ISCHEMIC STROKE / ACUTE THERAPY

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

IAT after previous mechanical thrombectomy