Safety of intra-arterial thrombolysis in the postoperative period

Background and Purpose-Limited systemic fibrinolysis and reduced dosage are features of intra-arterial thrombolyis (IAT) that may be advantageous in t he treatment of postoperative strokes. However, IAT may increase the risk o f surgical bleeding. We sought to determine the safety of postoperative IAT . Methods-This was a retrospective case series from 6 university hospitals. A ll cases of IAT within 2 weeks of surgery were identified. Demographics, st roke mechanism, stroke severity, imaging and angiographic findings, time be tween surgery and lysis, thrombolytic agent used, surgical site bleeding, i ntracranial bleeding, and mortality rates were determined. Death or complic ations directly related to IAT were determined. Results-Thirty-six patients (median age, 71.5 years; range, 45 to 85) were identified. Median time from surgery to stroke was 21.5 hours (range, 1 to 120). Open heart surgery was done in 18 (50%), carotid endarterectomy in 6 (17%), craniotomy in 3 (8%), ophthalmologic-ear, nose and throat surgery in 2 (6%), urologic-gynecologic surgery in 4 (11%), orthopedic surgery in 2 ( 6%), and plastic surgery in 1 (3%). The stroke causes were cardioembolism i n 24 (67%), large-vessel atherosclerosis in 4 (11%), dissection in 3 (8%), postendarterectomy occlusion in 4 (11%), and radiation arteriopathy in 1 (3 %). Median time to angiogram was 2.5 hours (0.1 to 5,5). Occlusion sites we re M1 in 19 (53%), M2 in 9 (25%), internal carotid artery in 5 (14%), basil ar artery in 2 (6%), and posterior communicating artery in 1 (3%). Thrombol ysis was completed at a median of 4.5 hours (range, 1 to 8.0). Tissue plasm inogen activator was used in 19 (53%) and urokinase in 17 (47%). Nine (26%) patients died. Surgical site bleeding occurred in 9 (25%) cases (minor in 6, major in 3). The major surgical bleeds were 2 post-craniotomy intracrani al hemorrhages and 1 hemopericardium after coronary artery bypass grafting; all were fatal. Six deaths were non-IAT related: 3 caused by cerebral edem a and 3 by systemic causes. Major bleeding complications were significantly more common among patients with craniotomy (P <0.02). Conclusions-Postoperative IAT carries a risk of bleeding in up to 25% of pa tients but is usually minor surgical site bleeding. Avoiding IAT in intracr anial surgery patients may reduce complications. Mortality rate in this ser ies was similar to that reported in prior IAT trials. IAT remains a viable therapeutic option for postoperative strokes.