thrombolysis alone. In addition, angiographic results, particularly reocclusion judged by follow-up studies, and clinical results in patients treated with PTA for MCA occlusion were compared with those in patients treated with thrombolysis alone for acute thrombotic MCA occlusion.
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Materials and Methods |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Between April 1989 and August 1996, 95 patients presenting with acute ischemic stroke were treated with intra-arterial thrombolytic therapy. Of this group, 13 patients were treated with PTA for acute occlusion of intracranial arteries. There were 7 women and 6 men ranging in age from 48 to 74 years (mean age, 66±8.2 years). The occluded arteries included 9 in the M1 segment of the MCA, 2 in the internal carotid artery, and 2 in the basilar artery. Informed consent was obtained from all patients or their relatives.
Our recent inclusion criteria for intra-arterial thrombolytic therapy were as follows: (1) no apparent hypodensity areas were observed on the admission CT scan, (2) patient could be treated within 6 hours of symptom onset, (3) occluded arteries suggested by symptoms were demonstrated by cerebral angiography, and (4) patient had a good residual cerebral blood flow (CBF) value by pretreatment single-photon emission CT (SPECT) showing an ischemic regional activity (R)–to–cerebellar activity (CE) ratio (R/CE) of more than 0.35.
Our inclusion criteria for acute angioplasty were as follows: (1) residual stenosis of more than 70% immediately after thrombolysis (immediate angioplasty), (2) no recanalization by thrombolysis (rescue angioplasty), (3) symptomatic restenosis or reocclusion within several hours or a few days after thrombolysis (delayed angioplasty), and (4) contraindications to thrombolysis.
For comparison with angiographic results including reocclusion and clinical results in 9 patients with MCA occlusion, 12 patients treated with thrombolysis alone for acute thrombotic MCA occlusion were selected. The diagnosis of thrombotic stroke was based on clinical, CT, and angiographic findings. Angiographic criteria for thrombotic occlusion were good collateral circulation with retrograde filling from the anterior or posterior cerebral artery or tapered occlusion with extensive atherosclerotic changes. Embolic stroke was diagnosed according to the guidelines of the Cerebral Embolism Task Force11 on the basis of onset pattern, angiographic findings, and results of cardiovascular examinations such as electrocardiography and echocardiography.
CT was performed on all patients immediately after admission. When no clear hypodensity area was noted at the sites suggested by the clinical symptoms, SPECT was performed using 99mTc-labeled hexamethylpropyleneamine oxime (99mTc-HMPAO) and a 4-head gamma camera (SPECT 2000H-40, Hitachi, Tokyo, Japan) with a low-energy high-resolution collimator. Details of our method of analyzing SPECT data have been described in our previous reports.4 12 In short, of 16 axial sections, the section most clearly showing the ischemic region was selected, and regions of interest were set within the ischemic region (a), the corresponding region on the contralateral side (b), the entire cerebellar hemisphere on the ischemic side (c), and the mean count was determined in each region. Linear adjustment was made by assuming the blood flow in the normal cerebellar hemisphere to be 55 mL/100 g per minute.13 14 CBF was assessed semiquantitatively by calculating as follows: the R/CE ratio=a/c, and the asymmetrical index (AI)=1+(b-a)/(a+b).
Digital subtraction angiography was performed using a 5 F catheter through a femoral artery. The tip of a FasTracker-18 (Target Therapeutics, Fremont, Calif) was advanced into the thrombus or upstream from the occlusion side over a 0.014-in Taper Dasher guidewire (Target Therapeutics). Urokinase (240 000 U) was dissolved in 20 mL of physiological saline and injected manually for about 10 minutes. The maximum dose of urokinase was 960 000 U used in thrombolysis for acute myocardial infarction. In the aged patient (>65 years of age), however, the maximum dose of urokinase was 720 000 U, in principle. In patients with immediate or delayed angioplasty, we finished intra-arterial thrombolysis when the antegrade flow of the occluded artery was found without intraluminal clots. In patients with rescue angioplasty, the maximum dose of urokinase was administered if it was still within 6 hours from symptom onset at that time. The FasTracker-18 catheter with the guidewire was moved frequently through the occluded segment to disrupt the thrombus mechanically. When residual stenosis of >70% remained and there was no evidence of dissection after intra-arterial infusion of urokinase, the angioplasty was performed with a Stealth balloon catheter (Target Therapeutics) 2.0 or 2.5 mm in diameter, which was introduced through a 6 F guide catheter. When intra-arterial thrombolysis failed to recanalize the occluded vessel, angioplasty also was performed if the guidewire could be navigated smoothly to the distal portion of the occluded site. The balloon was inflated once or twice to 3 to 4 atm for 10 to 20 seconds. In patient 8, however, intra-arterial thrombolysis before PTA was not performed because this patient was treated by intravenous thrombolysis before angiography to initiate treatment as early as possible.
