Intra arterial therapy in acute ischemic stroke dr. Intra arterial thrombolytic therapy can be very useful for the management of acute and chronic limb ischaemia, but complications do occur and patients should be carefully selected. Ischaemic stroke osama ragab lecturer of neurology tanta university 2016 2. Intra arterial thrombolysis for moderate or severe stroke up to 6 hours ott may be justified as offlabel treatment in specialized centers but is generally unapproved. Intraarterial therapy iat for acute ischemic stroke treatment is evolving. With the advancement in the thrombolytic treatment window of use that has reached 6 hours, the high safety profile of the treatment alternatives and the improvement in the thrombolysis techniques i. However, advanced machine learning algorithms offer an alternative, in. Selection of acute ischemic stroke patients for intraarterial thrombolysis with prourokinase by using aspects. Recent advances in the field of neurointerventional radional.
Intra arterial thrombolysis, administered within six hours of symptoms onset, has been shown in a randomized, prospective, multicenter trial and in several nonrandomized case series to be beneficial in acute ischemic stroke caused by occlusion of the middle cerebral artery or its major divisions. Previous article intra arterial thrombolysis for hyperacute stroke next article pumpless extracorporeal lung assist sirhiroshi nawashiro and shinji fukui raise several important issues about why some stroke patients respond to thrombolytic therapy. In the extending the time for thrombolysis in emergency neurological deficits intra arterial extendia trial, we sought to test the hypothesis that patients with anterior circulation. Selection of acute ischemic stroke patients for intraarterial. Endovascular treatment of acute ischemic stroke with aid of mechanical thrombectomy and intraarterial thrombolysis poster no c1036 congress. Although intravenous iv thrombolysis with tissue plasminogen activator tpa has. Local intraarterial fibrinolytic therapy in patients with stroke. Acute stroke practice guidelines for inpatient management of ischemic stroke and transient ischemic attack tia, ps 01. Introduction acute ischemic stroke ais is the leading cause of adult disability and the third leading cause of death in the united states, yet until recently it was considered to be untreatable. Intravenous versus intraarterial thrombolysis in ischemic stroke.
The aspects scoring system is simple and may be able to predict the outcome after intravenous thrombolytic therapy. Intraarterial fibrinolysis for acute ischemic stroke stroke. In ia thrombolysis, the cervicocephalic arterial tree is traversed with an endovascular microcatheter delivery system, the catheter port is positioned immediately within and adjacent to the offending thrombus, and fibrinolytic agents are infused directly into the clot. To show that this procedure can be performed in community hospitals, we describe our experience with a group of 11 patients treated for middle. A free powerpoint ppt presentation displayed as a flash slide show on id. Intra arterial thrombolysis for acute stroke is the property of its rightful owner. Intra arterial thrombolysis should only be administered by physicians with expertise in stroke and neurointerventional techniques. Accepted november 14 2014 introduction cerebral stroke is a. Intraarterial prourokinase for acute ischemic stroke. Background reperfusion following ischemic stroke can be attained by either intravenous thrombolysis ivt or intra arterial thrombolysis iat. Potential of intraarterial urokinase after incomplete. The proact ii trial randomised 180 patients with acute ischaemic stroke due to proven occlusion of the middle cerebral artery and without haemorrhage or major early infarction signs on ct scan to heparin and intra arterial prourokinase or heparin alone.
Intraarterial thrombolysis for acute stroke in patients 80 and older. Evolution of intraarterial therapy for acute ischemic. Endovascular therapy for ischemic stroke with perfusion. Intraarterial administration of recombinant tissuetype. Definition stroke is defined as an episode of focal neurologic brain, retina, spinal cord dysfunction even if less than 24 hours in duration in which the autopsy,computedtomographyctbrainscan,ormagneticresonance imaging mri brain scan shows features consistent with focal brain.
Intraarterial ia thrombolysis is an emerging treatment strategy for acute ischemic stroke. Intraarterial thrombolysis and thrombectomy for acute. Emerging therapies intraarterial thrombolysis, angioplasty, and. Intra arterial ia administration of rtpa for ischemic stroke has the potential for greater thrombolytic efficacy, especially for a large thrombus in the m1 or m2 segment of the middle cerebral artery mca.
