Safety of Post-operative Intra-arterial Thrombolysis
Objectives Limited systemic fibrinolysis and reduced dosage are features of intra-arterial thrombolyis (IAT) that may be advantageous in the treatment of post-operative (post-op) strokes. However, IAT may increase the risk of surgical bleeding. We sought to determine the safety of post-op IAT. Methods Retrospective case series from 6 university hospitals. All cases of IAT within 2 weeks of surgery were identified. Demographics, stroke mechanism, stroke severity, imaging and angiographic findings, time between surgery and lysis, thrombolytic agent used, surgical site bleeding, intracranial bleeding, and mortality were determined. Death or complications directly related to IAT were determined. Results 35 patients (median age 72 y; range 48–85)were identified. Median time from surgery to stroke was 21 h (range 1–120). Open heart surgery was done in 18 (51%), carotid endarterectomy 6 (17%), craniotomy 3 (9%), ophthalmologic-ENT surgery 3 (9%), urologic-gynecologic surgery 2 (6%), orthopedic surgery 1 (3%), plastic surgery 1 (3%)and spinal surgery 1 (3%). The stroke causes were cardioembolism in 24 (69%), large-vessel atherosclerosis 4 (11%), dissection 3(9%), and post-endarterectomy occlusion 4 (11%). Median time to angiogram was 2.6 h (0.1–5.5).Occlusion sites were M1 in 18 (52%), M2 9 (26%), ICA 5 (14%), basilar 2 (6%)and PCA 1(3%). Thrombolysis was completed at a median of 4.5 h (range 1–7.6). TPA was used in 18 (51%) and urokinase in 17 (49%). Nine (26%) patients died. Surgical site bleeding occurred in 9 (26%) cases (minor in 6, major in 3).The major surgical bleeds were 2 post-craniectomy intracranial hemorrhages and 1 hemopericardium post-CABG; all fatal. Six deaths were non-IAT related: 3 due to cerebral edema and 3 from systemic causes. Major bleeding complications were significantly more common among patients with craniotomy (p<0.02). Conclusions Post-op IAT carries a risk of bleeding in up to 26% of patients but is usually minor surgical site bleeding. Avoiding IAT in intracranial surgery patients may reduce complications. Mortality in this series was similar to that reported in prior IAT trials. IAT remains a viable therapeutic option for post-op strokes.