Intra-arterial therapy (IAT) has been used for three decades to promote recanalisation after stroke. Whereas results of the Prolyse in Acute Cerebral Thromboembolism-II trial (PROACT-II) showed significant improvement in clinical outcome with intraarterial fibrinolysis, the stroke specialty received some disturbing news in 2013. Results of the Interventional Management of Stroke-III (IMS-III), SYNTHESIS, and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) studies failed to show an increased benefit for IAT compared with intravenous alteplase (t-PA) or as an adjunctive approach to intravenous alteplase. [reference: Stroke roundup 2013. Lancet neurology, 2014]
The above description is for all IAT, not only for IAT of BA occlusion.
Although we continue to achieve high reperfusion rates with IAT, these successful radiographical outcomes do not always translate to good clinical outcomes. This gap raises the important issue of patient selection for IAT.
My comment: clinical outcome is the most important. Therefore, the important thing is whether and when the thrombolytic therapy should be done. As to the way of thrombolysis, IAT or IVT, I prefer IVT. Recognition of mode of onset is one of the important factors in making decision of intervention to treat BAO.
For those patients with high risk, prolonged low dose IVT may be a new treatment. This deserves further observation. [As to the issue about “Prolonged Low-Dose Thrombolysis in Posterior Circulation Stroke”, reference is Neurocrit Care. 2013 Nov 19. (Epub ahead of print)].
