Comparison of combined venous and arterial thrombolysis with primary arterial therapy using recombinant tissue plasminogen activator in acute ischemic stroke

J Stroke Cerebrovasc Dis. May-Jun 2008;17(3):121-8. doi: 10.1016/j.jstrokecerebrovasdis.2007.12.004.

Abstract

Objective: We sought to compare the safety and efficacy of combined intravenous (IV) and intra-arterial (IA) thrombolysis with primary IA therapy using tissue plasminogen activator for acute ischemic stroke presenting within 6 hours of symptom onset.

Methods: We performed quasirandomization of a single institution's prospectively collected stroke database, comparing IV/IA (0.6 mg/kg IV < or = 60 mg, followed by 0.3 mg/kg IA < or = 30 mg) versus primary IA. Outcome measures include 90-day modified Rankin scale score, mortality, symptomatic intracerebral hemorrhage, and recanalization rates. Statistical analysis was performed using bivariate and propensity score methods.

Results: Of 1057 patients, 41 patients were treated with IV/IA, and 55 with IA. There was significant difference in time to treatment (mean of 151 minutes for the combined group and 261 minutes for the IA, P < .0001) and arterial tissue plasminogen activator dose (17.5 mg for IV/IA v 22.8 mg for IA only, P = .05). Propensity score matching yielded 25 patients in each group. Symptomatic intracerebral hemorrhage rate was 12% in each group. Mortality was 20% in the IV/IA group versus 16% in the IA group (relative risk 1.3 [0.4-4.1], P = .7). More patients in IV/IA group had modified Rankin scale score less than or equal to 2 (odds ratio 1.6 [0.5-5.8], P = .3). Recanalization was 64% with IV/IA versus 48% with IA (odds ratio 1.9 [0.5-7.0], P = .3).

Conclusion: This study demonstrates that both combined IV/IA and primary IA recombinant tissue plasminogen activator therapy is feasible and safe in the treatment of acute ischemic stroke. Combined IV/IA therapy may be associated with an improvement in clinical outcome without a significant increase in the risk of symptomatic intracerebral hemorrhage and mortality compared with IA therapy.

Publication types

  • Comparative Study

MeSH terms

  • Acute Disease
  • Adult
  • Aged
  • Aged, 80 and over
  • Brain Ischemia / complications*
  • Brain Ischemia / drug therapy
  • Brain Ischemia / mortality
  • Cerebral Hemorrhage / etiology
  • Cerebral Hemorrhage / prevention & control
  • Databases, Factual
  • Drug Administration Schedule
  • Feasibility Studies
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Fibrinolytic Agents / adverse effects
  • Humans
  • Infusions, Intra-Arterial
  • Infusions, Intravenous
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Prospective Studies
  • Recombinant Proteins / administration & dosage
  • Risk Assessment
  • Stroke / complications
  • Stroke / drug therapy*
  • Stroke / etiology
  • Stroke / mortality
  • Thrombolytic Therapy*
  • Time Factors
  • Tissue Plasminogen Activator / administration & dosage*
  • Tissue Plasminogen Activator / adverse effects
  • Treatment Outcome

Substances

  • Fibrinolytic Agents
  • Recombinant Proteins
  • Tissue Plasminogen Activator