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Objective To evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) as an adjunct to endovascular clot retrieval (ECR) in ischaemic stroke, we performed a systematic review and meta-analysis of the literature. Methods Searches were performed using Medline, Embase, and Cochrane databases for studies that compared ECR to ECR with adjunctive IAT (ECR+IAT). Safety outcomes included symptomatic intracerebral haemorrhage (sICH) and mortality at three months. Efficacy outcomes included successful reperfusion (Thrombolysis in Cerebral Infarction score of 2b to 3), and functional independence, defined as a modified Rankin Scale score of 0 to 2 at three months. Results Five studies were identified that compared combined ECR+IAT (IA alteplase or urokinase) to ECR-only, and were included in the random effects meta-analysis. There were 1693 ECR patients, including 269 patients treated with combined ECR+IAT and 1424 patients receiving ECR-only. Pooled analysis did not demonstrate any differences between ECR+IAT and ECR-only in rates of sICH (OR: 0.61, 95% CI: 0.20-1.85; P=0.78), mortality (OR: 0.77, 95% CI: 0.54-1.10; P=0.15), or successful reperfusion (OR: 1.05, 95% CI: 0.52-2.15; P=0.89). There was a higher rate of functional independence in patients treated with ECR+IAT, although this was not statistically significant (OR: 1.34, 95% CI: 1.00-1.80; P=0.053). Conclusions Adjunctive IAT appears to be safe. In specific situations, neurointerventionists may be justified in administering small doses of intraarterial alteplase or urokinase as rescue therapy during ECR.

With an increase in recent years in the number of people receiving cosmetic facial injection treatments of hyaluronic acid, the incidence of hyaluronic acid embolism has also increased commensurately. Hyaluronic acid embolism leads to serious complications, including blindness, eye and eyelid movement disorders, skin necrosis, and cerebral embolism. However, there is a lack of robust clinical evidence regarding the benefits of treatment for hyaluronic acid embolism by intraarterial thrombolysis therapy.This study included 24 patients with a decrease in visual acuity and other complications induced by facial hyaluronic acid injection. Patients underwent emergency intraarterial thrombolysis therapy by injection of hyaluronidase (500 to 1500 units) alone or hyaluronidase (750 to 1500 units) combined with urokinase (100,000 to 250,000 units), followed in both cases by a general symptomatic treatment and nutritional therapy.Ten (42 percent) of 24 patients ultimately had improvements to visual acuity, even when the clinical application of the thrombolytic treatments had passed the recommended window for optimal treatment. In all cases, patients' facial skin necrosis was restored to nearly normal appearance. In addition, the authors found that hyaluronidase combined with urokinase was a more effective therapy than hyaluronidase alone.The authors' results indicate that intraarterial thrombolysis therapy is beneficial to patients suffering from blindness induced by hyaluronic acid embolism. The therapy was shown to be worthy of clinical application because it alleviated the impairment to patients' vision and was also beneficial in the recovery from other serious complications, including eye movement disorder, eye edema, headaches, and skin necrosis.Therapeutic, IV.

