Hemorrhage Rates and Outcomes When Using up to 100 mg Intra-Arterial t-PA for Thrombolysis in Acute Ischemic Stroke

Abstract

<jats:p> This work presents a unique single center experience with intra-arterial delivery of tissue plasminogen activator (t-PA) doses as high as 100mg for thrombolysis. Hemorrhage volumes, hemorrhage rates, clinical outcomes and radiographic outcomes were assessed. </jats:p><jats:p> Prospectively collected angiographic, clinical and laboratory information on 67 consecutive patients with acute ischemic stroke involving either the m1 segment of the middle cerebral artery, the intracranial internal carotid artery or the basilar artery were retrospectively analyzed. Patients who received more than 50 mg t-PA were compared with those patients receiving 50 mg or less. Outcome measures included: symptomatic hemorrhage, significant hemorrhage volume (greater than 25 ml), hemorrhage rate, change in National Institutes of Health stroke scale score at 24 hours and at hospital discharge, modified Rankin score at 90 days, in-hospital deaths, death within 90 days, reperfusion rate, and infarct volume. </jats:p><jats:p> Multivariate logistic regression analysis demonstrated that t-PA dose over 50 mg was associated with higher rates of hemorrhage and larger hemorrhages. Poor pial collateral formation, poor reperfusion (less than 50% of the territory involved), and platelet count below 200 K/μL influenced hemorrhage. Limiting t-PA dose to 100mg rather than 50mg improved documented reperfusion rates from 37% to 61%. </jats:p><jats:p> Restricting intra-arterial t-PA administration to 100mg rather than 50mg, is associated with higher overall reperfusion rates and improves overall outcomes, however, the hemorrhage rate is also elevated. Poor pial collateral formation and platelet count less than 200 K/μL may be reasons to curtail the use of higher t-PA dose to reduce hemorrhage rate. </jats:p>

Mechanically assisted intra-arterial thrombolysis in acute cerebral infarction

“…The results show that there was a significant difference in disease onset time and urokinase dosage between patients with and without bleeding complications. The probability of bleeding increases as the disease onset time and urokinase dosage increase (27). In contrast to previous findings, there is no statistical difference in disease onset age, preoperative NIHSS score and recanalization time between the two groups.…”

Reperfusion Rates Following Intra-Arterial Thrombolysis for Acute Ischemic Stroke: The Influence of the Method for Alteplase Delivery

“…Higher doses of alteplase delivery need to be used with caution. Accounting for cumulative reperfusion rates for M1 and carotid terminus occlusion higher upper limit doses has been shown to improve reperfusion rates 22 and increase hemorrhage rates. Furthermore, at 1 mg per minute, the alteplase delivery time is longer; however, the typical microcatheter placement time within the thrombus is more rapid than placement of a thrombectomy device.…”

Intravenous versus Intra-Arterial Thrombolysis in Ischemic Stroke: A Systematic Review and Meta-Analysis

“…In a study of patients who received IAT (together with other endovascular treatments) after ≥8 hours, Natarajan and colleagues documented approximate rates of 33% for both mortality at 90 days and immediate hemorrhage (subarachnoid and intracranial) [ 21 ]. The risk of ICH with IAT may be associated not only with the dose of thrombolytic used during IAT [ 22 ], but also with the severity of the stroke [ 23 ]. Regarding other complications, the PROACT II trial reported that 1% of patients receiving IAT with recombinant prourokinase experienced anaphylaxis and 7% experienced systemic hemorrhage [ 13 ].…”