Patients were given an intravenous injection of heparin (5000 U) before thrombolysis and 10% glycerol (200 mL) or 20% mannitol (300 mL) during treatment. If no intracranial hemorrhage or systemic bleeding tendency was observed after treatment, patients received a continuous infusion of heparin (10 000 U/24 h) for 24 hours after the procedure, and ticlopidine (200 mg/d) was administered from the day after treatment.
CT was obtained immediately, the next day, 1 or 2 weeks, and 1 month after treatment. Cerebral angiography was also performed the next day and 1 month after treatment. The neurological status was evaluated on admission, the next day, and 1 month after treatment according to the National Institutes of Health (NIH) Stroke Scale,15 which expresses the severity of neurological impairment numerically from 0 (normal) to 42. The outcome was evaluated 3 months after the onset according to the following 5-grade scale: excellent (no neurological defects were observed, and the patient had returned fully to previous daily activities); good (mild neurological defects remained, but the patient had returned partly to previous activities); fair (rehabilitation was difficult, but no assistance needed in activities of daily life); poor (assistance needed in activities of daily life); and death.
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Results |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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The clinical, angiographic, and outcome data are summarized in Table 1
. Immediate, delayed, and
rescue angioplasty were performed in 3, 3, and 7 patients,
respectively. Technical success rates for immediate, delayed, and
rescue angioplasty were 100%, 100%, and 71%, respectively, and that
of angioplasty for MCA occlusion was 100%. Delayed angioplasty was
performed 48 hours after thrombolysis in patient 1, 12
hours after in patient 9, and 20 hours after in patient 13. Every
patient who received rescue angioplasty for MCA occlusion had
successful dilatation. In particular, 2 patients (patients 6 and 8)
with cardioembolic MCA occlusion after failed
thrombolysis showed complete
recanalization immediately after the first
dilatation of the balloon catheter without occlusion of the distal
arteries. In 9 patients who had follow-up angiography 1 month later, no
restenosis or reocclusion was demonstrated. Ten patients (77%)
showed improvement in the NIH stroke score after treatment. Nine
patients (69%) had an excellent, good, or fair outcome 3 months after
treatment. In particular, all patients with MCA occlusion had complete
recanalization and a relatively good outcome.
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Comparison of clinical and angiographic results between the PTA and
thrombolysis-alone groups is summarized in Table 2. No significant difference between
these groups was observed in age, interval from symptom onset to
treatment, or urokinase dose. In the thrombolysis-alone
group, severe residual stenosis of the M1 segment of the MCA
after treatment was found in 2 patients (90% and 95%) who had
reocclusion within 24 hours. The other 2 patients with mild residual
stenosis (20% and 30%) after treatment did not have
reocclusion. The rates of recanalization (complete
and partial) in the PTA and thrombolysis-alone groups
were 100% and 83%, respectively. Changes in NIH stroke scores between
the next day and baseline and between 1 month and baseline in the PTA
group were much greater than those in the
thrombolysis-alone group (P<0.01). Two
patients (patients 10 and 11) who received rescue angioplasty for
intracranial internal carotid artery bifurcation occlusion had no
reperfusion without any technical complications and died within 1 week
after treatment. In 2 patients of basilar artery occlusion, patient 12
who had failed PTA died and patient 13 who had successful PTA had a
fair outcome.