Summary Introduction. The reason for using thrombolytic therapy is to eliminate vascular thrombosis and promote vascular permeability. Acute limb ischemia is associated with significant morbidity and mortality. ROCHESTER, STILE and TOPAS studies showed that thrombolytic therapy for acute limb ischemia decreases the rate of surgical interventions and significantly increases the rate of limb salvage. Aim of the Study. The purpose of this study is to assess the efficacy and outcomes of intra-arterial thrombolysis in the treatment of acute occlusions of the lower limb over a four-year period. Material and Methods. We analysed 103 patients who had been treated in our department. There were acute ischemias of stage IIa and IIb according to the Rutherford classification. The data prior to, and after thrombolysis was analysed. We used Alteplase as a thrombolytic agent (mean dose 62 mg ±23.5). Procedural success was based on angiographic and clinical outcomes. Statistics were calculated by SPSS 16. Results. The mean duration of symptoms prior to hospitalisation was 2.5 days (IQR 5-96 hours). The mean age at the time of thrombolysis was 63±11 for males 69±10 years for females. The success of intraarterial thrombolysis was defined by angiographic and clinical outcomes (successful in 86.4% and failed in 13.6%). Adjunctive angioplasty was performed on 39 (37.9%) patients, and immediate reconstructive surgery was required on 19 (18.4%) patients. The incidence of complications was 17,4 %, with the most common being-bleeding from the puncture side, the urinary tract or the gastrointestinal tract. Overall mortality was 8.7%. The women who required thrombolysis were older (p=0,034) and with a higher death rate (p=0.047). A CDT (catheter-directed thrombolysis) for an abdominal aorta thrombosis carries a significantly high mortality rate (p=0.00013). There were no statistically significant differences between the duration of symptoms and limb amputation and between other analysed data. Conclusions. Intraarterial thrombolysis is an effective treatment method in acute limb ischemia for selected patients, as long as accurate procedural monitoring is ensured. Thrombolysis often leads to the discovery of underlying vascular lesions. A CDT for an abdominal aorta thrombosis carries a significantly high mortality rate.

See related article, p 1662 In recent years, endovascular thrombectomy (EVT) has revolutionized care for stroke patients with occlusions of the internal carotid or M1 segment middle cerebral artery.1 In the patient population with distal occlusions, for example, M2 segment, we face increasing heterogeneity with regards to clinical presentation (nondisabling versus disabling symptoms, high versus low eloquence), anatomic variability (number, location, and diameter of different M2 segments) and to our perception of imaging (relative amount of ischemic changes in the segment artery’s territory). Yet, there is growing evidence on safety and efficacy of EVT over standard care practice for M2 segment occlusions.2–4 Distally located clots have not been a primary focus of EVT trials thus far. In this issue, Grossberg et al5 report their experience on EVT for distal vessel occlusions beyond the M2 segment and in any anterior or posterior cerebral artery segment. The most frequent occlusions that were treated were in the M3 segment. From a strict procedural point of view, this report demonstrates the technical feasibility of reopening distal vessel occlusions in 83%. The chosen treatments were stent-retriever technology in 38% of cases, intraarterial thrombolysis in 37% of cases, and aspiration in 31% of cases. Notably, the reperfusion rates were highest when stent-retrievers could be deployed (92%). The report by Grossberg et al5 provides us with insight on …

PURPOSE Hospitals designated as primary stroke centers offer noninvasive treatment for acute ischemic stroke, but only comprehensive stroke centers are equipped to provide endovascular treatment. When stroke patients needing endovascular treatment present to the emergency department at a primary stroke center, they then require inter-hospital transfer to a comprehensive center for definitive treatment. Recent studies have found significant treatment delays and poor clinical outcomes in patients requiring inter-hospital transfer1,2. The primary aim of this study is to determine if inter-hospital transfer impacts clinical outcomes after endovascular treatment for acute ischemic stroke. A secondary aim is to determine whether inter-hospital transfer coincides with any significant treatment delay. METHODS This study involves retrospective chart review for 107 patients undergoing endovascular treatment for acute ischemic stroke at one of three hospitals in Austin, Texas from October 2016 to September 2018. 26 patients required inter-hospital transfer, while 81 (the control group) presented directly to a hospital offering endovascular treatment. Two-tailed T- and U-tests were used for analysis of parametric and non-parametric variables pertaining to time intervals and baseline characteristics. Odds ratios were calculated to compare dichotomized outcomes between groups, with significance determined by chi-square. RESULTS Inter-hospital transfer significantly prolonged onset to groin (mean difference = 37.2 min, p=.02). The transfer group was more likely to experience intracranial hemorrhage (53.9% > 22.2%, p

