Published Online
on June 8, 2006

A more recent version of this article appeared on July 1, 2006

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Submitted on November 14, 2005
Revised on February 5, 2006
Accepted on April 11, 2006

Intravenous Versus Combined (Intravenous and Intra-Arterial) Thrombolysis in Acute Ischemic Stroke. A Transcranial Color-Coded Duplex Sonography-Guided Pilot Study

Lucka Sekoranja MD; Jaouad Loulidi MD; Hasan Yilmaz MD; Karl Lovblad MD; Philippe Temperli MD; Mario Comelli; and Roman F. Sztajzel MD^*

From the Department of Internal Medicine (L.S.), the Department of Neurology (J.L., R.S.), the Department of Radiology (H.Y., K.L.), and the Neurological Rehabilitation Unit (P.T.), University Hospital and Medical School Geneva, Switzerland; and the Department of Statistics (M.C.), University of Pavia, Italy.

^* To whom correspondence should be addressed. E-mail: Roman.Sztajzel{at}hcuge.ch.

Background and Purpose--Determine feasibility and safety of intravenous (IV) versus combined (IV-IA [intra-arterial]) thrombolysis guided by transcranial color-coded duplex sonography (TCCD).

Methods--Thirty-three patients eligible for IV thrombolysis, within 3 hours of onset of symptoms, with occlusion in middle cerebral artery territory (TCCD monitoring, thrombolysis in brain ischemia [TIBI] flow grade [0-3]), underwent IV thrombolysis (tissue plasminogen activator, 0.9 mg/kg). In case of recanalization (modification of TIBI score 1) after 30 minutes IV thrombolysis was continued over 1 hour; otherwise, it was discontinued, with subsequent IA thrombolysis. Recanalization was determined by TIBI (TCCD) and angiographically by thrombolysis in myocardial infarction (TIMI) flow grades. Clinical outcome measures were assessed at baseline, 24 hours (NIHSS) and 3 months (modified Rankin Scale).

Results--In the IV group, 10/17 patients (59%) with complete or partial recanalization after 30 minutes had a favorable outcome at 3 months (modified Rankin Scale 0 to 2). TIBI flow grades 3 to 5 after 30 minutes of IV thrombolysis predicted a good prognosis compared with TIBI grades 1 to 2 (P<0.05). In the combined IV/IA therapy group (no recanalization after 30 minutes), 9/16 patients (56%) had a favorable outcome at 3 months. One symptomatic intracerebral hemorrhage occurred in each group.

Conclusions--Combined IV-IA versus IV thrombolysis guided by TCCD was feasible and safe. Recanalization after 30 minutes of IV thrombolysis led to a favorable outcome in 59% of the patients, provided TIBI flow grades were of 3 to 5. In the absence of early recanalization during IV thrombolysis, there was clinical benefit to proceed to IA therapy for a significative proportion of patients (56%).

Key words: stroke • thrombolysis • transcranial • ultrasonography

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