Intra-arterial thrombolysis

Some have questioned the specificity of DWI in delineating particular areas of the brain that are destined for infarction, noting that some DWI lesions resolve at least partially in follow-up studies. However, it appears that reversibility of DWI lesions is quite unusual and typically involves only a small portion of initially abnormal tissue. One study found that reversal of a DWI abnormality occurred in 33% of patients following intra-arterial thrombolysis. However, in this study, the areas of reversal nevertheless went on to infarction in the majority of patients. ... 

Lev MH, Segal AZ, Farkas J, Hossain ST, Putman C, Hunter GJ, Budzik R, Harris GJ, Buonanno FS, Ezzeddine MA, Chang Y, Koroshetz WJ, Gonzalez RG, Schwamm LH. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis prediction of final infarct volume and clinical outcome. Stroke 2001 32 2021-2028. 

Local intra-arterial thrombolysis (lAT) has several theoretical advantages over IV thrombolysis. For instance, by using coaxial microcatheter techniques, the occluded intracranial vessel is directly accessible and the fibrinolytic agent can be infused directly into the thrombus. This permits a smaller dose of fibrinolytic agent to reach a higher local concentration than that reached by systemic infusion, and ideally it allows for more complete recanalization with lower total doses of thrombolytic. With the smaller dose, complications from systemic fibrinolytic effects, including ICH, can theoretically be reduced. 

Ueda T, Hatakeyama T, Kohno K, Kumon Y, Sakaki S. Endovascular treatment for acute thrombotic occlusion of the middle cerebral artery local intra-arterial thrombolysis combined with percutaneous transluminal angioplasty. Neuroradiology 1997 39 99-104. 

Qureshi Al, Siddiqui AM, Kim SH, Hanel RA, Xavier AR, Kirmani JF, Suri ME, Boulos AS, Hopkins LN. Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke. AJNR Am J Neuroradiol 2004 25 322-328. 

Nedeltchev K, Fischer U, Arnold M, BaUinari P, Haefeli T, Kappeler L, Brekenfeld C, Remonda L, Schroth G, Mattie FIP. Long-term effect of intra-arterial thrombolysis in stroke. Stroke 2006 37 3002-3007. 

Kase CS, Furlan AJ, Wechsler LR, Higashida RT, Rowley HA, Hart RG, Molinari GF, Frederick LS, Roberts HC, Gebel JM, Sila CA, Schulz GA, Roberts RS, Gent M. Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke the PROACT n trial. Neurology 2001 57 1603-1610. 

Arnold M, Nedeltchev K, Mattie HP, Loher TJ, Stepper F, Schroth G, Brekenfeld C, Sturzenegger M, Remonda L. Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions. J Neurol Neurosurg Psychiatry 2003 74 739-742. 

Furlan A, Higashida R. Intra-arterial thrombolysis in acute ischemic Stroke. In Mohr JP, Choi DW, Grotta JC, et al., eds. Stroke Pathophysiology, Diagnosis, and Management. 4th ed. Philadelphia, PA Churchill Livingstone 2004 p. 943-951. 

Schaefer PW, Hassankhani A, Putman C, Sorensen AG, Schwamm L, Koroshetz W, Gonzalez RG. Characterization and evolution of diffusion MR imaging abnormalities in stroke patients undergoing intra-arterial thrombolysis. Am J Neuroradiol2004 25 951-957. 

Khatri P, Broderick J, Khoury JC, Carrozzella J, Tomsick T, for the IMS-1 and 2 Investigators. Microcatheter contrast injections during intra-arterial thrombolysis increase intracranial hemorrhage risk. International Stroke Conference Kissimmee, Elorida 2006. 

Greer DM, Koroshetz WJ, Cullen S, Gonzalez RG, Lev MH. Magnetic resonance imaging improves detection of intracerebral hemorrhage over computed tomography after intra-arterial thrombolysis. Stroke 2004 35 491 95. 

Deshmukh VR, Fiorella DJ, Albuquerque FC, Frey J, Flaster M, Wallace RC, Spetzler RF, McDougall CG. Intra-arterial thrombolysis for acute ischemic stroke preliminary experience with platelet glycoprotein Ilb/IIIa inhibitors as adjunctive therapy. Neurosurgery 2005 56 46-54 [discussion 54 5]. 

Ueda T, Sakaki S, Nochide I, Kumon Y, Kohno K, Ohta S. Angioplasty after intra-arterial thrombolysis for acute occlusion of intracranial arteries. Stroke 1998 29 2568-2574. 

Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion an alternative option to intra-arterial thrombolysis. Stroke 2002 33 2872-2876. 

Arnold M, Nedeltchev K, Remonda L et al. (2005). Recanalisation of middle cerebral artery occlusion after intra-arterial thrombolysis different recanalisation grading systems and clinical functional outcome. Journal of Neurology, Neurosurgery Psychiatry 76 1373-1376... 

Intra-arterial thrombolysis has been proposed as a treatment for acute ischemic stroke since the 1980s and may potentially overcome many of the problems associated with patient selection for intravenous therapy ... 

There are few data to guide intra-arterial thrombolysis in the posterior circulation. Observational studies and the one existing very small randomized controlled trial of intraarterial thrombolysis for basilar occlusion show no evidence of benefit (Arnold et al 2004, Lindsberg and Mattie 2006). However, given the poor outcome of basilar occlusion, many clinicians believe thrombolysis is justified, even many hours after the event, particularly since there is some evidence that the ischemic penumbra and thus the available window for thrombolysis may extend for many hours in the posterior circulation. 

Comparisons between the different intra-arterial thrombolysis trials and between intraarterial thrombolysis and intravenous thrombolysis is hampered by differences in methodology and type of thrombolytic therapy. In addition, within the intra-arterial thrombolysis trials, thrombolytic deUvery has varied between regional into a parent vessel of the thrombosed vessel, local into the affected artery and into the thrombus itself, or combinations of these methods. In addition, the infusion process has been variable, ranging from continuous to pulsed infusion. Some studies have allowed physical clot dispersion using the tip of the microcatheter while this was prohibited in others, for instance in the PROACT trials. 

Clinical and radiological predictors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis. Journal of Neurology, Neurosurgery and Psychiatry 75 857-862... 

Christoforidis GA, Mohammad Y, Kehagias D, Avutu B, Slivka AP Angiographic assessment of pial collaterals as a prognostic indicator following intra-arterial thrombolysis for acute ischemic stroke. AJNRAmJ Neuroradiol 2005 26 pp. 1789-1797. 

Hill MD, Rowley HA, Adler F, Eliasziw M, Furlan A, Higashida RT et al (2003) Selection of acute ischemic stroke patients for intra-arterial thrombolysis with pro-urokinase by using ASPECTS. Stroke 34(8) 1925-1931. 

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