Objective: To evaluate the cost-effectiveness of neurothrombectomy with a stent retriever (Solitaire**Solitaire Revascularization Device is a registered trademark of Medtronic (Irvine, CA). View all notes Revascularization Device) in treating acute ischemic stroke patients from the UK healthcare provider perspective. Methods: A Markov model was developed to simulate health outcomes and costs of two therapies over a lifetime time horizon: stent-retriever thrombectomy in combination with intravenous tissue-type plasminogen activator (IV t-PA), and IV t-PA alone. The model incorporated an acute phase (0–90 days) and a rest of life phase (90+ days). Health states were defined by the modified Rankin Scale score. During the rest of life phase, patients remained in the same health state until a recurrent stroke or death. Clinical effectiveness and safety data were taken from the SWIFT PRIME study. Resource use and health state utilities were informed by published data. Results: Combined stent-retriever thrombectomy and IV t-PA led to improved quality-of-life and increased life expectancy compared to IV t-PA alone. The higher treatment costs associated with the use of stent-retriever thrombectomy were offset by long-term cost savings due to improved patient health status, leading to overall cost savings of £33 190 per patient and a net benefit of £79 402. Deterministic and probabilistic sensitivity analyses demonstrated that the results were robust to a wide range of parameter inputs. Limitations: The acute and long-term costs resource use data were taken from a study based on a patient population that was older and may have had additional comorbidities than the SWIFT PRIME population, resulting in costs that may not be representative of the cohort within this model. In addition, the estimates may not reflect stroke care today as no current evidence is available; however, the cost estimates were deemed reasonable by clinical opinion. Conclusions: Combined stent-retriever neurothrombectomy and IV t-PA is a cost-effective treatment for acute ischemic stroke compared with IV t-PA alone.

IA-Tx and advanced dynamic imaging studies have been adopted for ischemic stroke patient treatment. Many patients are treated with IV-tPA, but this treatment is not always feasible. In this study, IA-Tx was used for patients for whom IV-tPA was not indicated or when IV-tPA did not result in recanalization. A total of 156 patients treated with IA-Tx were retrospectively reviewed. Of these, 72 patients were treated with a full dose of IV-tPA before receiving the IA-Tx; the remaining 84 patients only received IA-Tx. An initial imaging study using CTA and acute stroke MRI followed. Patients’ demographics and clinical results were recorded and compared according to P/D mismatching and IV-tPA. Among P/D-mismatched patients, the recanalization rate was 80 % and the symptomatic intracranial hemorrhage rate was 14.5 %, while among P/D-matched patients, the rates were 63 % and 41.3 % respectively (p

Introduction Acute basilar artery occlusion (BAO) results in strokes characterized by poor outcome. Intravenous and intraarterial thrombolysis with rt-PA (IV rt-PA and IA rt-PA, respectively) and mechanical thrombectomy (MT) are the most commonly used techniques to treat BAO, but their efficacy remains unclear. Unlike in previous papers, we compared all three methods of the treatment in a single work, including an update of meta-analysis regarding each of the three therapeutic approaches with recent trials. Methods We systematically reviewed all original studies testing the efficacy of any of the three basic methods of BAO treatment dated up to the end of Jan 2017. Results The final analysis included 31 studies that summarized 1358 patients. These subjects were organized into three therapeutic groups: IV rt-PA, IA rt-PA ± IV rt-PA, MT ± IV rt-PA ± IA rt-PA. The weighted pooled estimates of a favorable outcome (mRS 0–2) were 32.57% (95% CI 16.44–51.03%/I2 = 67.5%, p = 0.0795) in the first group, 22.56% (95% CI 16.85–28.79%/I2 = 52.1%, p = 0.027) in the second group, and 37.04% (95% CI 32.27–41.92%/I2 = 32%, p = 0.0895) in the third group. The Q-test subgroup analysis revealed the statistical superiority of MT ± IV rt-PA ± IA rt-PA over IA rt-PA ± IV rt-PA (mRS 0–2: p = 0.0003, mRS 6: p = 0.0010) and over any rt-PA administration (either IV rt-PA or IA rt-PA ± IV rt-PA) (mRS 0–2: p = 0.0006, mRS 6: p = 0.0056). Conclusions Current data on the effects of the three basic approaches of the treatment of BAO are insufficient to generate high-class EBM guidelines. MT seems to be the most effective method of the treatment of acute BAO. The efficacy of IV or IA thrombolytic therapy in this indication remains unclear.