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There were no symptomatic or clinically deteriorating complications during or after the procedures. In patient 1, asymptomatic petechial hemorrhage was found in the frontal white matter on CT 1 week after treatment. Patient 4 suffered a mild asymptomatic dissection immediately after angioplasty, but follow-up angiography performed 1 month later showed complete resolution. Patient 12 suffered bilateral distal posterior cerebral artery occlusion after complete recanalization of the basilar artery, which was a potential distal embolism.
Illustrative Case Reports
Immediate Angioplasty
A 51-year-old man (patient 4, Figure 1) presented with acute onset of
right hemiparesis and total aphasia. CT findings were normal, and
carotid angiography demonstrated complete occlusion of the proximal
left M1 segment of the MCA. Intra-arterial
thrombolysis with injection of 480 000 U of urokinase
was performed 6 hours after symptom onset.
Postthrombolysis angiography showed complete
recanalization of the MCA with severe residual
stenosis. A Stealth 2.5x1.0-mm balloon catheter was advanced
to the stenotic segment, which was dilated twice at 3 atm for
20 seconds each time. Postangioplasty angiography revealed complete
dilatation of the stenotic segment with mild dissection.
Follow-up angiography 1 month later demonstrated complete patency of
the M1 segment without dissection. The patient had a good outcome.
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Delayed Angioplasty
A 72-year-old woman (patient 1, Figure 2) presented with acute onset of
right hemiparesis and total aphasia. CT showed no abnormal density.
Carotid angiography demonstrated total occlusion of the proximal left
M1 segment of the MCA 5 hours after symptom onset. After infusion of
480 000 U urokinase, there was complete
recanalization with residual stenosis. The
patient's neurological symptoms showed marked improvement after
thrombolysis, and she was continually heparinized for
24 hours after treatment. However, she deteriorated progressively,
showing her initial symptoms 43 hours after
thrombolysis. Emergency angiography 5 hours after
recurrent onset revealed a higher-grade stenosis of the M1
segment than seen on the previous angiogram. A Stealth 2.0x1.0-mm
balloon catheter was introduced into the M1 segment, which was dilated
once at 3 atm for 20 seconds. After angioplasty, complete dilatation
was obtained with neurological improvement. Follow-up angiography 1
month later demonstrated complete patency of the M1 segment. The
patient had an excellent outcome.
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Rescue Angioplasty
A 64-year-old woman (patient 8, Figure 3) whose past history included atrial
fibrillation presented with sudden right hemiparesis and total
aphasia. CT showed no abnormal density, and then SPECT was performed
5.5 hours after symptom onset. Therefore, 480 000 U urokinase was
administered intravenously 5 minutes after injection of
99mTc-HMPAO for 15 minutes during the acquisition
of SPECT data to recanalize the occluded vessel as early as possible
and to avoid reperfusion of irreversibly damaged tissue. Carotid
angiography demonstrated total occlusion of the proximal left M1
segment of the MCA 6.5 hours after the onset. To open the occluded
vessel as soon as possible, a Stealth 2.0x1.0-mm balloon catheter was
advanced into the M1 segment, which was dilated once at 3 atm for 10
seconds. An immediate postangioplasty angiogram demonstrated complete
recanalization of the left MCA with normal filling
of the distal circulation. The patient improved neurologically, but
still had minor deficits 1 month after treatment.
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Discussion |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Thrombolytic therapy for acute ischemic stroke is still under investigation. The purpose of this treatment is not only to improve the neurological outcome of patients but also to avoid hemorrhagic complications. A recent controlled multicenter study demonstrated that intravenous recombinant tissue-type plasminogen activator (rtPA) was effective in the first 3 hours after symptom onset. The other major study of intravenous rtPA using the therapeutic window of 6 hours reported no evidence of efficacy. Although the therapeutic window in humans is generally believed to be the first 6 hours after symptom onset, a previous study by our group indicated a variation among different individuals.12 The therapeutic window for potentially salvageable ischemic tissue is likely dependent on the degree of collateral flow.16 Our previous studies showed that pretreatment SPECT could provide useful parameters to predict patient outcome and that it might be useful to improve patient selection for thrombolytic therapy.4 12 We believe that the evaluation of tissue reversibility should be included in the selection of appropriate patients for angioplasty in acute stroke.
