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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 3  |  Page : 487

Intra-arterial thrombolysis after full-dose intravenous recombinant tissue plasminogen activator for patients older than 80 years with acute ischemic stroke: What is the safety limit?


Department of Neurology, Albert Einstein Hospital, Albert Einstein, 627/701, Morumbi, São Paulo - 05652-000, Brazil

Date of Acceptance22-Feb-2010
Date of Web Publication17-Jul-2010

Correspondence Address:
Alexandre Pieri
Department of Neurology, Albert Einstein Hospital, Albert Einstein, 627/701, Morumbi, São Paulo - 05652-000
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.65517

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How to cite this article:
Pieri A, Spitz M, Kihara EN, Gabbai AA. Intra-arterial thrombolysis after full-dose intravenous recombinant tissue plasminogen activator for patients older than 80 years with acute ischemic stroke: What is the safety limit?. Neurol India 2010;58:487

How to cite this URL:
Pieri A, Spitz M, Kihara EN, Gabbai AA. Intra-arterial thrombolysis after full-dose intravenous recombinant tissue plasminogen activator for patients older than 80 years with acute ischemic stroke: What is the safety limit?. Neurol India [serial online] 2010 [cited 2020 Apr 4];58:487. Available from: http://www.neurologyindia.com/text.asp?2010/58/3/487/65517


Sir,

Studies assessing recanalization with recombinant tissue plasminogen activator (rt-PA) have demonstrated that over 80% of the patients with National Institute of Health Stroke Scale score (NIHSSS) over 10 have persistent arterial occlusion after intravenous (IV) thrombolysis. [1] In the Intervention Management of Stroke (IMS) II Study, intra-arterial (IA) thrombolysis after IV rt-PA in selected patients was considered safe. [1],[2] However, currently, combined thrombolysis, IV followed by IA, is not recommended routinely except in clinical trials. [3]

We evaluated an 83-year-old patient who was subjected to IV thrombolysis with full-dose rt-PA, followed by rescue IA thrombolysis.

An 83-year-old woman had a sudden onset of weakness in the left upper and lower limbs and the NIHSSS was 20. Brain computed tomography (CT) scan detected a right hyperdense middle cerebral artery sign and the loss of gray-white matter differentiation in the insula. The patient was assigned to IV thrombolysis therapy with rt-PA 0.9 mg/kg. Following infusion, the NIHSSS was 15. Transcranial Doppler (TCD) showed a significant reduction in the right middle cerebral artery (MCA) velocity (mean velocity of 23 cm/s on the right and 65 cm/s on the left). Within 3 h and 50 min, IA rt-PA was administered (a total dose of 10 mg) following which there was recanalization of the MCA artery. Subsequent TCD showed no asymmetry between MCA velocities (62 cm/s on the right and 63 cm/s on the left). In the follow-up evaluations within 3 and 6 months, the patient was functionally independent, with NIHSSS of 1 and Modified Rankin Scale score of 1.

In the IMS II Study, 81 patients with NIHSS ≥ 10 received IV rt-PA (0.6 mg/kg for 30 min) within 3 h of the initial symptoms and, in cases in which cerebral angiography demonstrated persistent occlusion, an additional rt-PA dose of up to 22 mg in 2 h was administered by means of an IA microcatheter. [1] However, in this study none of the patients who received combined therapy was older than 80 years. A series of cases with 69 patients submitted to IA thrombolysis after full-dose rt-PA exhibited a high recanalization rate, followed by clinical improvement. [4] In this study the recanalization rate after combined thrombolysis was 72%, with a favorable prognosis in 55% of the patients. [1],[4]

The need for a randomized study with 3 arms comparing primary IA with IV thrombolysis, with full-dose rt-PA, followed or not by rescue IA thrombolysis in patients older than 80 years cannot be overemphasized.

 
 » References Top

1.The IMS II Trial Investigators. The Interventional Management of Stroke (IMS) II Study. Stroke 2007;38:2127-35.  Back to cited text no. 1      
2.NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-7.  Back to cited text no. 2      
3.Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-711.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Shaltoni HM, Albright KC, Gonzales NR, Weir RU, Khaja AM, Sugg RM, et al. Is intra-arterial thrombolysis safe after full-dose intravenous recombinant tissue plasminogen activator for acute ischemic stroke? Stroke 2007;38:80-4.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  



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