Comparison of Combined Venous and Arterial Thrombolysis with Primary Arterial Therapy Using Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke

Wolfe, Thomas; Suarez, Jose I.; Tarr, Robert W.; Welter, Elisabeth; Landis, Dennis; Sunshine, Jeffrey L.; Zaidat, Osama O.

doi:10.1016/j.jstrokecerebrovasdis.2007.12.004

« Previous Next »Journal of Stroke & Cerebrovascular Diseases
Volume 17, Issue 3 , Pages 121-128, May 2008

Comparison of Combined Venous and Arterial Thrombolysis with Primary Arterial Therapy Using Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke

Thomas Wolfe, MD
- Department of Neurology, Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin
Jose I. Suarez, MD
- Department of Neurology, Case Medical Center/Case Western Medical School, Cleveland, Ohio
Robert W. Tarr, MD
- Department of Neuroradiology, Case Medical Center/Case Western Medical School, Cleveland, Ohio
Elisabeth Welter, MS
- Department of Neurology, Case Medical Center/Case Western Medical School, Cleveland, Ohio
Dennis Landis, MD
- Department of Neurology, Case Medical Center/Case Western Medical School, Cleveland, Ohio
Jeffrey L. Sunshine, MD, PhD
- Department of Neuroradiology, Case Medical Center/Case Western Medical School, Cleveland, Ohio
Osama O. Zaidat, MD, MS
- Department of Neurology, Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin
- Department of Neurological Surgery, Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin
- Address correspondence to Osama O. Zaidat, MD, MS, Neurology and Neurosurgery, Medical College of Wisconsin/Froedtert Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226.

Received 4 September 2007; received in revised form 28 November 2007; accepted 7 December 2007.

Objective

We sought to compare the safety and efficacy of combined intravenous (IV) and intra-arterial (IA) thrombolysis with primary IA therapy using tissue plasminogen activator for acute ischemic stroke presenting within 6 hours of symptom onset.

Methods

We performed quasirandomization of a single institution's prospectively collected stroke database, comparing IV/IA (0.6 mg/kg IV ≤ 60 mg, followed by 0.3 mg/kg IA ≤ 30 mg) versus primary IA. Outcome measures include 90-day modified Rankin scale score, mortality, symptomatic intracerebral hemorrhage, and recanalization rates. Statistical analysis was performed using bivariate and propensity score methods.

Results

Of 1057 patients, 41 patients were treated with IV/IA, and 55 with IA. There was significant difference in time to treatment (mean of 151 minutes for the combined group and 261 minutes for the IA, P < .0001) and arterial tissue plasminogen activator dose (17.5 mg for IV/IA v 22.8 mg for IA only, P = .05). Propensity score matching yielded 25 patients in each group. Symptomatic intracerebral hemorrhage rate was 12% in each group. Mortality was 20% in the IV/IA group versus 16% in the IA group (relative risk 1.3 [0.4-4.1], P = .7). More patients in IV/IA group had modified Rankin scale score less than or equal to 2 (odds ratio 1.6 [0.5-5.8], P = .3). Recanalization was 64% with IV/IA versus 48% with IA (odds ratio 1.9 [0.5-7.0], P = .3).

Conclusion

This study demonstrates that both combined IV/IA and primary IA recombinant tissue plasminogen activator therapy is feasible and safe in the treatment of acute ischemic stroke. Combined IV/IA therapy may be associated with an improvement in clinical outcome without a significant increase in the risk of symptomatic intracerebral hemorrhage and mortality compared with IA therapy.

Key Words: Cerebrovascular, acute stroke, ischemic stroke, thrombolytics, combination therapy, recombinant tissue plasminogen activator, endovascular