Intra-Arterial Alteplase Thrombolysis during Mechanical Thrombectomy for Acute Ischemic Stroke

Heiferman, Daniel M.; Li, Daphne D.; Pecoraro, Nathan C.; Smolenski, Angela M.; Tsimpas, Asterios; Ashley, William W.

doi:10.1016/j.jstrokecerebrovasdis.2017.07.031

Cited by 42 publications

(44 citation statements)

References 13 publications

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“…To date, little is known about the use of IA thrombolysis in the current era of endovascular stroke therapy. Recent studies after the landmark MT trials (5–10) have investigated IA-rtPA use in conjunction with MT (2–4); however, these studies were limited by their retrospective non-randomized nature, small sample size, and heterogeneous populations and techniques. Our study revealed that most respondents use IA thrombolysis in their current clinical practice; however, few implement standardized protocols for IA-rtPA administration.…”

Section: Discussionmentioning

confidence: 99%

“…The ESCAPE Trial protocol recommended a maximum dose of 10 mg rtPA via micro-catheter for use as adjunctive therapy. Two retrospective studies reported dosing of IA rt-PA of up to 15 mg and <5 mg (3, 4). As there are no standardized dosing guidelines, prospective studies are warranted to determine the dosing threshold for IA-rtPA.…”

Section: Discussionmentioning

confidence: 99%

“…Intra-arterial (IA) thrombolysis, once a first-line therapy for LVOs prior to the advent of MT, has reemerged with a potential new role in the modern endovascular era. Recent studies have demonstrated promising results of IA recombinant tissue plasminogen activator (rtPA) in the context of MT (2–4); however, the role of IA thrombolysis in contemporary endovascular therapy is not well-understood and limited data exists on its current use in real-world practice. Here, we surveyed the neuro-interventional field to evaluate the current clinical practices and opinions of IA thrombolysis in the context of MT and to better understand its future role in endovascular stroke therapy.…”

Section: Introductionmentioning

confidence: 99%

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Insights Into Intra-arterial Thrombolysis in the Modern Era of Mechanical Thrombectomy

et al. 2019

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Background and Purpose: The role of intra-arterial (IA) thrombolysis in modern endovascular therapy is not well-understood. Here, we surveyed neurointerventionalists to understand their current clinical practices and opinions of IA thrombolysis in the new era of mechanical thrombectomy (MT).Method: A 24-question anonymous survey was distributed via email to the members of the Society of Vascular and Interventional Neurology.Results: One hundred and four responses were included in the analysis. Most respondents were interventional neurologists (76.9%) and had ≥5-years in neuro-interventional practice (80.8%). IA thrombolytics are presently used by 60.6%. Aspiration plus stent-retriever was the most common MT approach used with IA-thrombolysis (66.0%). IA-thrombolysis was used in mainly three approaches: (1) treatment of primary distal occlusions, (2) as rescue after proximal occlusion thrombectomy, and (3) or as adjunct therapy to primary MT approach. The most frequent IA-rtPA dose was 3–10 mg, with 1 mg/min infusion rate (56.6%). 84.9% do not have a standardized protocol for administering IA-rtPA. About half (50.9%) believed there should be no time limit for administering IA lytic if there is a favorable imaging profile, while 30.2% indicated ≤6 h. Most respondents (76.5%) would consider using IA-tenecteplase in a trial setting. Only 12.9% felt there was no role for IA thrombolysis in modern endovascular practice. Respondents with ≥10-years' experience were less supportive of the future of IA lytic (98.0 vs. 76.4%, p = 0.006).Conclusion: IA-thrombolysis is currently used in clinical practice; however, there is no clear consensus on best practices or criteria for administration. Further studies are needed to define the role of IA-thrombolysis in the context of MT.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Insights Into Intra-arterial Thrombolysis in the Modern Era of Mechanical Thrombectomy

et al. 2019

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“…In the era of recent EVT trials, the role of IA thrombolysis remains uncertain. Observational studies of IA r-tPA as either adjuvant or rescue therapy after failed thrombectomy have shown encouraging results with acceptable safety profile and improved reperfusion rates [17,18]. The American Heart Association/American Stroke Association (AHA/ASA) guidelines continue to recommend IA thrombolysis in appropriately selected AIS patients within 6 h provided they were not candidates for IV r-tPA (Class I, Level of Evidence: B) [5].…”

Section: From Systemic Intravenous To Local Intra-arterial Thrombolysismentioning

confidence: 99%

“…Both DAWN and DEFUSE 3 trials demonstrated significant benefit of EVT within 16-24 h of last known well by selecting patients with clinical imaging mismatch (i.e., severe clinical deficit and small infarct core) per advanced imaging tools. The median NIHSS score with IQR was 17 (13-21) and 16 (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) while the median infarct core with IQR was 7.6 (2-18) and 9.4 (2.3-25.6) mL, respectively (Table 2) [14,15]. The astoundingly large treatment effect in these late-window trials, termed the latewindow paradox, has been attributed to both trials having enrolled patients with very slow infarct growth or progression rates [71].…”

Section: Expanding the Therapeutic Time Windowmentioning

confidence: 99%

Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next?

Shafie

2021

Transl. Stroke Res.

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In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.

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Safety and Efficacy of Intra-arterial Urokinase After Failed, Unsuccessful, or Incomplete Mechanical Thrombectomy in Anterior Circulation Large-Vessel Occlusion Stroke

et al. 2020

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IMPORTANCE Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion after incomplete MT are sparse.OBJECTIVE To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT. DESIGN, SETTING, AND PARTICIPANTSThis observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019.INTERVENTION One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections. MAIN OUTCOMES AND MEASURESPrimary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of Յ2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. RESULTSAfter exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 [interquartile range, 62.6-82.2] years; 505 [50.9%] women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI<3) after MT (53 [53.0%]). After adjusting for baseline characteristics underlying case selection, intra-arterial urokinase was not associated with an increased risk of sICH (adjusted odds ratio [aOR], 0.81; 95% CI, 0.31-2.13) or 90-day mortality (aOR, 0.78; 95% CI, 0.43-1.40). Among 53 cases of partial or near-complete reperfusion and treated with intra-arterial urokinase, 32 (60.4%) had early reperfusion improvement, and 18 of 53 (34.0%) had an improvement in TICI grade. Correspondingly, patients treated with intra-arterial urokinase had higher rates of functional independence after adjusting for the selection bias favoring a priori poor TICI grades in the intra-arterial urokinase group (aOR, 1.93; 95% CI, 1.11-3.37). CONCLUSIONS AND RELEVANCEIn selected patients, adjunctive treatment with intra-arterial urokinase during or after MT was safe and improved angiographic reperfusion. Systemic evaluation of this approach in a multicenter prospective registry or a randomized clinical trial seems warranted.

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Intra-Arterial Alteplase Thrombolysis during Mechanical Thrombectomy for Acute Ischemic Stroke

Cited by 42 publications

References 13 publications

Insights Into Intra-arterial Thrombolysis in the Modern Era of Mechanical Thrombectomy

Insights Into Intra-arterial Thrombolysis in the Modern Era of Mechanical Thrombectomy

Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next?

Safety and Efficacy of Intra-arterial Urokinase After Failed, Unsuccessful, or Incomplete Mechanical Thrombectomy in Anterior Circulation Large-Vessel Occlusion Stroke

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