Kim, Sun-Yong, M.D.

Department of RadiologyAjou University Hospital, Suwon, Korea

AGGRESIVE MECHANICAL CLOT DISRUPTION FOR ACUTE ISCHEMIC STROKE WITH LOW DOSE INTRA-ARTERIAL UROKINASE AFTER

FAILURE OF IV THROMBOLYSIS

Introduction:• IV tPA within 3 hours of stroke : - Estabilished treatment for acute ischemic stroke - Large artery occlusion : Early recanalization rate (?)• Following IA therapy with thrombolytics symptomatic intracerebral hemorrhage• Aggressive mechanical clot disruption - Increasing the recanalization rate - Decreasing the time to recanalization - Decrease the dose of thrombolytics

PurposeTo evaluate the efficacy, feasibility

and safety in various aggresive me-chanical thrombus disruption, for low dose intraarterial urokinase after failure of IV thrombiolysis in acute is-chemic stroke

Material & Methods

August 2007 ~ September 2009 : All patients were initially treated and failed by IV tPA

31 patients -Mean age: 66 years(range,37~79years)

Various combinded aggresive me-chanical thrombus disruption

for low dose intraarterial urokinase

Time to treatmentDuration of the procedure Recanalization rate Urokinase dose Rate of symptomatic hemorrhage were analyzed

Clinical outcome measure(NIHSS) - on admission - at discharge - 3 months follow up(mRS>2)

Material & Methods

Results: Angiographic Occlusion Site

T-bifurcation of ICA : 8

M1 segment of MCA : 20

Basilar artery: 3

Mechanical Clot DisruptionTechniques

Microcatheter/microguidewirePeumbraModified Penumbra method (manual Sucction)Stent assisted

Results: IV rt-PA

Average NIHSS score on admission : 16(10-23)

Median time from neurologic symptom on-set :

116 min. (77~177 min)

Dosage of tPA - 0.9 mg/kg : 17 patients - 0.6 mg/kg : 14 patients

Mean time from Sx onset to IA therapy : 195 min.(170~300min)Time lag between IV tPA and IA therapy : 55 ~ 155 minDuration of IA therapy : 61 min(30~80min)Sx onset ~completion of IA therapy: 275 minutes ( 235 -350 min)Median dose of urokinase : 190,000U (in 5 patients urokinase was not used)No procedure related complications

Results: IA therapy

Results: Recanalization RateThrombolysis in Cerebral Is-chemia(TICI)0 (No perfusion) 1 (3%) I (penetration but no perfusion) 2 (6%) II (partial perfusion) IIa (with incomplete distal fiilling<50%) 3

(9%) IIb ( 50-99%) 1 (3%) IIc (near complete perfusion but with 21

(63%) delay in contrast runoff) III (full normal perfusion) ; 3 (9%)

Grade No (%)

Clinical Outcomes Author

IMS I Study(n=80)

IMS II Study(n =81)

Mortality rate at 3 months (%) 3.2 (1) 16 16

Symptomatic ICH (%) 3.2 (1) 6.3 9.9

AsymptomaticICH (%) 9.6 (3) 42.5 32.1

mRS 0-2 At 3 months (%) 75 43 46

NIHSS Score : Initial, 16(10 – 23) , Discharge , 5 ( 3 – 13)

Outcomes at 3Mo : Excellent: 8, Good: 17, Poor: 6

F/75 Rt. Hemiparesis, Sensory aphasia Atrial fibrillation, Onset to door: 40 minutesIV rt-PA : 50mg (NIHSS 14, duration: min. 5Hr30min)

IA UK 150,000U with mechanical dis-ruptionNIHSS, Initial : 14 - NIHSS at 3 day: 7

F/75IV rt-PA: 55 mgOnset to door: 150 minutes

Uk: 100,000U

Initial 3 days later

MTT TTPCBF

M/42 Rt. Hemiparesis, Sensory aphasia IVtPA: 0.9mg/kg , NIHSS 14, duration: min. 2Hr max. 3Hr30min)

CBV

Penumbra system aspiration

IA UK 100,000U with mechanical dis-ruption

NIHSS score, Initial : 14, at discharge: 6

M/83IV rt-PA: 58 mgAtrial fibrillation / Congestive heart failure / Pericardial effu-sionNIHSS 15, duration: : 5hours 30min

???????

UK: 120,000U

MR Diffusion/Perfusion after Treatment

NIHSS( Initial) : 15 at dis-charge: 5

Conclusions Even after failed IV thrombolysis patients with acute is-

chemic stroke, aggressive mechanical thrombus disruption IA therapy relatively high recanalization rate low dose IA urokinase less symptomatic hemorrhages

Excellent clinical out-comes

• Primary use of technique, may enhance neurologic recovery