Angiographically documented hemorrhagic conversion of a. Only a limited number of randomized prospective studies have compared the efficacy and safety of ivt and iat. Advances in thrombolytic therapy, brain imaging, and neurointerventional techniques provide new therapeutic options for acute stroke. Cerebral stroke, intra arterial thrombolysis treatment, ct perfusion imaging. Intraarterial cerebral thrombolysis for acute ischemic.
Intraarterial versus systemic thrombolysis for acute. Intraarterial thrombolysis for hyperacute stroke the lancet. By delivering a higher concentration of drug directly into a clot, intra arterial ia thrombolysis may be more effective than intravenous therapy at opening a blocked artery. Intraarterial thrombolysis in stroke linkedin slideshare. Intra arterial thrombolysis poses other unique stroke trial design issues. However, iat may increase the risk of surgical bleeding. Clinical outcome was measured by means of the modified rankin scale score and recanalization with the thrombolysis in cerebral infarction scale. A traditional recanalization approach based on historical controls and pathophysiological consideration is local intra arterial thrombolysis iat in eligible patients. Intraarterial cerebral fibrinolytic therapy for acute stroke was first described in 1983 by zeumer et al 11. Intravenous versus intraarterial thrombolysis in ischemic.
Intraarterial thrombolysis and thrombectomy for acute ischemic stroke. Introduction stroke is a major cause of death and disability. The total dose of intra arterial therapy is about onethird of the intravenous dose. Background and purpose the clinical benefits of intra arterial thrombolysis for ischemic stroke must be weighed against the risks, including hemorrhagic conversion. This metaanalysis investigated possible clinical benefits of iat relative to ivt in patients with acute ischemic stroke. If so, share your ppt presentation slides online with. Combined intravenous and intra arterial rtpa versus intra arterial therapy for acute stroke. Intraarterial thrombolysis for perioperative stroke after.
Acute stroke practice guidelines for inpatient management. Intraarterial thrombolysis for acute ischemic stroke. Intraarterial thrombolysis has proved to be a potent therapeutic tool. Recent advances in the field of neurointerventional. Hemorrhagic stroke is a rare but serious complication of thrombolytic therapy. Ppt intraarterial thrombolysis powerpoint presentation. Machine learning for outcome prediction of acute ischemic. A modified rankin score of 2 or less has been used as an indicator of functional independence in other thrombolysis stroke trials. Intraarterial thrombolysis intra arterial thrombolysis should be given in stroke centres with the appropriate level of experience in patients who fulfil the criteria. Intraarterial versus systemic thrombolysis for acute ischemic stroke synthesis exp the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. At present, use of intra arterial thrombolytic therapy for ischemic stroke is investigational and should be confined to clinical trials or highly selected patients. Thrombolysis, also known as thrombolytic therapy, is a treatment to dissolve dangerous clots in blood vessels, improve blood flow, and prevent damage to tissues and organs. Previous article intra arterial thrombolysis for hyperacute stroke next article pumpless extracorporeal lung assist sirhiroshi nawashiro and shinji fukui raise several important issues about why some stroke patients respond to thrombolytic therapy and others do not, some of whom seem to be harmed by it.
As clinical trials of thrombolysis for acute ischemic stroke exclude patients with recent major surgery, the safety of intraarterial thrombolysis in this setting is unknown. Intravenous tissue plasminogen activator tpa is the only approved. Evolution of intra arterial therapy for acute ischemic stroke in the netherlands. This article provides a brief overview of acute ischemic stroke, a summary of the major intra arterial stroke therapy trials, and comments on current training requirements for the performance of intra arterial therapies. Intraarterial thrombolytic therapy in the management of. Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Endovascular thrombectomy for large vessel ischaemic stroke substantially reduces disability, with recent positive randomised trials leading to guideline changes worldwide. Intraarterial therapy iat for acute ischemic stroke refers to endovascular catheterbased approaches to achieve recanalization using mechanical clot disruption, locally injected thrombolytic agents or both. If a patient has had thrombolysis before, an allergy against the thrombolytic drug. Iat techniques included thrombectomy n19, ia thrombolysis n17, stenting n14, and angioplasty n7. Discussion focuses on recognition and management of risk factors for. Safety and efficacy of intraarterial thrombolysis for. On the other hand, thrombolytic infusion was the first and, for more than 15 years, the only intra arterial stroke treatment modality shown to provide any benefit to the patient population with lvo. Intra arterial ia thrombolysis provides an alternative to intravenous iv thrombolysis in selected patients with acute ischemic stroke.