Thrombosis, mainly venous, is a rare and well-recognized extraintestinal manifestation of inflammatory bowel disease (IBD). We describe a 25-year-old Caucasian man affected by ulcerative colitis and sclerosing cholangitis with an episode of right middle cerebral arterial thrombosis resolved by intraarterial thrombolysis. We perform a brief review of the International Literature.

BackgroundPostinterventional cerebral hyperdensities (PCHDs) are a common finding after endovascular stroke treatment. There is uncertainty about the extent to which PCHDs correspond to hemorrhage or contrast staining. Our aim was to evaluate the use of PCHD density on immediate postinterventional CT, and PCHD evolution on follow-up CT for differentiating contrast staining from hemorrhage after endovascular treatment.MethodsWe retrospectively reviewed the imaging data of 84 patients who underwent endovascular treatment for acute arterial ischemic stroke in the anterior circulation and who received an immediate postinterventional CT, a follow-up CT within 36 h, and a follow-up MRI within 10 days.ResultsPCHDs were seen in 62 of 84 patients in a total of 130 Alberta Stroke Program Early CT Score (ASPECTS) areas. A specificity of 100% to predict hemorrhage was only seen for PCHDs with densities ConclusionsThere are no density thresholds for PCHDs that allow predicting the absence or presence of hemorrhage with 100% specificity and acceptable sensitivity. A CT scan performed at least 19–24 h after endovascular therapy is the only reliable method to differentiate contrast staining from hemorrhage.

Bei gezielter Indikationsstellung kann das Risiko einer Langzeitbehinderung bei Patieten mit akutem Hirninfarkt durch eine intravenöse Thrombolyse und/oder durch endovaskuläre Behandlungsstrategien signifikant vermindert werden. Bei fehlenden Kontraindikationen sollten Patienten mit akutem Hirninfarkt, die innerhalb des Zeitfensters auf der Notfallstation eintreffen, konsequent und ohne Zeitverzögerung mittels Thrombolyse behandelt werden. Die aktuellen Daten weisen darauf hin, dass Patienten mit einem schwergradigen akuten Hirninfarkt und einem proximalen Gefäßverschluss (i. e. Hauptstamm der Arteria cerebri media, posterior, evtl. auch anterior, Arteria carotis interna und basilaris) endovaskulär, Patienten mit einem peripheren Gefäßverschluss (Ast der Arteria cerebri media, anterior und posterior) und leichtgradigen Symptomen intravenös behandelt werden sollten.

In this study, we propose a new method for the enhancement of intraarterial thrombolysis by use of an endovascular vibrating polymer actuator probe (VPAP), which is fabricated from an ionic polymer metal composite (IPMC) actuator. The endovascular VPAP was fabricated by combining 0.8 × 0.8 × 10 mm3 IPMC samples, 0.22 mm × 50 cm copper wires, and 40 cm of Teflon tube. The purpose of this study was to evaluate the thrombolysis efficiency of an endovascular VPAP in a dog model. Both renal arteries of the enrolled dogs (n = 5) were used in the current study. A distal portion of the renal artery in a mongrel dog was occluded by a blood clot from autologous venous whole blood. Intraarterial thrombolysis was performed by use of a VPAP without the actuation force (control group), by a VPAP-only (VPAP-only group), or with a combination of recombinant tissue plasminogen activator (rtPA) and a VPAP (VPAP + rtPA group). The thrombolysis efficiency was evaluated by the modified Thrombolysis in Myocardial Infarction (TIMI) grading system based on the consensus between two radiologists. The grading scales were compared according to each intraarterial thrombolysis method. The VPAP + rtPA and VPAP-only groups showed a significantly higher thrombolysis efficiency than did the control group (p < 0.05). The VPAP-only group also showed a significantly higher thrombolysis efficiency than did the control group (p < 0.05). The VPAP+ rtPA group showed a significantly higher thrombolysis efficiency than did the VPAP-only group (p < 0.05). The use of an endovascular VPAP was a feasible and useful method for intraarterial thrombolysis, and it enhanced the thrombolysis efficiency when combined with the thrombolytic agent rtPA.

