Combined intravenous and intra-arterial recombinant tissue plasminogen activator in acute ischemic stroke

Background and Purpose-A retrospective analysis was performed on 20 consecu tive patients who presented with severe acute ischemic stroke and were eval uated for a combined intravenous (IV) and local intra-arterial (IA) recombi nant tissue plasminogen activator (rtPA) thrombolytic approach within 3 hou rs of onset. Methods-Twenty consecutive patients with carotid artery distribution stroke s were evaluated and treated using a combined IV and IA rtPA approach over a 14-month period (September 1998 to October 1999). rtPA (0.6 mg/kg) was gi ven intravenously (maximum dose 60 mg); 15% of the IV dose was given as bol us, followed by a continuous infusion over 30 minutes. A maximal IA dose, u p to 0.3 mg/kg or 24 mg, whichever was less, was given over a maximum of 2 hours. IV treatment was initiated within 3 hours in 19 of 20 patients. All 20 patients underwent angiography, and 16 of 20 patients received local IA rtPA. Results-The median baseline National Institutes of Health Stroke Scale (NIH SS) score for the 20 patients was 21 (range 11 to 31). The median time from stroke onset to IV treatment was 2 hours and 2 minutes, and median time to initiation of IA treatment was 3 hours and 30 minutes. Ten patients (50%) recovered to a modified Rankin Scale (mRS) of 0 or 1; 3 patients (15%), to an mRS of 2; and 5 patients (25%), to an mRS of 4 or 5. One patient (5%) de veloped a symptomatic intracerebral hemorrhage and eventually died. One oth er patient (5%) expired because of complications from the stroke. Conclusions-We believe that the greater-than-expected proportion of favorab le outcomes in these patients with severe ischemic stroke reflects the shea time to initiation of both IV and IA thrombolysis.