Intravenous or Intra-Arterial Thrombolysis?

See related article, pages 2191–2195. Intravenous recombinant tissue plasminogen activator (rt-PA) given within 3 hours of stroke onset is considered the standard treatment of stroke and is approved by the health authorities of most countries. It increases the rate of favorable outcomes from the range of 20% to 38% to 31% to 50%.1 Patients with mild or moderate strokes, persons younger than 75 years, and patients treated very early have the best chance for a favorable outcome to treatment.2,3 Nevertheless, more than half of stroke victims face a bleak outlook. Therefore, better means to treat stroke are needed. Intra-arterial thrombolysis (IAT) with pro-urokinase and a small dose of heparin has been tested in a phase III trial to treat stroke patients of <6 hours duration because of middle cerebral artery (MCA) main stem (M1 segment) and main branch (M2 segment) occlusion.4 Recanalization rates were 66% when treated with pro-urokinase and 18% with placebo ( P <0.001). At 90 days, 40% of patients treated with pro-urokinase but only 25% assigned to placebo had regained independency (modified Rankin scale of 0, 1, or 2; P =0.04).The FDA has not approved pro-urokinase for stroke treatment. Nevertheless, IAT mostly with rt-PA or urokinase is used increasingly at stroke centers by interventionalists. Since the FDA granted approval of the MERCI retriever for arterial embolectomy, mechanical recanalization has gained popularity as well.5 Forty-five percent of occluded MCAs and 53% of occluded intracranial internal carotid arteries were recanalized successfully with the MERCI retriever. Vessel recanalization rose to …