Intra-arterial versus intra-venous thrombolysis within and after the first 3 hours of stroke onset

• Published in: Archives of medical science Vol. 6; no. 3; pp. 303 - 315
• Main Authors: Padma, Srivastava, Majaz, Moonis
• Format: Journal Article
• Language: English
• Published: Poland Termedia Publishing House 30.06.2010
• Subjects: Review Paper; thrombolysis; intravenous; re-canalization; intra-arterial; ischemic stroke
• ISSN: 1734-1922; 1896-9151
• DOI: 10.5114/aoms.2010.14248

The NINDS trial demonstrated for the first time the effectiveness of intravenous thrombolysis in improving outcome after acute ischemic stroke. The absolute benefit of this intervention was 11-13% greater chance of being normal or near normal (MRS ≤ 1) at 3 months. However, if patients with severe stroke were considered (NIHSS ≥ 20), the absolute benefit dropped to 5-6%, indicating that IV thrombolysis may not be as effective for large vessel occlusion. This observation was further supported by TCD studies that clearly demonstrated that large artery occlusions had a recanalization rate of 13-18% with IV rt-PA. Intra-arterial thrombolysis achieves recanalization rates of 60-70%. Since tissue viability is clearly important, it is time to stop defining rigid time windows and if there is a large penumbra (20-50%) and the occlusion is in a large artery, there exists a logic and a growing evidence to consider either bridge therapy or direct intra-arterial therapy.