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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 58, Num. 3, 2010, pp. 487-487

Neurology India, Vol. 58, No. 3, May-June, 2010, pp. 487

Letter To Editor

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
Correspondence Address: Alexandre Pieri, Department of Neurology, Albert Einstein Hospital, Albert Einstein, 627/701, Morumbi, São Paulo - 05652-000, Brazil, apieri@

Date of Acceptance: 22-Feb-2010

Code Number: ni10124

PMID: 20644289
DOI: 10.4103/0028-3886.65517


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.


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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