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

2. Introduction: IV tPA within 3 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 various aggresive mechanical thrombus disruption, for low dose intraarterial urokinase 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) Various combinded aggresive mechanical thrombus disruption for low dose intraarterial urokinase

5. 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) Material & Methods

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

7. Mechanical Clot Disruption Techniques Microcatheter/microguidewire Peumbra Modified Penumbra method (manual Sucction) 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. 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 Results: IA therapy

10. Results: Recanalization Rate Thrombolysis 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%) Grade No (%)

11. Clinical Outcomes Author IMS I Study (n=80) IMS II Study (n =81) Mortality rate at 3 months (%) 3.2 (1) 16 Symptomatic ICH (%) 3.2 (1) 6.3 9.9 Asymptomatic ICH (%) 9.6 (3) 42.5 32.1 mRS 0-2 At 3 months (%)75 43 46 NIHSS Score : Initial, 16(10 – 23), Discharge, 5 ( 3 – 13) Outcomes at 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 3 days later

16. MTTTTPCBF M/42 Rt. Hemiparesis, Sensory aphasia IVtPA: 0.9mg/kg, NIHSS 14, duration: min. 2Hr max. 3Hr30min) 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, may enhance neurologic recovery