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Intra-arterial Thrombolysis for Acute Ischemic Stroke: Preliminary Experience with Platelet Glycoprotein IIb/IIIa Inhibitors as Adjunctive Therapy

Deshmukh, Vivek R. M.D.; Fiorella, David J. M.D.; Albuquerque, Felipe C. M.D.; Frey, James M.D.; Flaster, Murray M.D.; Wallace, Robert C. M.D.; Spetzler, Robert F. M.D.; McDougall, Cameron G. M.D.

Neurosurgery:
doi: 10.1227/01.NEU.0000145785.69942.B3
Clinical Studies: CEREBROVASCULAR
Abstract

OBJECTIVE: To evaluate the safety profile of platelet glycoprotein IIb/IIIa inhibitors administered as adjunctive therapy to patients with large-vessel occlusion and acute ischemic stroke refractory to pharmacological thrombolysis with recombinant tissue plasminogen activator (rtPA) and mechanical disruption, balloon angioplasty, or both.

METHODS: Twenty-one patients (mean age, 62 yr; range, 29–88 yr) met the following criteria: 1) large-vessel occlusion and acute ischemic stroke syndrome at presentation, 2) failure to recanalize after administration of rtPA (intra-arterial and/or intravenous) with or without mechanical thrombolysis, and 3) subsequent treatment with IIb/IIIa inhibitors (intra-arterial or intravenous).

RESULTS: Eleven patients had ischemia in the dominant hemisphere, 8 in the vertebrobasilar system, and 2 in the nondominant hemisphere. Twelve patients received intravenous rtPA without significant improvement; 9 patients were not candidates for intravenous rtPA. All patients received intra-arterial rtPA. The IIb/IIIa inhibitors were administered intravenously in 3 patients, intra-arterially in 16, and both intravenously and intra-arterially in 2. Balloon angioplasty was performed in 18 patients. Complete or partial recanalization was achieved in 17 of the 21 patients. After thrombolysis, 15 improved clinically. Three patients (14%) sustained an asymptomatic intracerebral hemorrhage after thrombolytic therapy. No patient was clinically worse after intervention. At last follow-up (mean, 8.5 mo), 13 patients were functionally independent (modified Rankin score, 0–3) and 8 were disabled or dead.

CONCLUSION: IIb/IIIa inhibitors are an alternative for achieving recanalization. The risk of hemorrhage may be low. As part of an escalating protocol that includes pharmacological and mechanical thrombolysis, IIb/IIIa inhibitors may improve clinical outcomes.

Author Information

Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona (Deshmukh, Fiorella, Albuquerque, Frey, Flaster, Wallace, Spetzler, McDougall

Reprint requests: Cameron G. McDougall, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, AZ 85013. Email: neuropub@chw.edu

Received, March 12, 2004.

Accepted, September 10, 2004.

Copyright © by the Congress of Neurological Surgeons