Introduction: Intravenous administration of tissue plasminogen activator (iv-tPA) is accepted as a standard treatment for acute cerebral stroke, but the clinical outcomes cannot be warranted in patients who are not recanalized after iv-tPA or not indication for iv-tPA. Recently intra-arterial thrombolytic therapy (IA-Tx) reported good results. But, clinical outcomes was not compared who treated IA-Tx by chemical and mechanical methods. Authors analyze the IA-Tx sub-group end results.
Methods: 154 patients were divided into a chemical thrombolysis group (n=92: Urokinase, Rheopro, etc) and mechanical thrombolysis group (n=62: Solitair, balloon, other devices). Mechanical thrombolysis groups were sub-divided according to weather used Solitair or not. And other clinical data sub-analyzed by tPA used or perfusion/diffusion mismatch (P/D-mismatching) or not. Treatment results were compared by recanalization rate, clinical outcomes, mortality, and significant intra-cerebral hemorrhage rate.
Results: Recanalization rate was 58.% in chemical thrombolysis group and 79.0% in the mechanical thrombolysis group (?2, p<0.05). Favorable outcome (modified Rankin Scales score of 0–2), mortality and significant intra-cerebral hemorrhage were similar in the two groups(?2, p>0.05). And sub-group of mechanical thrombolysis group shows that recanalization rate was better in Solitair group but clinical outcomes shows no statistical difference (?2, p>0.05). Complications such as clinical significant intra-cerebral hemorrhage and cerebral edema happened more frequent in chemical group (?2, p>0.05). P/D-mismatching checked just before the IA-Tx, was constant significant prognostic indicator in our analysis (?2, p<0.05).
Conclusions: In our study, mechanical thrombolysis group shows better recanalization rate and best in Solitair group compared with chemical thrombolysis group. But clinical outcomes show no difference in all treatment group. While P/D-mismatching was constant significant prognostic indicator in our analysis. So IA-x might be applied as additional treatment modality for patients with DWI/PWI mismatching.
Patient Care: To improve the patients outcome, randomized control trial should be performed, which therapy, iv-tPA or IA-Tx is proper for large-artery intracranial occlusion patients. And dynamic images such as CT-angiograogy or MR-angiograohy should incluse as an initial evaluation image instead non-enhance CT.
Learning Objectives: Although, mechanical thrombolysis is definitely improve the recanalization rate of major vessel occlusion. But end neurologic outcomes (mRS at 90 days after treatment) should be compared in a systemic approach. We need another therapeutic approach system, such as dynamic brain image to evaluated the vascular status and applied tailored therapeutic treatment method.
References: J Neurointerv Surg. 2013 Sep 23. doi: 10.1136/neurintsurg-2013-010895. [Epub ahead of print]
North American Solitaire Stent Retriever Acute Stroke registry: post-marketing revascularization and clinical outcome results.
Stroke. 2013 Nov 21.Outcome of Standard and High-Risk Patients With Acute Anterior Circulation Stroke After Stent Retriever Thrombectomy.
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