Intra-arterial thrombolysis was reported to have a relatively higher recanalization rate and a lower hemorrhagic rate compared with intravenous thrombolysis. Analysis of the data from 274 patients in 10 recent studies in which intra-arterial thrombolysis was used showed a 60% recanalization rate and a 21% hemorrhage rate,1 2 3 4 5 6 17 18 19 20 whereas 4 major studies on the use of intravenous thrombolysis with angiographic control showed recanalization rates ranging from 21% to 59%,21 22 23 24 and 1 major study showed a 42.8% overall hemorrhage rate and a 19.8% large parenchymal hemorrhage rate.21 Advantages of this approach include reliable delivery of a high concentration of thrombolytic agents at a lower dose than intravenous infusion and actual mechanical disruption of clots by the microcatheter and the micro–guidewire.
However, there are several problems in intra-arterial thrombolysis. First, the efficacy of intra-arterial thrombolysis still remains unproved, so that a large, randomized, and placebo-controlled study is needed to validate the technique's usefulness. Currently, 1 clinical trial using recombinant pro-urokinase suggested that initial data in 40 patients with MCA occlusion treated within 6 hours demonstrated recanalization rates of 57% for the pro-urokinase group compared with only 15% for the placebo group.2 Second, intra-arterial thrombolysis depends on rapid access to an angiographic laboratory 24 hours a day and needs to be performed by an experienced multidisciplinary team. Finally, there are some technical problems in patients with persistent or recurrent occlusion after thrombolysis. In particular, multiple or large hardened clots are difficult to lyse with the thrombolytic agent, and vessel occlusion with hardened plaques of atherosclerotic changes is difficult to recanalize completely. Therefore, we tried to perform angioplasty for patients that were difficult to treat by intra-arterial thrombolysis alone.
Although there are several recent reports suggesting the benefit of angioplasty for the stenosis of intracranial arteries in the chronic stage,25 26 reports of angioplasty for intracranial arteries in acute ischemic stroke are still rare. Some reports suggest that PTA as an adjunct to thrombolysis for acute thrombotic MCA occlusion might be safely performed to prevent rethrombosis and reocclusion.8 9 Our study showed a high success rate for immediate or delayed angioplasty for severe residual stenosis after successful thrombolysis and demonstrated the usefulness of these procedures for preventing reocclusion. The technical feasibility of rescue angioplasty for an occluded artery after failed thrombolysis was also demonstrated. We did not try to perform direct angioplasty (without thrombolysis),27 because PTA alone might not be able to dissolve the clots or reestablish the blood flow effectively, particularly in perforating or small arteries, and the safety of this procedure had not been established at that time.
Rescue angioplasty may be applicable not only for thrombotic occlusion but also for embolic occlusion. However, it is uncertain whether rescue angioplasty should be attempted in every patient with documented failure of thrombolysis, because this procedure may not save a significant amount of ischemic tissue, considering the time delay associated with the infusion of the thrombolytic agent, recognition of failed thrombolysis, and initiation of rescue angioplasty. Furthermore, the technical success rate of rescue angioplasty is lower than that of immediate or delayed angioplasty. The application of this strategy may be suitable to improve mortality for high-risk patients.
On the other hand, rescue angioplasty after failed intravenous thrombolysis (patient 7) may be of benefit to recanalize as soon as possible the occluded artery without additional infusion of the thrombolytic agent. Recently, a new strategy for the treatment of acute ischemic stroke was tried in our institution: first, intravenous rtPA thrombolysis was started during preparation for angiography after CT or during acquisition of SPECT data; and, second, intra-arterial thrombolysis using a minimum dose of urokinase with or without angioplasty was performed, if angiography demonstrated occlusion or severe residual stenosis of the vessels. We believe that this method may make it possible to shorten the duration from occlusion to recanalization of the vessel and to improve the success rate of recanalization. More experience is required to evaluate the benefits of this method.