Unenhanced computed tomography (CT) revealed hyperattenuating lesions in two patients with acute stroke immediately after clot retrieval with the Merci device in one patient and after intraarterial thrombolysis in the other. These areas of hyperattenuation were noted in the middle cerebral artery territory in the first patient and involving the brainstem, cerebellum, and tentorium in the second. Both were falsely interpreted as subarachnoid hemorrhage. The area of hyperattenuation resolved within a few hours in both patients, reflecting contrast medium extravasation/leakage. This report highlights the need to improve physician skill in recognizing contrast medium extravasation that is common following neuroendovascular procedures, which are becoming commonplace in modern day medicine.

Intraarterial thrombolysis and mechanical embolectomy have been studied for endovascular treatment of stroke. The MERCI and Multi MERCI trials of mechanical embolectomy with or without adjuvant intraarterial thrombolysis demonstrated effective recanalization, but with a higher mortality compared with control patients in the PROACT II trial of intraarterial thrombolysis. Differences in trial design may account for this mortality difference.We identified patients in the MERCI and Multi MERCI trials who would have been eligible for PROACT II. Rates of good outcome (mRSor =2) and mortality at 90 days were compared, adjusting for differences in baseline NIHSS score and age.Sixty-eight patients enrolled in MERCI and 81 enrolled in Multi MERCI were eligible for PROACT II. In both unadjusted and adjusted analyses, PROACT II-eligible embolectomy patients showed a trend toward better clinical outcomes compared to the PROACT II control arm (adjusted, MERCI 35.4% [p = ns], Multi MERCI 42.8% [p = 0.048], PROACT II control, 25.4%). In both unadjusted and adjusted analyses, mortality rates did not significantly differ between embolectomy patients and PROACT II control patients (adjusted analysis, MERCI 29.1%, Multi MERCI 18.0%, PROACT II control, 27.1%). Compared with the PROACT II treatment group, embolectomy groups showed similar rates of good outcome and mortality.Differences in mortality and proportion of good outcome between the MERCI/Multi MERCI trials and the PROACT II trial are explained by differences in study design and baseline characteristics of patients. Mechanical embolectomy and IA thrombolysis may each be reasonable strategies for acute stroke; a randomized trial is necessary to confirm these results.

Up to the mid-1990 s, the treatment of acute ischemic stroke was almost anecdotal. The introduction of systemic thrombolysis dramatically changed the scenario improving patient outcomes and becoming the standard of care for patients who present within 3 h from the onset of symptoms. Other options, such as intraarterial thrombolysis, or different mechanical reperfusion approaches, have been tested in the past few years. The benefit-risk profile of these approaches is discussed in this review. The current main challenge in the therapy of acute stroke is to define the optimal strategy for patients excluded from thrombolysis because of delayed presentation or older age and for patients treated with thrombolysis that do not reperfuse.

INTRODUCTION: Intraarterial thrombolysis of acute arterial occlusions in the lower limbs is an established therapeutic procedure. However, its value as a primary treatment is discussed controversially and it is mostly seen as a competing procedure to primary vascular surgical interventions. METHODS: From January 2001 to December 2004, we performed a total of 132 intraarterial thrombolysis propcedures in 112 patients with acute or subacute ischaemia of the lower limbs. In the majority of the cases, there was an ischaemia of stage I or II a according to Rutherford, a few further cases were in stage II b at the start of treatment. The patients' ages at the time of thombolysis was 64.7 ± 11.3 years (mean value ± standard deviation, range: 27-91 years). There were 46 female and 86 male patients. RESULTS: The average duration of thrombolysis was 35.2 ± 20.8 hours (mean ± standard deviation, range: 6-142 hours). As median 2 (range: 0-8) angiographic controls were performed. In 100 cases (75.8 %), an operation could be avoided by thrombolysis alone or in combination with an supplementary intervention. On the other hand, in 32 cases (24.2 %) a subsequent operative therapy including 10 major amputations (7.6 %) was necessary. Because of hemorrhagic complications, 15 thrombolysis procedures (11.4 %) had to be terminated prematurely but only 2 patients required an inguinal revision. Therapy-related mortality was 0.8 % (1 patient). CONCLUSION: In the majority of our patients, primary intraarterial thrombolysis was successful and often led to the discovery of the underlying vascular lesion. It can serve both as a therapeutic alternative to a primary vascular surgical intervention and as the foundation further interventional or vascular surgical therapies although this cannot always be predicted for individual cases.

