Abstract 3600: A Critical Analysis of Intra-arterial Thrombolytic Doses in Acute Ischemic Stroke Patients.
Background: Intra-arterial (IA) recombinant tissue plasminogen activator (IV rt-PA, Alteplase), Tenecteplase, and Retplase are currently used in patients with acute ischemic stroke, the relationship between IA dose and hemorrhage rates, clinical outcomes and radiographic outcomes have not been rigorously studied.
Objective: We evaluated the safety and recanalization efficacy associated with various doses of intra-arterial thrombolytics for treating acute ischemic stroke patients.
Methods: Consecutive patients with acute ischemic stroke who underwent emergent endovascular treatment over seven years from our prospectively maintained database were included. Univariate and multivariate analyses were performed to determine the dose response relationship between thrombolytic doses and outcomes. For standardization we used a conversion of newer thrombolytics to establish a standard dosage throughout cases (10mg alteplase = 2 Units of Reteplase = 6.3 Units of Tenectaplase). Patient characteristics and outcomes were analyzed including age, weight, risk factors, use of intravenous rt-PA,and use of additional mechanical thrombolysis. The rates of intracerebral hemorrhage (ICH) and favorable clinical outcomes (discharge modified Rankin score (mRS) = 0-2) were analyzed with various doses after adjusting for potential confounders.
Results: There were 290 patients [male 52% (n=150)] who received endovascular treatment for acute ischemic stroke, of those 210 (72%) were treated with IA rt-PA or equivalent thrombolytics with doses up to 69 mg of alteplase. There were 115 patients (40%) [men 46% (n=53)] who received both IV and IA therapy. Mean±SD IA tPA dose was 10±9 mg (range: 1.5-69mg) and total IA+IV tPA dose 85±21 mg (range: 43-149mg). Neither the dose of IA tPA nor total tPA dose (IV+IA) was associated with favorable outcomes or ICH (p=NS). Mean IA tPA dose was no different between the patients with and without ICH [9.9 versus 9.8, p=0.4]. Adjusting for age, admission NIHSS score, and IA tPA/equavalent dose, the use of combined mechanical and thrombolytic IA therapy was associated with higher ICH rate (OR=4, p=0.004) but not with favorable outcomes (p=0.2) compared to thrombolytic therapy alone. Multivariate analysis showed administration of IV rt-PA significantly improved favorable outcomes compared to IA therapy alone (OR=1.8, p=0.04) with no increased risk of hemorrhage (p=NS).
Conclusion: Our study demonstrates that IA rt-PA or equivalent thromboytics in doses up to 69 mg are safe without any evidence of dose related adverse events even in those patients who had received IV rt-PA prior to procedure presumably due to the short-half life of rt-PA.
- © 2012 by American Heart Association, Inc.