With respect to treatment for acute MCA occlusion, our data from a small number of patients may not be able to prove the effectiveness of PTA in clinical outcome because our study is not a controlled prospective analysis. Furthermore, we think that the purpose of angioplasty should be to provide sufficient perfusion to reduce ischemic symptoms and not to achieve an angiographic cure.28 However, this study suggests that the improvement in NIH stroke scores in the PTA group is greater than that in the thrombolysis-alone group. Angioplasty for acute MCA occlusion may have the potential to contribute to early improvement of neurological symptoms by increasing the rate of recanalization and avoiding reocclusion.
Potential technical complications related to angioplasty for intracranial arteries include dissection of the vessel wall, acute occlusion after the procedure, distal embolisms due to thrombus, and inadvertent occlusion of perforators with crushed plaque.25 28 29 Particularly, blind wire and catheter manipulation when rescue angioplasty is attempted may cause perforation or dissection of the vessel. Although the incidence of these complications is still unknown, it is reported to be very low in the coronary arteries.10 30 31 No technical complications, with deterioration of neurological symptoms, were found in this study.
There were no symptomatic hemorrhagic complications in this series. However, if early recanalization had been obtained in patient 10 or 11, these patients might have been at high risk for hemorrhage because of very low residual CBF assessed by pretreatment SPECT. At that time, we had not assigned a cutoff value for the indication of thrombolytic therapy. Because these patients might have taken a rapidly fatal course without alternative therapies, we attempted to perform angioplasty. Moreover, not all patients had successful angioplasty. A successful procedure depends on the size and hardness of the clot and the degree of kinking by atherosclerotic vessel changes. In some of our patients, the dilatation catheter could not be advanced to the stenotic lesion due to severe atherosclerotic changes.
This limited study demonstrates the technical feasibility of angioplasty for intracranial arteries in acute ischemic stroke and suggests that angioplasty may be an effective option for improving the success rate of recanalization and preventing reocclusion of the occluded artery, particularly the M1 segment of the MCA. Although this study is preliminary and the efficacy of this procedure should be assessed by well-designed clinical trials in a large number of patients, the present results encourage us to perform further trials in acute ischemic stroke.
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Acknowledgments |
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We thank Yoshifumi Sugawara, MD, PhD, and all the staff members of the Department of Radiology, Ehime University School of Medicine, Japan, who cooperated in this study, and Phyllis Bergman for her expert assistance in the preparation of this manuscript.
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Footnotes |
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Address correspondence to Toshihiro Ueda, MD, PhD, Department of Radiology, The University of Iowa College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242.
Address reprint requests to Toshihiro Ueda, MD, PhD, Department of Neurological Surgery, Ehime University School of Medicine, Shitsukawa, Shigenobu-cho, Onsen-gun, Ehime, 791-0295, Japan.
Received July 9, 1998; revision received August 26, 1998; accepted September 11, 1998.
