J Korean Med Assoc.  2009 Apr;52(4):340-355. 10.5124/jkma.2009.52.4.340.

Thrombolytic Treatment of Acute Stroke

• Sohn SI
• Cho AH

• KMID: 2137719
• DOI: http://doi.org/10.5124/jkma.2009.52.4.340

Abstract

For the patients suffering from acute ischemic infarct from abrupt occlusion of vessels, prompt reperfusion is necessary to save the ischemic penumbra, eventually leading to a good prognosis. Regarding this, intravenous (IV) recombinant tissue plasminogen activator (rt-PA) thrombolysis as a reperfusion therapy is the only approved method. The IV rt-PA therapy gives us a clinical benefit of 30% or more likelihood of favorable outcome compared to the placebo. However, there is about 6% symptomatic intracranial hemorrhagic risk. Therefore, prudent decision-making by selecting of indicated patients is the role of neurologists. Besides intravenous rt-PA thrombolysis, application of intra-arterial therapy or bridging concept of intra-arterial combined with IV rt-PA is promising. They showed better recanalization rate than that of IV therapy according to the controlled studies. Although the clinical evidence is lacking, they have been performed occasionally in well-facilitated institutions. The results of ongoing trials to support the clinical benefit of these active therapies are expected. In this article, we reviewed the major clinical trials for thrombolytic treatment of acute ischemic stroke and various trials which are under investigation for the extension of the time window for thrombolysis.

Keyword

Acute stroke; Thrombolysis; Tissue-plasminogen activator; Intra-arterial therapy

MeSH Terms

Humans
Prognosis
Reperfusion
Stress, Psychological
Stroke
Tissue Plasminogen Activator
Tissue Plasminogen Activator

Figure

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  Figure 1 Model estimating odds ratio for favorable outcome at 3 months in rt-PA treated patients compared with controls by onset to treatment (OTT, min). Lancet 2004; 363: 768-774.

• 

  Figure 2 A 55-year-old man was admitted with a sudden onset of right hemiplegia and global aphasia within 5 hours after symptom onset. There was large diffusion-perfusion mismatch because diffusion-weighted image showed multiple small lesions on the left middle cerebral artery (MCA) territory (A) and perfusion-weighted image showed large perfusion defects on the left MCA territory (B). MR angiography demonstrated occlusion of the M1 portion of left MCA (C). Emergent conventional angiography was performed revealing the proximal portion of the left MCA (D). Through the microcatheter, 200,000 IU of urokinase was infused and followed by mechanical disruption of the clot using a micro-guide wire was done (E). Although slight recanalization was achieved after intra-arterial thrombolysis, the MCA was reoccluded within 10 minutes. Although we attempted to recanalize by use of balloon catheter (F), improvement of flow was not seen. After placement of coronary stent across clot followed by infusion of 14 mg of abciximab (G), the MCA was kept up the good flow (H). His symptoms were completely recovered after 3 days.

• 

  Figure 3 Proposed algorithm for treatment of patients with acute ischemic stroke.

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