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To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1552-6569.2008.00357.x Byline: Marc Ribo (1), Carlos A. Molina (1), Beatriz Alvarez (1), Marta Rubiera (1), Jose Alvarez-Sabin (1), Manel Matas (1) Keywords: Stroke; ultrasound; intra arterial; thrombolysis; microbubbles Abstract: ABSTRACT BACKGROUND Microbubbles (MB) and ultrasound have been shown to enhance thrombolysis. We sought to evaluate safety and efficacy on middle cerebral artery (MCA) recanalization of local MB administration during intra-arterial (IA) thrombolysis and continuous transcranial Doppler (TCD) monitoring. METHODS Patients with acute M1-MCA occlusion were treated with intravenous tissue plasminogen activator (iv-tPA) and continuously monitored with TCD. If recanalization was not achieved during first-hour bridging IA-rescue was adopted: MB + tPA direct intraclot microcatheter infusion. TCD flow monitoring allowed continuous insonation at clot location. Recanalization was angiographically assessed (thrombolysis in cerebral infarction [TICI] score) and compared with simultaneous TCD data. IA procedures were stopped at 6 hours. Recanalization was reassessed at 12 hours (TCD). Neurological status was repeatedly assessed (National Institutes of Health Stroke Scale [NIHSS]). At three months, patients were considered independent if mRS [less than or equal to] 2. RESULTS Of the 18 included patients (mean age 72), 16 received standard iv-tPA (.9 mg/kg). Nine patients were recanalized during tPA infusion and 9 patients underwent IA-rescue procedures. Median pre-IA NIHSS score: 20. Median time to IA initiation was 175 [+ or -] 63 minutes. Mean IA doses were tPA = 10 [+ or -] 3 mg and MB = 3 [+ or -] 1 mL. TCD monitoring allowed direct visualization of massive MB arrival during every administration. In-procedure recanalization was observed in 78% (n= 7): complete-TICI3 in 22% (n= 2), partial-TICI2 in 56% (n= 5). Perfect correlation was observed between TICI and TCD scores. At 12 hours complete recanalization increased to 56%, partial to 22%. One patient (11%) experienced symptomatic intracranial hemorrhage accounting for the only death. Median NIHSS evolution was 12 at 24 hours and 10 at discharge. At 3 months 4 patients (44%) were independent. CONCLUSION The combination of ultrasound and IA MB and tPA may be a strategy to enhance the thrombolytic effect and increase recanalization rates. Author Affiliation: (1)From the Unitat Neurovascular, Servei de Neurologia, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain (MR, CAM, MR, JA-S); Servei de Cirurgia Vascular i Endovascular, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain (BA, MM). Article History: Acceptance: Received July 21, 2008, and in revised form October 12, 2008. Accepted for publication November 1, 2008. Article note: Correspondence: Address correspondence to Marc Ribo, Unitat Neurovascular, Servei de Neurologia, Hospital Vall d'Hebron., Passeig de la Vall d'Hebron 119-129, Barcelona 08035, Spain. E-mail: marcriboj@hotmail.com

Background and Purpose: The role of Alberta Stroke Program Early CT score (ASPECTS) in predicting which patients are likely to benefit from endovascular therapy (EVT) is not well defined. An automated software (e-ASPECTS) has been created to solve its poor interrater reliability. We aim to evaluate correlation between radiologist (Rx) and e-ASPECTS scoring with cerebral blood volume (CBV) infarct core and with final infarct volume; as well as with long-term functional outcome.Methods: We included patients with acute ischemic stroke and large vessel occlusion who underwent EVT. We measured baseline radiologist (Rx) ASPECTS and e-ASPECTS, and baseline CBV infarct core on CT perfusion. Final infarct volume was measured on 24-hour control CT.Results: We included 184 patients, in which 82.1% of patients achieved complete recanalization. Median Rx-ASPECTS/e-ASPECTS was 9 (IQR 8-10 vs. IQR 7.75-10) and mean CBV lesion was 29.51 (±47.41) mL. Correlation (rs ) between ASPECTS and e-ASPECTS was .44 (P < .01). Both ASPECTS scores correlated with CBV after 180 minutes of symptom onset (rs = -.41 vs. -.54, P < .01) and with final infarct volume in patients with complete recanalization (rs = -.40 vs. -.43, P < .01). In a logistic regression, either Rx-ASPECTS, e-ASPECTS, and CBV (OR 1.60 vs. 1.87 vs. .96; P < .05) predicted a low infarct volume. Rx-ASPECTS and e-ASPECTS also predicted functional independence (mRS 0-2) at 3 months (1.52 vs. 1.37; P < .05).Conclusion: ASPECTS and e-ASPECTS showed a mild correlation with CBV. Rx-ASPECTS, e-ASPECTS, and CBV predicted a low infarct volume after thrombectomy in recanalized patients but only Rx-ASPECTS and e-ASPECTS predicted functional independence at 3 months. [ABSTRACT FROM AUTHOR]

BACKGROUND Acute ischemic stroke treatment is meant to induce early reperfusion before ischemic lesion becomes definitive; unfortunately, in many cases, recanalization occurs too late. We present a case in which oxygenated blood was perfused through the occluding clot during intra-arterial (IA) thrombolysis to anticipate reperfusion. A 63-year-old woman was admitted 1 hour after acute left-sided hemiplegia National Institutes of Health Stroke Scale (NIHSS 18). Transcranial Doppler (TCD) showed proximal right middle cerebral artery (MCA) occlusion. Systemic thrombolysis failed to recanalize MCA, so IA rescue was initiated. During the procedure, TCD recorded flow in MCA. A microcatheter was passed through the clot and 20 mL of oxygenated blood was injected over 2 minutes beyond occlusion. During blood perfusion, TCD detected nonpulsating flow in distal M2 branches. Then, tissue plasminogen activator (t-PA) was injected directly intrathrombus; mechanic fragmentation was also attempted. No recanalization was observed, however, neurological status partially improved. The process was repeated until 6 hours after symptom onset. Only partial Thrombolysis in Cerebral Ischemia (TICI-2a) recanalization was achieved, but physical examination revealed substantial improvement: NIHSS score of 11. Repeated TCD showed partial recanalization (9 hours) and complete recanalization (12 hours). At 24 hours, NIHSS score was 1. CONCLUSION Momentary reperfusion of ischemic penumbra with oxygenated blood is feasible and may allow to “buy time” until definitive reperfusion is achieved. [ABSTRACT FROM AUTHOR]