Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis

Background and Purpose-Intraarterial and intravenous thrombolysis are often ineffective for the treatment of acute ischemic stroke and are associated with a significant risk of intracranial hemorrhage (ICH). Multimodal rescue therapy combining mechanical disruption and platelet GPIIb/IIIa receptor antagonists may improve recanalization. Methods-Patients who did not recanalize with thrombolysis were treated with GPIIb/IIIa antagonists, angioplasty, or an embolectomy device. Treatment was individualized based on vascular anatomy, stroke mechanism, patient status, and symptom duration. Results-Twelve patients were treated within 3.8 +/- 2.2 hours. The mean National Institutes of Health Stroke Scale (NIHSS) score was 19.4 +/- 4.1. Six patients had carotid terminus occlusion, whereas 5 had middle cerebral artery and 1 had basilar artery occlusion. The average doses of intraarterial tPA and reteplase were 17.1 +/- 8.6 mg and 2 +/- 0.6 units, respectively. All patients received either an intravenous or intraarterial abciximab bolus ( mean 11.8 +/- 5.8mg) and heparin (mean 3278 +/- 1716U). Eleven were treated with angioplasty and 4 had mechanical embolectomy or stenting. Complete ( 8) or partial ( 3) recanalization was achieved in 11 cases. There was only one (8.3%) symptomatic hemorrhage. Patients had a favorable outcome at discharge ( mean NIHSS 8.9 +/- 8.7) and 6 (50%) had an NIHSS <= 4 at discharge. Conclusions-Multimodal rescue therapy was effective at recanalizing occluded cerebral vessels that failed thrombolysis without an excess risk of ICH.