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S. Mangiafico, M. Cellerini, P. Nencini, G. Gensini, and D. Inzitari Intravenous Glycoprotein IIb/IIIa Inhibitor (Tirofiban) followed by Intra-Arterial Urokinase and Mechanical Thrombolysis in Stroke AJNR Am. J. Neuroradiol., November 1, 2005; 26(10): 2595 - 2601. [Abstract] [Full Text] [PDF]
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S. Mangiafico, M. Cellerini, P. Nencini, G. Gensini, and D. Inzitari Intravenous Tirofiban With Intra-Arterial Urokinase and Mechanical Thrombolysis in Stroke: Preliminary Experience in 11 Cases Stroke, October 1, 2005; 36(10): 2154 - 2158. [Abstract] [Full Text] [PDF]
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E. A. Noser, H. M. Shaltoni, C. E. Hall, A. V. Alexandrov, Z. Garami, E. D. Cacayorin, J. K. Song, J. C. Grotta, and M. S. Campbell III Aggressive Mechanical Clot Disruption: A Safe Adjunct to Thrombolytic Therapy in Acute Stroke? Stroke, February 1, 2005; 36(2): 292 - 296. [Abstract] [Full Text] [PDF]
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 J. R. Fulgham, T. J. Ingall, L. G. Stead, H. J. Cloft, E. F. M. Wijdicks, and K. D. Flemming Management of Acute Ischemic Stroke Mayo Clin. Proc., November 1, 2004; 79(11): 1459 - 1469. [Abstract] [PDF]
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S. R. Ramee, R. Subramanian, R. A. Felberg, K. L. McKinley, J. S. Jenkins, T. J. Collins, R. C. Dawson, and C. J. White Catheter-Based Treatment for Patients With Acute Ischemic Stroke Ineligible for Intravenous Thrombolysis Stroke, May 1, 2004; 35(5): e109 - e111. [Abstract] [Full Text] [PDF]
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H. P. Adams Jr, R. J. Adams, T. Brott, G. J. del Zoppo, A. Furlan, L. B. Goldstein, R. L. Grubb, R. Higashida, C. Kidwell, T. G. Kwiatkowski, et al. Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke Association Stroke, April 1, 2003; 34(4): 1056 - 1083. [Full Text] [PDF]
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S. Nakano, T. Iseda, T. Yoneyama, H. Kawano, and S. Wakisaka Direct Percutaneous Transluminal Angioplasty for Acute Middle Cerebral Artery Trunk Occlusion: An Alternative Option to Intra-arterial Thrombolysis Stroke, December 1, 2002; 33(12): 2872 - 2876. [Abstract] [Full Text] [PDF]
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H. J. Cloft, T. A. Tomsick, D. F. Kallmes, J. H. Goldstein, and J. J. Connors Assessment of the Interventional Neuroradiology Workforce in the United States: A Review of the Existing Data AJNR Am. J. Neuroradiol., November 1, 2002; 23(10): 1700 - 1705. [Full Text] [PDF]
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 J. P. Broderick and W. Hacke Treatment of Acute Ischemic Stroke: Part I: Recanalization Strategies Circulation, September 17, 2002; 106(12): 1563 - 1569. [Full Text] [PDF]
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B. Eckert, C. Koch, G. Thomalla, J. Roether, and H. Zeumer Acute Basilar Artery Occlusion Treated With Combined Intravenous Abciximab and Intra-arterial Tissue Plasminogen Activator: Report of 3 Cases Stroke, May 1, 2002; 33(5): 1424 - 1427. [Abstract] [Full Text] [PDF]
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J. A. Chalela, I. Katzan, D. S. Liebeskind, P. Rasmussen, O. Zaidat, J. I. Suarez, D. Chiu, R. P. Klucznick, E. Jauch, B. L. Cucchiara, et al. Safety of Intra-Arterial Thrombolysis in the Postoperative Period Editorial Comment : Safety of Intra-Arterial Thrombolysis in the Postoperative Period Stroke, June 1, 2001; 32(6): 1365 - 1369. [Abstract] [Full Text] [PDF]
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 A. Furlan, R. Higashida, L. Wechsler, M. Gent, H. Rowley, C. Kase, M. Pessin, A. Ahuja, F. Callahan, W. M. Clark, et al. Intra-arterial Prourokinase for Acute Ischemic Stroke: The PROACT II Study: A Randomized Controlled Trial JAMA, December 1, 1999; 282(21): 2003 - 2011. [Abstract] [Full Text] [PDF]
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M. T. Edwards, M. M. Murphy, J. J. Geraghty, J. A. Wulf, and J. P. Konzen Intra-arterial Cerebral Thrombolysis for Acute Ischemic Stroke in a Community Hospital AJNR Am. J. Neuroradiol., October 1, 1999; 20(9): 1682 - 1687. [Abstract] [Full Text]
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T. Mori, K. Kazita, T. Mima, and K. Mori Balloon Angioplasty for Embolic Total Occlusion of the Middle Cerebral Artery and Ipsilateral Carotid Stenting in an Acute Stroke Stage AJNR Am. J. Neuroradiol., September 1, 1999; 20(8): 1462 - 1464. [Abstract] [Full Text]
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