Background and Purpose - Because of the risk of hemorrhage, especially in the brain, thrombolytic therapy with intravenous alteplase is restricted by guidelines, and only a small number of selected patients are being treated. Findings from metaanalyses, post hoc analyses of the randomized trials, and postlicensing experience suggest that more subjects, who otherwise have a poor predicted outcome without treatment, might benefit from intravenous alteplase. Summary of Review - There is a strong indication that treatment may still be beneficial beyond 3 hours up until 4.5 hours. The risk of symptomatic intracerebral hemorrhage is not increased in patients aged 80 years or older. Excluding patients with severe stroke or with early ischemic changes in more than one third of the middle cerebral artery territory on baseline CT scan is probably not necessary when treatment is started

Even 10 years after the approval of thrombolysis this life-saving and disability reducing therapy is still underused. important reasons for that are very strict inclusion criteria such as the early and narrow time-window, fear of bleeding complications and doubts regarding the effectivity. An intensive and constant effort is required to educate the public that stroke is a treatable emergency. In addition to the medical reasons, economic considerations in a context of decreasing resources emphasize the importance of effective stroke treatment. The results of numerous recent studies such as the European register SITS-MOST help to strengthen the confidence in thrombolysis. In addition the development and advancement of new imaging tools such as multiparametric MRI and advanced CT-techniques will improve patient selection and may enable us to extend the time-window for treatment. Intraarterial thrombolysis,,,bridging" methods and new devices for intravascular intervention are the subjects of intensive ongoing research. Even though no randomized trials are available intraarterial thrombolysis is the treatment of choice for acute basilar occlusion, but if this intervention is not available an intravenous approach may be an equal alternative.

We performed intraarterial thrombolysis in 36 patients with evolving acute cerebral infarction due to occlusion of the middle cerebral artery (MCA). Angiographic sites of arterial occlusion were divided into 3 types: 1) M1 proximal occlusion type, MCA trunk occlusion proximal to the lenticulostriate arteries (16 patients), 2) M1 middle portion occlusion type, MCA trunk occlusion with partial involvement of the lenticulostriate arteries (9 patients), and 3) M1 distal occlusion type, MCA trunk occlusion distal to the lenticulostriate arteries (11 patients). The modified Rankin Scale (mRS) was used to assess clinical outcome at discharge. The rate of partial or complete recanalization in the proximal occlusion group was 44%, that in the middle portion occlusion group was 67%, and that in the distal occlusion group was 73%. There were trends toward the better recanalization rate in distal occlusions. Excellent or good outcome (mRS score 0 to 2) was seen in 13% of patients in the proximal occlusion group, 45% of those in the middle portion occlusion group, and 73% of those in the distal occlusion group. There was a significantly higher incidence of functionally independent patients in the distal occlusion group (p

Ischemic stroke is a major cause of morbidity and mortality. Despite the fact that it is the third most common cause of death in the United States, there is only one FDA approved treatment for patients. This is Intravenous recombinant tissue plasminogen activator given within 3 hours of symptom onset. Furthermore, despite the approval of this drug, it has been underutilized in the community. The limited time window of 3 hours disqualifies many patients from receiving the drug. In addition, fears of intracranial hemorrhage have resulted in underutilization of the drug in the community setting. Efforts to increase the time window to treatment include utilization of the intraarterial route for delivery of thrombolytic drug and interventional mechanical strategies to revascularize intracranial vessels. In this report we review the major intraarterial thrombolysis trials and review the mechanical strategies being developed to treat patients with acute ischemic stroke.

