Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Intra-Arterial Thrombolysis Using Double Devices: Mechanicomechanical or Chemicomechanical Techniques

  • Park, Hyun (Department of Neurosurgery, Jeju National University Hospital, Jeju National University School of Medicine) ;
  • Hwang, Gyo-Jun (Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University and Graduate School of Kangwon University) ;
  • Jin, Sung-Chul (Department of Neurosurgery, Cerebrovascular Center, Inje University College of Medicine, Haeundae Paik Hospital) ;
  • Bang, Jae-Seung (Department of Neurosurgery, Seoul National University Bundang Hospital) ;
  • Oh, Chang-Wan (Department of Neurosurgery, Seoul National University Bundang Hospital) ;
  • Kwon, O-Ki (Department of Neurosurgery, Seoul National University Bundang Hospital)
  • Received : 2011.03.09
  • Accepted : 2012.02.24
  • Published : 2012.02.28
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Abstract

Objective : To optimize the recanalization of acute cerebral stroke that were not effectively resolved by conventional intraarterial thrombolysis (IAT), we designed a double device technique to allow for rapid and effective reopening. In this article, we describe the feasibility and efficacy of this technique. Methods : From January 2008 to September 2009, twenty patients with acute cerebral arterial occlusion (middle cerebral artery : n=12; internal carotid artery terminus : n=5; basilar artery : n=3) were treated by the double device technique. This technique was applied when conventional thrombolytic methods using drug, microwires, microcatheters and balloons did not result in recanalization. In the double device technique, two devices are simultaneously placed at the lesion (for example, one microcatheter and one balloon or two microcatheters). Chemicomechanical or mechanicomechanical thrombolysis was performed simultaneously using various combinations of two devices. Recanalization rates, procedural time, complications, and clinical outcomes were analyzed. Results : The initial median National Institute of Health Stroke Scale (NIHSS) was 16 (range 5-26). The double device technique was applied after conventional IAT methods failed. Recanalization was achieved in 18 patients (90%). Among them, 55% (11 cases) were complete (thrombolysis in cerebral infarction 2B, 3). The median thrombolytic procedural time including the conventional technique was $135{\pm}83.7$ minutes (range 75-427). Major symptomatic hemorrhages (neurological deterioration ${\geq}4$ points in NIHSS) developed in two patients (10%). Good long term outcomes (modified Rankin Scale ${\leq}2$ at 90 days) occurred in 25% (n=5) of the cases. Mortality within 90 days developed in two cases (10%). Conclusion : The double device technique is a feasible and effective technical option for large vessel occlusion refractory to conventional thrombolysis.

Keywords

References

  1. Abou-Chebl A, Bajzer CT, Krieger DW, Furlan AJ, Yadav JS : Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis. Stroke 36 : 2286-2288, 2005 https://doi.org/10.1161/01.STR.0000179043.73314.4f
  2. Arnold M, Nedeltchev K, Mattle HP, Loher TJ, Stepper F, Schroth G, et al. : Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions. J Neurol Neurosurg Psychiatry 74 : 739-742, 2003 https://doi.org/10.1136/jnnp.74.6.739
  3. Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A, et al. : The Penumbra System : a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol 29 : 1409-1413, 2008 https://doi.org/10.3174/ajnr.A1110
  4. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. : Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study : a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 282 : 2003-2011, 1999 https://doi.org/10.1001/jama.282.21.2003
  5. Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, et al. : Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34 : e109-e137, 2003 https://doi.org/10.1161/01.STR.0000082721.62796.09
  6. Kim DJ, Kim DI, Byun JS, Jung JY, Suh SH, Kim EY, et al. : Simple microwire and microcatheter mechanical thrombolysis with adjuvant intraarterial urokinase for treatment of hyperacute ischemic stroke patients. Acta Radiol 49 : 351-357, 2008 https://doi.org/10.1080/02841850701819143
  7. Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D, et al. : Self-expanding stents for recanalization of acute cerebrovascular occlusions. AJNR Am J Neuroradiol 28 : 816-822, 2007
  8. Lin R, Vora N, Zaidi S, Aleu A, Jankowitz B, Thomas A, et al. : Mechanical approaches combined with intra-arterial pharmacological therapy are associated with higher recanalization rates than either intervention alone in revascularization of acute carotid terminus occlusion. Stroke 40 : 2092-2097, 2009 https://doi.org/10.1161/STROKEAHA.108.544783
  9. Linfante I, Llinas RH, Selim M, Chaves C, Kumar S, Parker RA, et al. : Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 33 : 2066-2071, 2002 https://doi.org/10.1161/01.STR.0000021001.18101.A5
  10. Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S : Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion : an alternative option to intra-arterial thrombolysis. Stroke 33 : 2872-2876, 2002 https://doi.org/10.1161/01.STR.0000038985.26269.F2
  11. Nogueira RG, Schwamm LH, Buonanno FS, Koroshetz WJ, Yoo AJ, Rabinov JD, et al. : Low-pressure balloon angioplasty with adjuvant pharmacological therapy in patients with acute ischemic stroke caused by intracranial arterial occlusions. Neuroradiology 50 : 331-340, 2008 https://doi.org/10.1007/s00234-007-0340-z
  12. Qureshi AI, Siddiqui AM, Suri MF, Kim SH, Ali Z, Yahia AM, et al. : Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke : a prospective study. Neurosurgery 51 : 1319-1327; discussion 1327-1329, 2002 https://doi.org/10.1097/00006123-200211000-00040
  13. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. : Mechanical thrombectomy for acute ischemic stroke : final results of the Multi MERCI trial. Stroke 39 : 1205-1212, 2008 https://doi.org/10.1161/STROKEAHA.107.497115
  14. Yoon W, Park MS, Cho KH : Low-dose intra-arterial urokinase and aggressive mechanical clot disruption for acute ischemic stroke after failure of intravenous thrombolysis. AJNR Am J Neuroradiol 31 : 161-164, 2010 https://doi.org/10.3174/ajnr.A1746

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