Abstract 3301: Clinical Outcomes and Rates of Symptomatic ICH May be Better Among Patients Receiving only IA tPA in the 4.5 Hour Window

BACKGROUND: Intravenous tissue plasminogen activator (IV tPA) has established benefit in the treatment of acute ischemic stroke (AIS) among selected patients. Intra-arterial (IA) thrombolysis, though still of unproven efficacy, is postulated to have greater success in recanalizing large artery occlusion (LAO), and also offers an alternative treatment for patients disqualified from IV tPA. Combination therapy delivers the standard of care with potentially higher recanalization rates, but the safety of this is unknown. OBJECTIVE: To evaluate hemorrhage, recanalization, and outcome for different modes of thrombolysis in AIS. METHODS: We retrospectively selected consecutive patients with LAO presenting to 2 medical centers within three-4.5 hours between August 2006 and July 2011 and divided them into three groups based on the mode of thrombolysis: group 1) IV-IA, group 2) IA, and group 3) IV. Patients who received IV tPA and underwent mechanical thrombolysis without additional IA tPA were excluded. We compared age, baseline and one week/discharge National Institutes of Health stroke scale scores (NIHSSS), pre/post intervention thrombolysis in myocardial infarction (TIMI) scores, one to three month modified Rankin Scale (mRS) and rates of symptomatic hemorrhage (sICH) using chi-square tests and analysis of variance. RESULTS: A total of 116 patients were included as follows: group 1, n=71; group 2, n=31; group 3, n=14. The mean age was 67+/-15 years, and initial NIHSSS 16+/-8, with minor inter-group differences. Times to IV tPA were 104+/- 42 (group 1) versus 140 +/-48 minutes (group 2, p=0.012). One week NIHSSS among survivors were 14+/-14 (group 1), 10+/-9 (group 2), and 12+/-12 (group 3). Initial angiographic data was retrievable for 52, among whom 71% had initial TIMI 0 scores in groups 1 and 2 (mean 0+/-1). Final TIMI scores were available in 39 patients with mode scores of 2 in 59% patients in group 1 (mean 2 +/-1) versus 71% in group 2 (mean 2+/-1). Long term outcomes were available for 42 patients, with median mRS of 4 in groups 1 and 3 versus 3 in group 2. There were 2 sICH in groups 1 and 3, and none in group 2. CONCLUSIONS: Though there was a trend towards better outcomes with lower rates of hemorrhage in group 2 patients, the above findings did not reach statistical significance in this analysis. As ongoing trials compare outcomes between patients receiving IV versus IV and IA tPA, additional studies evaluating groups receiving only IA tPA are needed.