Published online before print December 27, 2007, doi: 10.1161/STROKEAHA.107.500959
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(Stroke. 2008;39:e27.)
© 2008 American Heart Association, Inc.
Letters to the Editor |
Stent-Assisted Endovascular Thrombolysis Versus Intravenous Thrombolysis in Internal Carotid Artery Dissection With Tandem Internal Carotid and Middle Cerebral Artery Occlusion
Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
Department of Neurology, University Hospital of Berne, Berne, Switzerland
Institute of Diagnostic and Interventional Neuroradiology, University Hospital Berne, Berne, Switzerland
Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
Department of Neurology, University Hospital of Berne, Berne, Switzerland
To the Editor:
We have read the exciting article entitled "Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion."1 The authors compared 4 patients who underwent intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator administered according to National Institute of Neurological Disorders and Stroke (NINDS) guidelines with 6 patients who were treated with an IV bolus of the glycoprotein (GP) IIb/IIIa antagonist abciximab (0.25 mg/kg body weight) and carotid stenting followed by mechanical thrombectomy in 5 cases and intra-arterial thrombolysis with 40 mg recombinant tissue plasminogen activator in the remaining case.1 Three-month outcome was worse in the IVT group although the presenting neurological deficit was comparable in the 2 groups and the mean time from stroke to treatment onset was 90 minutes longer in patients treated with endovascular techniques. These results differ from our findings observed in 18 consecutive patients with internal carotid artery dissection causing carotid occlusion and a symptomatic middle cerebral artery occlusion defined by a hyperdense middle cerebral artery sign in native brain CT in all cases, and in addition by catheter angiography in 4 and CT angiography in 6 cases (Table). Four patients were treated with carotid stenting followed by intra-arterial thrombolysis with urokinase (mean dose 625 000±227 000 IE; 3 patients have already been reported2), and 14 with IVT using recombinant tissue plasminogen activator according to the NINDS criteria. Severity of the baseline deficit was similar in both groups, and mean time from the onset of stroke to thrombolytic treatment was similar in both treatment groups as well as in comparison to Lavallée’s series.1 In contrast, 3-month outcome was similar in the present 2 groups, which differs with the study of Lavallée et al.1 The low number of investigated patients is the most likely cause of the different clinical results in the 2 series. Another reason for the differences in outcome in the present IVT group compared with Lavalée’s endovascularly treated group might be that the latter patients received an IV bolus of the GP IIb/IIIa antagonist abciximab, which corresponds to 74% of the abciximab dose administered in acute stroke.3 This abciximab dose provides the target of >80% occupancy of the GP IIb/IIIa receptor for at least 3 hours.4 Preliminary data of animal5 and human6–9 studies suggest that IV administration of a GP IIb/IIIa antagonist followed by intra-arterial thrombolysis with plasminogen activator or mechanical thrombolysis might improve clinical outcome. Another explanation of the better outcome in the present compared with Lavallée’s IVT group might be that 3 patients in this study underwent hemicraniectomy and survived, whereas surgical treatment for intracranial hypertension was not used by Lavallée et al.1
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It is also remarkable that Lavallée et al1 observed no intraluminal thrombus in the dissected carotid artery, which would have been a contraindication for stenting, which confirms the observations of our group and other authors,10 although publication bias might have occurred.
We agree with the conclusion of Lavallée et al1 that a controlled randomized trial comparing IVT with endovascular treatment in patients with internal carotid artery dissection causing symptomatic occlusion of the middle cerebral artery is needed.
Acknowledgments
Disclosures
None.
References
1. Lavalleé PC, Mazighi M, Saint-Maurice JP, Meseguer E, Abboud H, Klein IF, Houdart E, Amarenco P. Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke. 2007; 38: 2270–2274.
2. Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba C, Dai-Do D, Arnold M, Mattle HP, Schroth G. Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results. Radiology. 2005; 237: 1029–1037.
3. Abciximab Emergent Stroke Treatment Trial (AbESTT) Investigators. Emergency administration of abciximab for treatment of patients with acute ischemic stroke: results of a randomized phase 2 trial. Stroke. 2005; 36: 880–890.
4. Kereiakes DJ, Broderick TM, Roth EM, Whang D, Shimshak T, Runyon JP, Hattemer C, Schneider J, Lacock P, Mueller M, Abbottsmith CW. Time course, magnitude, and consistency of platelet inhibition by abciximab, tirofiban, or eptifibatide in patients with unstable angina pectoris undergoing percutaneous coronary intervention. Am J Cardiol. 1999; 84: 391–395.[CrossRef][Medline] [Order article via Infotrieve]
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6. Lee DH, Jo KD, Kim HG, Choi SJ, Jung SM, Ryu DS, Park MS. Local intraarterial urokinase thrombolysis of acute ischemic stroke with or without intravenous abciximab: a pilot study. J Vasc Interv Radiol. 2002; 13: 769–774.[Medline] [Order article via Infotrieve]
7. Deshmukh VR, Fiorella DJ, Albuquerque FC, Frey J, Flaster M, Wallace RC, Spetzler RF, McDougall CG. Intra-arterial thrombolysis for acute ischemic stroke: preliminary experience with platelet glycoprotein IIb/IIIa inhibitors as adjunctive therapy. Neurosurgery. 2005; 56: 46–54.[CrossRef][Medline] [Order article via Infotrieve]
8. Mangiafico S, Cellerini M, Nencini P, Gensini G, Inzitari D. Intravenous glycoprotein IIb/IIIa inhibitor (tirofiban) followed by intra-arterial urokinase and mechanical thrombolysis in stroke. AJNR Am J Neuroradiol. 2005; 26: 2595–2601.
9. Mangiafico S, Cellerini M, Nencini P, Gensini G, Inzitari D. Intravenous tirofiban with intra-arterial urokinase and mechanical thrombolysis in stroke: preliminary experience in 11 cases. Stroke. 2005; 36: 2154–2158.
10. Georgiadis D, Baumgartner RW. Thrombolysis in cervical artery dissection. In: Baumgartner RW, Bogousslavsky J, Caso V, Paciaroni M, eds. Handbook on Cerebral Artery Dissection. Basel: Karger; 2005: 140–146.
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