Thrombolytic reperfusion therapy

Busch E, Kruger K, Allegrini PR, Kerskens CM, Gyngell ML, Hoehn-Berlage M, Hossmann KA (1998) Reperfusion after thrombolytic therapy of embolic stroke in the rat magnetic resonance and biochemical imaging. J Cereb Blood Flow Metab 18 407-418... 

With the development of thrombolytic therapies (NINDS Stroke-Trial 1995 Hack e et al. 1995) there is a high demand for new methods which provide detailed information on the infarcted parenchyma, especially for those methods which enable characterization of tissue that is potentially salvageable by reperfusion therapy. Since the concentration of key metabolites may play a pivotal role, MR spectroscopy may have an impact on treatment decisions. 

No preclinical studies of neuroprotectives plus hypothermia in permanent occlusion stroke models without thrombolysis have been reported. This is of particular importance because these permanent ischemia models may better simulate the events that occur clinically in the vast majority of stroke patients who do not receive reperfusion therapy with a thrombolytic agent. Such studies will be necessary before proceeding with clinical trials in stroke patients. 

The ideal marker of myocardial injury should (1) provide early detection of injury, (2) allow rapid diagnosis of cardiac injury, (3) serve as a risk stratification tool in patients with ACS, (4) assess the success of reperfusion after thrombolytic therapy, (5) detect reocclusion and reinfarction, (6) determine the timing of an infarction as well as infarct size, and (7) detect procedural-related perioperative MI during cardiac or noncardiac surgery. At present, the perfect biomarker to satisfy all these needs does not exist. It is the function of the laboratory to provide advice to physicians about cardiac biomarker characteristics. 

The clinical utility of cardiac biomarkers for monitoring reperfusion following thrombolytic therapy has not gained favor as a routine form of testing for determining the success or failure of reperfusion therapy It is accepted that... 

Since the proximate cause of MI is intracoronary thrombosis, reperfusion therapies are critically important, employing, when possible, direct percutaneous coronary interventions (PCIs) for acute MI, usually using drug-eluting intracoronary stents. Thrombolytic agents are administered at hospitals where emergency PCI is not performed, but outcomes are better with direct PCI than with thrombolytic therapy. 

Early application of reperfusion therapy with thrombolytic agents has significantly improved the outcomes of acute myocardial infarction and other conditions, such as pulmonary embolism, DVT, arterial thrombosis, acute thrombosis of retinal vessel, extensive coronary emboli, and peripheral vascular thromboembolism (124). 

Warach S, Latour LL. Evidence of reperfusion injury, exacerbated by thrombolytic therapy, in human focal brain ischemia using a novel imaging marker of early blood-brain barrier disruption. Stroke 2004 35 2659-2661. 

Combination GP Ilb/IIIa and rt-PA Therapy for Acute Stroke The combination of antiplatelet and thrombolytic drugs has proven efficacy in the setting of myocardial ischemia where an additive effect is seen. In acute stroke thrombolysis with a very narrow time window and less than 50% optimal reperfusion rates,adjunctive therapy with antiplatelets may be a promising approach. However, MAST-I concluded that the group of patients receiving streptokinase plus aspirin had a marked increase in 10-day mortality. 

The clear alternative to fibrinolytic therapy in the reperfusion strategy of ST-segment elevation acute myocardial infarction is primary coronary angioplasty. This therapy has a clinical benefit over the optimal thrombolytic strategy front-loaded rt-PA or tenecteplase (13). The major drawback of primary angioplasty is its limited availability and treatment delay. The... 

The continuum of myocardial injury that is initiated by a coronary ischemic event and perpetuated by reperfusion [ischemia/reperfusion (l/R) injury] may be clinically manifested in patients undergoing thrombolytic therapy following an... 

The specific choice of treatments to be used in combination with hypothermia could be based on a variety of different approaches. First, there could be a direct synergistic effect between hypothermia and the other proposed treatment modality, presumably as a result of a complementary mode of action. For example, combining hypothermia with thrombolytic therapy might be an appropriate pairing in which the hypothermia prolongs the therapeutic window for subsequent definitive reperfusion. Similarly, hypothermia could be used just after thrombolysis, to prevent reperfusion induced injury and prolonging the viability of injured but not irreversibly damaged tissue. 

---