Intravenous Glycoprotein IIb/IIIa Inhibitor (Tirofiban) followed by Intra-Arterial Urokinase and Mechanical Thrombolysis in Stroke
Salvatore Mangiaficoa,
Martino Cellerinia,
Patrizia Nencinib,
Gianfranco Gensinic and
Domenico Inzitarib
a Department of Neuroradiology, Careggi Hospital, Florence, Italy
b Department of Neurological and Psychiatric Sciences, Careggi Hospital, Florence, Italy
c Department of Critical Care Medicine and Surgery, Careggi Hospital, Florence, Italy
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FIG 1. Patient 19 with chronic atrial fibrillation on warfarin (INR = 2.5) and sudden onset of left hemiplegia and mental confusion (NIHSS score=19).
Subtle early signs of cerebral ischemia were seen in the right basal ganglia region on the pretreatment plain CT (A). The subsequent DSA with selective right common carotid injection in the AP view (B) showed a thromboembolic right siphon occlusion in the absence of collateral circulation (not shown). Clot aspiration, PTA, and local administration of as much as 500,000 IU of urokinase resulted in reopening of the siphon with good filling of the proximal M1 tract, anterior cerebral artery, posterior cerebral artery, and ophthalmic artery, the latter originating directly from the siphon through the posterior communicating artery (C). The late arterial phase of selective right internal carotid injection (LL view) showed retrograde filling of distal MCA branches through leptomeningeal anastomosis as well as a deep avascular area (D). The immediate postprocedural CT scan showed marked (>90 HU) enhancement of right basal ganglia with mass effect consistent with contrast extravasation (E). After a transitory clinical improvement (>4 points in the NIHSS score) the patient worsened dramatically 6 hours later and on the control CT scan a devastating cerebral bleeding with intraventricular inundation was observed (F). The patient died the following day.
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FIG 2. Patient 8 with parossistic atrial fibrillation and acute onset of dysarthria, right hemiplegia and third cranial nerve palsy followed by loss of consciousness (NIHSS score=18).
The AP view of selective left vertebral artery injection (A) showed complete occlusion of the basilar artery. The left PCA completely filled through the posterior communicating artery during selective left internal carotid artery injection as observed in the LL view (B). Mechanical clot disruption (PTA) and as much as 1,000,000 IU of locally administered urokinase resulted in a complete recanalization of the basilar artery and its collaterals (C). Persistent embolic occlusion of the right P2–P3 segments of the PCA is also seen. The AP view of selective left vertebral artery injection obtained at the control DSA 24 hours later showed complete revascularization of the right PCA (D). Turbo spin-echo T2-weighted MR images in the sagittal plane 3 months later demonstrated a small cortical infarct in the left posterior and basal aspect of the temporal lobe with scattered ischemic spots in the brain stem and cerebellar hemispheres (E). The patient was discharged with a NIHSS score of 5 and at 3-month follow-up was able to conduct a completely independent lifestyle (mRS score=1).
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