Combined full-dose IV and endovascular thrombolysis in acute ischaemic stroke

Authors

  • Rohit Bhatia,

    1. Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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  • Nandavar Shobha,

    1. Bangalore Neuro Centre, Vagus Superspeciality hospital, Bhagwan Mahaveer Jain Hospital, Vikram hospital, Bangalore, India
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  • Bijoy K. Menon,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Simerpreet P. Bal,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Puneet Kochar,

    1. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Vanessa Palumbo,

    1. Department of Neurological and Psychiatric Sciences, University of Florence, Italy
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  • John H. Wong,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    3. Department of Neurosurgery, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • William F. Morrish,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Mark E. Hudon,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • William Hu,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Shelagh B. Coutts,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Phillip A. Barber,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Tim Watson,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Mayank Goyal,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Andrew M. Demchuk,

    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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  • Michael D. Hill

    Corresponding author
    1. Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    2. Department of Radiology, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    3. Departments of Medicine, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    4. Departments of Community Health Sciences, Calgary Stroke Program, Foothills Hospital, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
    • Correspondence: Michael D. Hill, Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Foothills Hospital, Room 1242A, 1403 29th Street NW, Calgary, Alberta, T2N 2T9, Canada.

      E-mail: michael.hill@ucalgary.ca

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  • Conflict of interest: Drs. Hill, Demchuk, and Goyal are members of the IMS-3 Steering Committee. The remaining authors have no conflicts of interest to declare.

Abstract

Background

There is an increasing trend to treating proximal vessel occlusions with intravenous–inter-arterial (IV-IA) thrombolysis. The best dose of IV tissue plasminogen activator (tPA) remains undetermined. We compared the combination of full-dose IV recombinant tissue plasminogen activator (rtPA) and IA thrombolytic therapy to IA therapy.

Methods

Between 2002 and 2009, we reviewed our computed tomographic angiography database for patients who received full-dose intravenous rtPA and endovascular therapy or endovascular therapy alone for acute ischaemic stroke treatment. Details of demographics, risk factors, endovascular procedure, and symptomatic intracranial haemorrhage were noted. Modified Rankin Scale ≤2 at three-months was used as good outcome. Recanalization was defined as Thrombolysis in Myocardial Ischaemia 2–3 flow on angiography.

Results

Among 157 patients, 104 patients received IV-IA treatment and 53 patients underwent direct IA therapy. There was a higher recanalization rate with IV-IA therapy compared with IA alone (71% vs. 60%, P < 0·21) which was driven by early recanalization after IV rtPA. Mortality and independent outcome were comparable between the two groups. Symptomatic intracranial haemorrhage occurred in 8% of patients (12% in the IA group, 7% in the IV-IA group) but was more frequent as the intensity of intervention increased from device alone to thrombolytic drug alone to device plus thrombolytic drug(s). Recanalization was a strong predictor of reduced mortality risk ratio (RR) 0·48 confidence interval95 0·27–0·84) and favourable outcome (RR 2·14 confidence interval95 1·3–3·5).

Conclusions

Combined IV-IA therapy with full-dose intravenous rtPA was safe and results in good recanalization rates without excess symptomatic intracranial haemorrhage. Testing of full-dose IV tPA followed by endovascular treatment in the IMS3 trial is justified.

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