Clinician-to-Clinician Update Clinician-to-Clinician Update

Intra-arterial Thrombolysis Halts Brain Stem Stroke

January 2017

Contributed by Mustapha Ezzeddine, MD, Andrew W. Grande, MD, and Amy Reichert, RN

Recent reviews of literature have identified the benefits in functional outcomes offered by the use of endovascular therapy as an adjunct treatment for ischemic strokes secondary to occlusions of the anterior circulation.1, 2, 3 To fully realize the benefits of this treatment approach, however, stroke patients need access to advanced imaging and comprehensive, team-based care.

January-2017-Stroke-Consult-Case-Study-Image-Stroke-Case-Figure
— Lateral (A) and AP (B) views demonstrate clot in the basilar artery (black arrows). Patient was also found to have a very atretic vertebral artery (white arrows), which made access to the clot very dangerous and challenging. We elected to administer rtPA intra-arterially delivered from catheter, as seen in the vertebral artery in figure A.

Patient

An elderly male patient was transported to University of Minnesota Medical Center for treatment of a suspected acute ischemic stroke. CT imaging at the referring hospital had ruled out hemorrhagic stroke, and prior to his transport, the patient had been given intravenous recombinant tissuetype plasminogen activator (r-tPA). Upon presenting at University of Minnesota Medical Center, the patient was having difficulty breathing and moving, symptoms indicative of a possible brain stem stroke. Although his symptoms had improved with administration of r-tPA, his NIH Stroke Scale score was above 6.

Management

Cerebral angiography was performed to evaluate the patient for a possible stent removal of the clot. The angiogram revealed a partial occlusion of the basilar artery. It also revealed that one of the vertebral arteries was not connected in circulation with the basilar artery and that the remaining vertebral artery through which the neurosurgeon hoped to access the clot via stent retriever was significantly compromised by vascular disease. After consulting with the attending stroke neurologist, the neurosurgeon concluded that stent retrieval of the clot posed an excessive risk to the structure of the weakened vertebral artery. The incomplete occlusion of the basilar artery indicated to attending physicians that the intravenous r-tPA had been partially successful in dissolving the clot, and they chose to pursue r-tPA as the treatment approach. Intra-arterial r-tPA was injected directly into the patient’s vertebral artery where it joins the basilar artery circulation. The patient’s symptoms improved, and he regained function over several hours. Post-treatment imaging confirmed that the treatment had dissolved the clot.

Discussion

Endovascular therapy, in particular thrombectomy via stent retriever, when combined with r-tPA has been found effective in the treatment of acute ischemic stroke.1, 2 The approach, however, is not without risk, and its benefits must be weighed in light of the state of the artery of access. For this patient, access to a full range of stroke care and stroke team members and a conservative approach to clot remediation provided a successful outcome.

References

  1. Rodrigues FB, Neves JB, Caldeira D, et al. Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis. BMJ. 2016;353:i1754.
  2. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:3020–3035. doi.org/10.1161/STR.0000000000000074
  3. Smith EE, Schwamm LH. Endovascular clot retrieval therapy: implications for the organization of stroke systems of care in North America. Stroke. 2015; 46(6):1462-1467.
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