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?

Alexandre Pieri, Mariana Spitz, Eduardo Noda Kihara, Alberto Alain Gabbai

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@ einstein.br

Date of Acceptance: 22-Feb-2010

Code Number: ni10124

PMID: 20644289
DOI: 10.4103/0028-3886.65517

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

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