Kim, Sun-Yong, M.D. Department of Radiology Ajou University Hospital, Suwon, Korea

1. AGGRESIVE MECHANICAL CLOT DISRUPTION FOR ACUTE ISCHEMIC STROKE WITH LOW DOSE INTRA-ARTERIAL UROKINASE AFTER FAILURE OF IV THROMBOLYSIS Kim, Sun-Yong, M.D. Department of Radiology Ajou University Hospital, Suwon, Korea

2. Introduction: • IV tPA within3 hours of stroke : - Estabilished treatment for acute ischemic stroke - Large artery occlusion : Early recanalization rate (?) • Following IA therapy with thrombolytics  symptomatic intracerebral hemorrhage • Aggressive mechanical clot disruption - Increasing the recanalization rate - Decreasing the time to recanalization - Decrease the dose of thrombolytics

3. Purpose • To evaluate the efficacy, feasibility and safety in variousaggresivemechanical thrombus disruption, for low dose intraarterialurokinase after failure of IV thrombiolysis in acute ischemic stroke

4. Material & Methods • August 2007 ~ September 2009 : All patients were initially treated and failed by IV tPA • 31 patients -Mean age: 66 years(range,37~79years) • Variouscombindedaggresive mechanical thrombus disruption for low dose intraarterialurokinase

5. Material & Methods • Time to treatment • Duration of the procedure • Recanalization rate • Urokinase dose • Rate of symptomatic hemorrhage were analyzed • Clinical outcome measure(NIHSS) - on admission - at discharge - 3 months follow up(mRS>2)

6. Results: Angiographic Occlusion Site • T-bifurcation of ICA : 8 • M1 segment of MCA : 20 • Basilar artery: 3

7. Mechanical Clot DisruptionTechniques • Microcatheter/microguidewire • Peumbra • Modified Penumbra method (manualSucction) • Stent assisted

8. Results: IV rt-PA • Average NIHSS score on admission : 16(10-23) • Median time from neurologic symptom onset : 116 min. (77~177 min) • Dosage of tPA - 0.9 mg/kg : 17 patients - 0.6 mg/kg : 14 patients

9. Results: IA therapy • Mean time from Sx onset to IA therapy : 195 min.(170~300min) • Time lag between IV tPA and IA therapy : 55 ~ 155 min • Duration of IA therapy : 61 min(30~80min) • Sx onset ~completion of IA therapy: 275 minutes ( 235 -350 min) • Median dose of urokinase : 190,000U (in 5 patients urokinase was not used) • No procedure related complications

10. Results: Recanalization RateThrombolysis in Cerebral Ischemia(TICI) • 0 (No perfusion) 1 (3%) • I (penetration but no perfusion) 2 (6%) • II (partial perfusion) IIa(with incomplete distal fiilling<50%) 3 (9%) IIb ( 50-99%) 1 (3%) IIc(near complete perfusion but with 21 (63%) delay in contrast runoff) • III (full normal perfusion) ; 3 (9%) No (%) Grade

11. Clinical Outcomes NIHSS Score : Initial, 16(10 – 23) , Discharge , 5 ( 3 – 13) Outcomesat 3Mo : Excellent: 8, Good: 17, Poor: 6

12. F/75 Rt. Hemiparesis, Sensory aphasia Atrial fibrillation, Onset to door: 40 minutes IV rt-PA : 50mg (NIHSS 14, duration: min. 5Hr30min) IA UK 150,000U with mechanical disruption NIHSS, Initial : 14 - NIHSS at 3 day: 7

13. F/75 IV rt-PA: 55 mg Onset to door: 150 minutes

14. Uk: 100,000U

15. Initial 3days later

16. M/42 Rt. Hemiparesis, Sensory aphasia IVtPA: 0.9mg/kg , NIHSS 14, duration: min. 2Hr max. 3Hr30min) CBF MTT TTP CBV

17. Penumbra system aspiration

19. IA UK 100,000U with mechanical disruption NIHSS score, Initial : 14, at discharge: 6

20. M/83 IV rt-PA: 58 mg Atrial fibrillation / Congestive heart failure / Pericardial effusion NIHSS 15, duration: : 5hours 30min ???????

21. UK: 120,000U

22. MR Diffusion/Perfusion after Treatment NIHSS( Initial) : 15 at discharge: 5

23. Conclusions • Even after failed IV thrombolysis patients with acute ischemic stroke, aggressive mechanical thrombus disruption IA therapy  relatively high recanalization rate  low dose IA urokinase  less symptomatic hemorrhages Excellent clinical outcomes • Primary use of technique, • mayenhanceneurologicrecovery