What is the role of intra-arterial delivery of fibrinolytic agents in the treatment for ischemic stroke?

Updated: May 27, 2020
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

Theoretically, intra-arterial delivery may produce higher local concentrations of the fibrinolytic agent at lower total doses (and thus possibly lower the risk of a systemic bleed) and allow a longer therapeutic window. However, the longer time for initiating intra-arterial administration may mitigate some of this advantage and earlier phase II studies did not show a statistically significant difference in clinical outcomes. [1]

The Interventional Management of Acute Stroke Study (IMS-III) was halted for futility after showing no additional benefit from intra-arterial therapies (rt-PA, mechanical thrombectomy with mostly first-generation devices, or both) compared with intravenous rt-PA in patients with large-vessel occlusions. Additional analyses of the IMS III data are under way to better understand the results and potentially identity subsets of patients who may benefit from the combined approach. [95]

Intra-arterial fibrinolysis has been the traditional approach for patients with stroke from basilar artery occlusion. However, results of the Basilar Artery International Cooperation Study (BASICS), a prospective registry study in 592 patients, did not support unequivocal superiority of intra-arterial fibrinolysis over intravenous fibrinolysis. [96]

A meta-analysis of case studies involving a total of 420 patients with basilar artery occlusion did indicate that recanalization was achieved more frequently with intra-arterial fibrinolysis than with intravenous fibrinolysis (65% vs 53%), but the report also found that death and long-term disability were equally common with the 2 techniques. [97] These researchers concluded that intravenous fibrinolysis represents probably the best treatment that can be offered to these patients in hospitals without a 24-hour interventional neuroradiologic service. [97]


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