doi: 10.1161/hs0102.101900
(Stroke. 2002;33:279.)
© 2002 American Heart Association, Inc.
Research Reports |
Acute Intravenous–Intra-Arterial Revascularization Therapy for Severe Ischemic Stroke
From the Departments of Clinical Neurosciences (M.D.H., P.A.B., A.M.D., A.M.B., N.J.N., A.C.-H., K.R., L.S., A.B., R.F.) and Diagnostic Imaging (W.H., M.E.H., W.M., R.J.S., R.F.), University of Calgary, Calgary, Alberta, Canada.
Correspondence to Michael D. Hill, Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada. E-mail michael.hill{at}crha-health.ab.ca
Abstract
Background— Intravenous alteplase for acute ischemic stroke is least efficacious for patients with proximal large-artery occlusions and clinically severe strokes. Intra-arterial therapy has the theoretical advantage of establishing a neurovascular diagnosis and high symptomatic artery patency rate but the disadvantage of requiring extra time and technical expertise. A combination of these two approaches may provide the best chance of improving outcome in severe acute ischemic stroke. We sought to assess the safety and feasibility of this approach.
Methods— This was a prospective, open-label study. Sequential patients arriving to our center within 3 hours of stroke onset who were treated with intravenous alteplase were screened for possible additional intra-arterial therapy using noninvasive neuroimaging. Clinical measures and outcomes were recorded prospectively.
Results— A total of 861 patients with ischemic stroke were admitted to Calgary hospitals during the study period. Eight patients over 21 months underwent a combined intravenous–intra-arterial approach. Six received intra-arterial alteplase and 1 underwent intracranial angioplasty; in a final patient, technical aspects prevented intra-arterial therapy. Early neurovascular and/or neurometabolic imaging identified the location of occlusion and tissue-at-risk (DWI-PWI mismatch) in all 8 patients. Two patients had a poor outcome, 1 patient suffered a significant groin hematoma, and there were no instances of symptomatic intracerebral hemorrhage.
Conclusions— Intravenous followed by intra-arterial therapy is a promising approach to the treatment of severe acute ischemic stroke. Early noninvasive neurovascular and neurometabolic imaging is very helpful in choosing candidates for this type of therapy. On-going monitoring of alteplase-treated patients may allow the opportunity to perform rescue intra-arterial therapy.
Key Words: intra-arterial therapy • stroke, acute • stroke, ischemic • tissue plasminogen activator
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.J. Cloft, A. Rabinstein, G. Lanzino, and D.F. Kallmes Intra-Arterial Stroke Therapy: An Assessment of Demand and Available Work Force AJNR Am. J. Neuroradiol., March 1, 2009; 30(3): 453 - 458. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Sugiura, K. Iwaisako, S. Toyota, and H. Takimoto Simultaneous Treatment with Intravenous Recombinant Tissue Plasminogen Activator and Endovascular Therapy for Acute Ischemic Stroke Within 3 Hours of Onset AJNR Am. J. Neuroradiol., June 1, 2008; 29(6): 1061 - 1066. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Ogawa, E. Mori, K. Minematsu, W. Taki, A. Takahashi, S. Nemoto, S. Miyamoto, M. Sasaki, T. Inoue, and for The MELT Japan Study Group Randomized Trial of Intraarterial Infusion of Urokinase Within 6 Hours of Middle Cerebral Artery Stroke: The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan Stroke, October 1, 2007; 38(10): 2633 - 2639. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Mikulik, M. Ribo, M. D. Hill, J. C. Grotta, M. Malkoff, C. Molina, M. Rubiera, R. Delgado-Mederos, J. Alvarez-Sabin, A. V. Alexandrov, et al. Accuracy of Serial National Institutes of Health Stroke Scale Scores to Identify Artery Status in Acute Ischemic Stroke Circulation, May 22, 2007; 115(20): 2660 - 2665. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. M. Shaltoni, K. C. Albright, N. R. Gonzales, R. U. Weir, A. M. Khaja, R. M. Sugg, M. S. Campbell III, E. D. Cacayorin, J. C. Grotta, and E. A. Noser Is Intra-Arterial Thrombolysis Safe After Full-Dose Intravenous Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke? Stroke, January 1, 2007; 38(1): 80 - 84. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
The IMS Study Investigators Hemorrhage in the Interventional Management of Stroke Study Stroke, March 1, 2006; 37(3): 847 - 851. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P A Barber, M D Hill, M Eliasziw, A M Demchuk, J H W Pexman, M E Hudon, A Tomanek, R Frayne, A M Buchan, and for the ASPEC Study Group Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging J. Neurol. Neurosurg. Psychiatry, November 1, 2005; 76(11): 1528 - 1533. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Adams, R. Adams, G. Del Zoppo, and L. B. Goldstein Guidelines for the Early Management of Patients With Ischemic Stroke: 2005 Guidelines Update A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association Stroke, April 1, 2005; 36(4): 916 - 923. [Full Text] [PDF]
|
|
|
|
 |
|
 M. L. Flaherty, D. Woo, B. Kissela, E. Jauch, A. Pancioli, J. Carrozzella, J. Spilker, P. Sekar, J. Broderick, and T. Tomsick Combined IV and intra-arterial thrombolysis for acute ischemic stroke Neurology, January 25, 2005; 64(2): 386 - 388. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Y. Lee, D. I. Kim, S. H. Kim, S. I. Lee, H. W. Chung, Y. W. Shim, S. M. Kim, and J. H. Heo Sequential Combination of Intravenous Recombinant Tissue Plasminogen Activator and Intra-Arterial Urokinase in Acute Ischemic Stroke AJNR Am. J. Neuroradiol., October 1, 2004; 25(9): 1470 - 1475. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P A Barber, A M Demchuk, M D Hill, J H W. Pexman, M E Hudon, R Frayne, and A M Buchan The probability of middle cerebral artery MRA flow signal abnormality with quantified CT ischaemic change: targets for future therapeutic studies J. Neurol. Neurosurg. Psychiatry, October 1, 2004; 75(10): 1426 - 1430. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
The IMS Study Investigators Combined Intravenous and Intra-Arterial Recanalization for Acute Ischemic Stroke: The Interventional Management of Stroke Study Stroke, April 1, 2004; 35(4): 904 - 911. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. D. Hill, H. A. Rowley, F. Adler, M. Eliasziw, A. Furlan, R. T. Higashida, L. R. Wechsler, H. C. Roberts, W. P. Dillon, N. J. Fischbein, et al. Selection of Acute Ischemic Stroke Patients for Intra-Arterial Thrombolysis With Pro-Urokinase by Using ASPECTS Stroke, August 1, 2003; 34(8): 1925 - 1931. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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]
|
|
|
|
|
|
I. Linfante, R. H. Llinas, M. Selim, C. Chaves, S. Kumar, R. A. Parker, L. R. Caplan, and G. Schlaug Clinical and Vascular Outcome in Internal Carotid Artery Versus Middle Cerebral Artery Occlusions After Intravenous Tissue Plasminogen Activator Stroke, August 1, 2002; 33(8): 2066 - 2071. [Abstract] [Full Text] [PDF]
|
|