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Intraarterial thrombolysis in stroke
1. Intra arterial therapy in acute
ischemic stroke
Dr. Bhavin J Patel
DM neurology resident
GMC, Kota
2.
3. 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.
4. Intra arterial therapy
Intra arterial thrombolysis
Multimodal approach:- IV+IA thrombolysis
IA thrombolysis + IV GP 2b/3a
antagonist
Mechanical thrombectomy
7. IA thrombolysis :- theoretical
advantage
Higher concentrations delivered to clot
Gentle mechanical disruption of clot
Precise imaging of anatomy and
collateral pattern
Exact degree and timing of
recanalization
10. Conclusions:- for ant.
circulation
The lack of recanalization is linked to
poor outcome
Better rate of recanalizaton: 70% vs
34%
Likely better outcome than iv tPA
Larger therapeutic window
Can be given post operative
Haemorrhage rate 7 to 10%
Drawback:- technique, time to
intiation, dose variation
11. Conclusions:- vertebrobasilar
circ.
No satisfactory studies
IAT only life saving therapy available
Benefit in mortality and morbidity after
recanalization
Upto 24 hr of detoriation or 48 hr of
onset
Less benefit in coma, quadriparesis
and large infarct pre treatment.
19. only rely on imaging parameters ?
Beyond 12 hrs? Possible?
20. 6 to 16 hours
after a patient
was
last known to be
well
endovascular
therapy plus
standard medical
therapy resulted
in better
functional
outcomes than
standard medical
therapy alone
21. known to be well 6 to
24 hours earlier and
who had a mismatch
between clinical
deficit and infarct,
outcomes for
disability at 90 days
were better with
thrombectomy plus
standard care than
with standard care
alone.
23. Conclusion
Under the imaging guidance, the
future of acute ischemic treatment is
likely to have longer windows and
multiple treatment modalities used
together:
IV thrombolysis+
IA thrombectomy+
Anticoagulants+
hypothermia+
neuronal protecting agents
24. Identify patient early
The earlier, the more option we have
Using imaging to identify those outside
window
Identify patient ea
The earlier, the m
Using imaging to
the window
Stronger and bett
be used in evolvin
an even later time
27. Conclusion:-
Direct comparison with iv tPA
Provide flexibility in treatment
Appropriate selection lead to timely
and rapid reopening of occluded
vessel
29. 2) Should IV be performed
before thrombectomy in LVO
strokes ?
In favour of IV:-
Softening thrombus for thrombectomy
(less passes, less cost, shorter
procedure)
Reperfusion of persisting distal emboli
post thrombectomy !
30. 2) Should IV be performed
before thrombectomy in LVO
strokes ?
Against IV r-tPA:-
IV t-PA Cost
More symptomatic hemorrhages
within/without the infarct
Increased delay to thrombectomy (drip
and ship +++)
Proximal thrombus migration
31. Contraindications: IAT
Intracerebral hemorrhage (lobar,
subdural, intraventicular)
Subarachnoid hemorrhage
History of intracerebral hemorrhage
(ICH)
Cerebral arteriovenous malformation
or giant thrombosed cerebral
aneurysma
32. Contraindications: IAT
Computed tomographic evidence of
>1/3 middle cerebral artery (MCA)
territory acute infarct or large ischemic
core on perfusion imaging
Absence of ischemic penumbra
Uncontrolled hypertension >185/110
mmHg
Unknown stroke duration
33. Contraindications: IAT
Thrombocytopenia <100,000
Bleeding diathesis
International normalized ratio >1.7 (if
fibrinolysis is planned)
History of Alzheimer’s disease or
amyloid angiopathy
34. complications
Distal embolization in a different
territory
Intramural arterial dissection
Arterial perforation
Access-site complications leading to
intervention
35. limitations
Recanalization efficacy
Recanalizaton not equated with
reperfusion
Intracerebral haemorrhage
Reperfusion injury or cytotoxicity
No fixed dose or definition of failure for
iv r-tPA.
