Published Online
on December 20, 2007

A more recent version of this article appeared on February 1, 2008

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Submitted on April 26, 2007
Revised on June 9, 2007
Accepted on July 12, 2007

Comparison of Intraarterial and Intravenous Thrombolysis for Ischemic Stroke With Hyperdense Middle Cerebral Artery Sign

Heinrich P. Mattle MD^*; Marcel Arnold MD; Dimitrios Georgiadis MD; Christian Baumann MD; Krassen Nedeltchev MD; David Benninger MD; Luca Remonda MD; Christian von Büdingen MD; Anca Diana MS; Athina Pangalu MD; Gerhard Schroth MD; and Ralf W. Baumgartner MD

From the Departments of Neurology (H.P.M., M.A., K.N., A.D.) and Neuroradiology (L.R., G.S.), University Hospitals of Bern, and the Departments of Neurology (D.G., C.B., D.B., C.v.B., R.W.B.) and Neuroradiology (A.P.), University Hospital of Zürich, Switzerland.

^* To whom correspondence should be addressed. E-mail: heinrich.mattle{at}insel.ch.

Background and Purpose—It is unclear whether intraarterial (IAT) or intravenous (IVT) thrombolysis is more effective for ischemic stroke with hyperdense middle cerebral artery sign (HMCAS) on computed tomography (CT). The aim of this study was to compare IAT and IVT in stroke patients with HMCAS.

Methods—Comparison of data from 2 stroke units with similar management of stroke associated with HMCAS, except that 1 unit performed IAT with urokinase and the other IVT with plasminogen activator. Time to treatment was up to 6 hours for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the modified Rankin Scale (mRS), dichotomized at 3 months into favorable (mRS 0 to 2) and unfavorable (mRS 3 to 6).

Results—One hundred twelve patients exhibited a HMCAS, 55 of 268 patients treated with IAT and 57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age were similar in both groups. Mean time to treatment was longer in the IAT group (244±63 minutes) than in the IVT group (156±21 minutes; P=0.0001). However, favorable outcome was more frequent after IAT (n=29, 53%) than after IVT (n=13, 23%; P=0.001), and mortality was lower after IAT (n=4, 7%) than after IVT (n=13, 23%; P=0.022). After multiple regression analysis IAT was associated with a more favorable outcome than IVT (P=0.003) but similar mortality (P=0.192).

Conclusion—In this observational study intraarterial thrombolysis was more beneficial than IVT in the specific group of stroke patients presenting with HMCAS on CT, even though IAT was started later. Our results indicate that a randomized trial comparing both thrombolytic treatments in patients with middle cerebral artery occlusion is warranted.

Key words: acute stroke • therapy • thrombolysis

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