Stroke is a common cause of death and disability in industrialized nations. Technical advances and the increased availability of noninvasive brain imaging techniques have permitted precise and early diagnosis of acute cerebral ischemia. This has made emergent thrombolytic therapy for rapid restoration of cerebral perfusion increasingly possible. Herein, the authors present a review of the clinical trials investigating acute stroke treatment with intraarterial thrombolysis.

To investigate factors effecting the safety and recanalization efficacy of local intraarterial (IA) recombinant tissue plasminogen activator (r-tPA) delivery in patients with acute ischemic stroke. Eleven patients with anterior circulation acute ischemic stroke were treated. The neurological status of the patients were graded with the Glasgow Coma Scale (GCS) and National Institute of Health Stroke Scale (NIHSS). All patients underwent a computed tomography (CT) examination at admission. In addition four patients had diffusion-weighted and one patient had a perfusion magnetic resonance (MR) examinations. Patients were treated within six hours from stroke onset. Immediate, six hours, and 24 hours follow-up CT examinations were performed in order to evaluate the haemorrhagic complications and the extent of the ischemic area. The Rankin Scale (RS) was used as an outcome measure. Two of the 11 patients had carotid “T” occlusion (CTO), nine had middle cerebral artery (MCA) main trunk occlusion. Four patients had symptomatic haemorrhage with a large haematoma rupturing into the ventricles and subarachnoid space. Of these, three patients died within 24 hours. The remaining seven patients had asymptomatic haematomas that were smaller compared to symptomatic ones, and showed regression in size and density on follow-up CTs. At third month five patients had a good outcome and three patients had a poor outcome. In acute ischemic stroke, local IA thrombolysis is a feasible treatment when you select the right patient. Haemorrhage rate does not seem to exceed that occuring in the natural history of the disease and in other treatment modalities.

近年,脳主幹動脈の急性閉塞症において局所血栓溶解療法が行われ,主に中大脳動脈閉塞症についての有効性が報告されているが,内頸動脈閉塞症においてはその有効性は疑問視されている。しかし一方で,いわゆるwatershed typeの脳血流低下ではなく,中大脳動脈領域全域で脳血流低下をきたすような,側副血行が著しく乏しい内頸動脈閉塞症については,再開通が得られなければ高率に死亡する病態であるにもかかわらず,その治療法が確立していないのが現状である。今回われわれは,当院で過去5年間に行ったalteplaseによる局所血栓溶解療法患者32症例を対象に,内頸動脈閉塞15例と中大脳動脈閉塞17例の2群に分け,その有効性についてretrospectiveに比較検討した。内頸動脈閉塞症では中大脳動脈閉塞症に比べ,xenon-enhanced computed tomographyによって測定した中大脳動脈領域の局所脳血流が低値で,意識障害も重篤であった。局所血栓溶解療法における再開通率や頭蓋内出血率には両群で差を認めないものの,原病死亡(脳死)率は60%と18%,合併症死を含めた院内死亡率は80%と41%で,ともに内頸動脈閉塞症で高率であった。一方,局所血栓溶解療法によって再開通が得られ,頭蓋内出血を起こさなかった治療結果良好群と,再開通が得られなかった,もしくは頭蓋内出血を引き起こした治療結果不良群とに分けて検討したところ,内頸動脈閉塞症においてのみ治療結果が原病死亡率に直接影響を与えていることが示された。側副血行が不良な内頸動脈閉塞症は脳血流低下や意識障害の程度,および転帰において中大脳動脈閉塞症より重篤な病態である。局所血栓溶解療法の治療結果と転帰に相関が認められたのは現時点では前者においてのみであり,今後も本療法の適応病態についての詳細な検討が必要であると考えられた。