'New Horizon' for Stroke Treatment

Laurie Barclay, MD

November 26, 2002

Nov. 26, 2002 — Patients ineligible for standard-dose thrombolytic therapy for stroke may respond either to low-dose intra-arterial thrombolytic therapy or a combination of drugs plus mechanical disruption of the clot, according to a report in the November issue of Neurosurgery.

"This trial opens up a new horizon for stroke treatment," lead author Adnan I. Qureshi, MD, from the State University of New York, Buffalo, says in a news release. "The biggest fear in stroke treatment is that the situation can be made worse. In this pilot study, none of the patients experienced damaging hemorrhages."

This prospective study treated 19 consecutive patients who were considered poor candidates for intravenous alteplase therapy or who did not improve after intravenous thrombolysis. Mean age was 64.3 ± 16.2 years, and there were 10 men. Initial National Institutes of Health (NIH) Stroke Scale scores ranged from 11 to 42. Occlusion sites were in the middle cerebral artery in nine patients, the cervical internal carotid in seven, the basilar in two, and the intracranial internal carotid in one. Time from onset to treatment ranged from one to nine hours.

Treatment began with intra-arterial reteplase in 1-U increments via superselective catheterization to a maximum total dose of 4 U. If the initial doses did not result in recanalization, patients underwent mechanical angioplasty for proximal occlusion or snare manipulation for distal occlusion. The remaining doses of thrombolytics were then given as needed for further recanalization. Of the 19 patients, five had thrombolysis alone, 11 had angioplasty, and five had snare maneuvers.

Complete angiographic restoration of blood flow, or modified Thrombolysis in Myocardial Infarction (TIMI) criteria grade 4, was observed in 12 patients. Four patients had near-complete restoration of flow (modified TIMI grade 3), one had minimal response (modified TIMI grade 1), and two had no response (modified TIMI grade 0). At 24 hours, seven patients had neurologic improvement (reflected in decline of at least four points in NIH Stroke Scale score), and five other patients had further improvement at seven to 10 days. No vessel rupture, dissection, or symptomatic intracranial hemorrhages were observed.

At one- to three-month follow-up, 10 patients had died, one soon after treatment, six of a massive second stroke, one of a myocardial infarction, and three of complications of pneumonia. Two patients developed disability related to the stroke, but seven of the original 19 patients were functionally independent.

"Almost all of these patients would be expected to do really poorly," Quereshi says. "More than one-third now are able to live with good functional capacity.... Given the selection of patients, this is an impressive result."

Comments accompanying the article stress the need for a prospective, randomized clinical trial.

Neurosurgery. 2002;251(5):1319-1329

Reviewed by Gary D. Vogin, MD