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Combined Intravenous and Intraarterial Revascularization Therapy Using MRI Perfusion/Diffusion Mismatch Selection for Acute Ischemic Stroke at 3–6 h After Symptom Onset

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Abstract

Background and Purpose

Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) has demonstrated favorable clinical outcomes in a 3–6 h window in patients selected with perfusion/diffusion mismatch. However, the advantages of combined IV and intraarterial (IA) thrombolysis after 3 h of stroke onset are unexplored.

Methods

Acute ischemic stroke patients with persistent occlusion of intracranial large arteries were screened prospectively for thrombolysis by evaluating perfusion/diffusion mismatch on MRI. The IV rt-PA was initiated within 3–6 h, and additional urokinase (UK) was then administered via the IA route after angiography.

Results

Four patients had middle cerebral artery occlusion and one patient had an internal carotid artery occlusion. The median time from the symptom onset to the initiation of IV therapy and to the initiation of IA treatment was 215 ± 30 min and 292 ± 41 min, respectively. The median National Institutes of Health Stroke Scale (NIHSS) scores were as follows: initial, 13; immediately after IA treatment, 8; at 24 h, 5; and at 7 days, 3. The Thrombolysis in Myocardial Infarction (TIMI) score after the completion of thrombolysis was 2–3. Four patients without intracerebral hemorrhage recovered completely or exhibited mild disability and one patient with hemorrhage also demonstrated a favorable outcome.

Conclusion

This preliminary result suggests that if a significant perfusion/diffusion mismatch on MRI is identified, a sequential combination thrombolysis of IV rt-PA and IA UK is potentially beneficial in moderate to severe acute ischemic stroke patients who are treated within 3–6 h after symptom onset.

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Acknowledgments

This study was supported partly by a grant of the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (A060171) and a grant of the SNUBH Research Fund (09-2004-007).

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Authors and Affiliations

  1. Department of Neurology, Seoul National University Bundang Hospital, 300, Gumi-Dong, Bundang-Gu, Seongnam, 463-707, Korea

    Moon-Ku Han, Sang-Bae Ko, Seong-Ho Park & Hee-Joon Bae

  2. Department of Radiology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea

    Sung Hyun Kim & Jae Hyoung Kim

  3. Department of Rehabilitation Medicine, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea

    Nam-Jong Paik

  4. Department of Neurosurgery, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea

    O-Ki Kwon & Chang-Wan Oh

  5. Department of Neurology, Seoul National University Boramae Hospital, Seoul, Korea

    Yong-Seok Lee

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  1. Moon-Ku Han
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Correspondence to Hee-Joon Bae.

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Han, MK., Kim, S.H., Ko, SB. et al. Combined Intravenous and Intraarterial Revascularization Therapy Using MRI Perfusion/Diffusion Mismatch Selection for Acute Ischemic Stroke at 3–6 h After Symptom Onset. Neurocrit Care 8, 353–359 (2008). https://doi.org/10.1007/s12028-007-9046-7

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