Published Online
on November 22, 2006

A more recent version of this article appeared on January 1, 2007

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Submitted on May 27, 2006
Revised on August 7, 2006
Accepted on August 22, 2006

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^*; and 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.

^* To whom correspondence should be addressed. 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

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