The results of the melt trial, reported in this issue of stroke, are therefore very welcome, providing additional information regarding intra arterial fibrinolytic therapy that complements and supports previous studies. Pdf intraarterial thrombolysis in acute ischemic stroke. Logistic regression models allow for the identification and validation of predictive variables. Intracranial hemorrhage ich is a concern with ia or intravenous iv administration especially as the therapeutic window is extended. Summary of case a case of angiographically documented hemorrhagic conversion of an ischemic stroke during intra arterial thrombolysis is presented. To predict the increased risk of symptomatic haemorrhagic transformation after intra arterial fibrinolysis, other methods such as local cerebral blood flow studies and diffusionweighted magnetic resonance imaging, might be needed. Listing a study does not mean it has been evaluated by the u. Limited systemic fibrinolysis and reduced dosage are features of intra arterial thrombolyis iat that may be advantageous in the treatment of postoperative strokes.
Thirteen patients with acute ischemic stroke within 12 days of cardiac operation underwent. Intraarterial therapy iat for acute ischemic stroke refers to. Intra arterial thrombo lys is randomized controlled. Endovascular treatment of acute ischemic stroke with aid. Accurately predicting stroke outcome from a set of predictive variables may identify highrisk patients and guide treatment approaches, leading to decreased morbidity. Intra arterial thrombolysis for symptom onset within 6 hours. The clinical efficacy and safety of ia thrombolysis with the selective thrombolytic rprourokinase rprouk has been demonstrated in two randomized acute stroke. Intra arterial thrombolysis may be an option for patients with cerebral embolism in the perioperative period. Intra arterial thrombo lys is free download as powerpoint presentation. The role of recombinant prourokinase rprouk and intra. Intraarterial therapy for acute ischemic stroke ncbi. Six patients with acute ischemic stroke underwent intra arterial thrombolysis after recent open heart surgery without clinically significant bleeding complications, although one patient developed a small, asymptomatic cerebellar hemorrhage.
Antithrombotic and thrombolytic therapy for ischemic stroke. Intra arterial thrombolysis for acute stroke ppt download. Ischemic stroke is a major public health problem worldwide. Proact prolyse in acute cerebral thromboembolism trial was the first prospective randomized controlled trial rct to investigate the safety and efficacy of intra arterial recombinant prourokinase iaprouk and heparin compared with intra arterial heparin alone, applied within 6 h of stroke symptom onset in patients with middle cerebral artery occlusion. Taking advantage of the delay until october 2005 of regulatory approval in japan of intravenous tissue plasminogen activator.
Safety of intraarterial thrombolysis in the postoperative. The most common complication was haematoma at the site of cannulation of the vessel. Background and purpose basilar artery occlusion bao is an infrequent form of acute stroke, which invariably leads to death or longterm disability if not recanalized. The potential to cure stroke patients with intravenous thrombolytic therapy has evolved to the use of intra arterial thrombolytic agents. Intraarterial thrombolysis should be given in stroke centres with the appropriate level of experience in patients who fulfil the criteria for iv. Subsequently, multiple anecdotal reports and small nonrandomized or controlled series have also supported that intraarterial thrombolytic therapy may be useful for treatment of acute. Intraarterial stroke management pubmed central pmc. Intraarterial thrombolysis in acute ischemic stroke. Stroke thrombolysis is considered to be one of the most beneficial stroke management techniques.
At present, for thrombolysis in ischemic stroke only intravenous alteplase is licensed in most countries, whereas urokinase, prourokinase, and desmoteplase are investigational. Acute stroke intervention american heart association. Comprehensive analysis of intraarterial treatment for. Intra arterial thrombolysis treated patients with acute ischemic stroke due to cervical artery dissection the majority of patients had multiple iat techniques, with a median of 2 23 techniques. Acute ischemic stroke after cardiac operations is a devastating complication with limited therapeutic options. Use of salvage technical adjuncts including intra arterial thrombolysis may be reasonable to achieve mtici 2b3 angiographic result. We sought to determine the safety of postoperative iat.