ISCHEMIC STROKE / ACUTE THERAPY
Intra-arterial thrombolysis
Created 16/09/2022, last revision 12/04/2023
- intra-arterial thrombolysis (IAT) = administration of thrombolytic agent via catheter directly into the occluded artery
- several trials using prourokinase (MELT, PROACT) and alteplase ( IMS-3, SYNTHESIS) showed the benefit of this therapy
- MELT The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial)
- PROACT-2 (Prolyse in Acute Cerebral Thromboembolism)
- IMS 3 (Interventional Management of Stroke trial)
- demonstrated that the combined IV+IA approach to recanalization may be more effective than standard IVT alone for moderate to severe strokes with a similar safety profile
- alteplase (tPA) is used in clinical practice; dosage is not standardized
- the standard therapeutic window for IAT was 0-6h; studies with advanced imaging (showing penumbra) are not available (the individual window can theoretically be taken from IVT studies – but this is not discussed in the guidelines)
Indications
- indications are the same as for mechanical thrombectomy (MT)
- IAT is nowadays rarely used as a stand-alone procedure; MT is preferred as a more potent recanalization technique
- IAT can be performed:
- when the thrombus is inaccessible for mechanical recanalization (extreme kinking, etc.)
- to treat distal embolization (incl. those occurring during embolectomy) (Khatri, 2022) [Kaesmacher, 2019]
- as a rescue procedure after failed MT; the good effect of MT followed by IAT was reported in the CHOICE trial (Zaidi,2019)
Contraindications
Apart from the usual contraindications to thrombolysis :
- arterial dissection
- proximal (usually carotid) stenosis or significant coiling preventing a microcatheter delivery to the occluded segment
- extensive signs of ischemia on CT or absence of penumbra on CT perfusion
Procedure
Dosing according to original IAT protocols
Content available only for logged-in subscribers (registration will be available soon) |
IAT after previous mechanical thrombectomy
- tPA dosing according to the CHOICE trial – alteplase 0.225 mg/kg; max 22.5 mg, administered within 15-30 minutes in patients with TICI 2b-3