Thrombolytic Treatment of Acute Stroke

Sung-Il Sohn; A-Hyun Cho

doi:10.5124/jkma.2009.52.4.340

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Sohn and Cho: Thrombolytic Treatment of Acute Stroke

Focused Issue of This Month

Acute Management of Stroke

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2009; 52(4): 340-355.

Published online: 30 April 2009

DOI: https://doi.org/10.5124/jkma.2009.52.4.340

Thrombolytic Treatment of Acute Stroke

Sung-Il Sohn, MD¹, A-Hyun Cho, MD²

¹Department of Neurology, Keimyung University School of Medicine, Korea. docsohn@dsmc.or.kr

²Department of Neurology, The Catholic University of Korea, St. Mary's Hospital, Seoul, Korea. ahyun@catholic.ac.kr

Abstract

For the patients suffering from acute ischemic infarct from abrupt occlusion of vessels, prompt reperfusion is necessary to save the ischemic penumbra, eventually leading to a good prognosis. Regarding this, intravenous (IV) recombinant tissue plasminogen activator (rt-PA) thrombolysis as a reperfusion therapy is the only approved method. The IV rt-PA therapy gives us a clinical benefit of 30% or more likelihood of favorable outcome compared to the placebo. However, there is about 6% symptomatic intracranial hemorrhagic risk. Therefore, prudent decision-making by selecting of indicated patients is the role of neurologists. Besides intravenous rt-PA thrombolysis, application of intra-arterial therapy or bridging concept of intra-arterial combined with IV rt-PA is promising. They showed better recanalization rate than that of IV therapy according to the controlled studies. Although the clinical evidence is lacking, they have been performed occasionally in well-facilitated institutions. The results of ongoing trials to support the clinical benefit of these active therapies are expected. In this article, we reviewed the major clinical trials for thrombolytic treatment of acute ischemic stroke and various trials which are under investigation for the extension of the time window for thrombolysis.

Keywords: Acute stroke, Thrombolysis, Tissue-plasminogen activator, Intra-arterial therapy

Figures and Tables

Figure 1

Model estimating odds ratio for favorable outcome at 3 months in rt-PA treated patients compared with controls by onset to treatment (OTT, min). Lancet 2004; 363: 768-774.

Figure 2

A 55-year-old man was admitted with a sudden onset of right hemiplegia and global aphasia within 5 hours after symptom onset. There was large diffusion-perfusion mismatch because diffusion-weighted image showed multiple small lesions on the left middle cerebral artery (MCA) territory (A) and perfusion-weighted image showed large perfusion defects on the left MCA territory (B). MR angiography demonstrated occlusion of the M1 portion of left MCA (C). Emergent conventional angiography was performed revealing the proximal portion of the left MCA (D). Through the microcatheter, 200,000 IU of urokinase was infused and followed by mechanical disruption of the clot using a micro-guide wire was done (E). Although slight recanalization was achieved after intra-arterial thrombolysis, the MCA was reoccluded within 10 minutes. Although we attempted to recanalize by use of balloon catheter (F), improvement of flow was not seen. After placement of coronary stent across clot followed by infusion of 14 mg of abciximab (G), the MCA was kept up the good flow (H). His symptoms were completely recovered after 3 days.

Figure 3

Proposed algorithm for treatment of patients with acute ischemic stroke.

Table 1

Factors related to symptomatic intracerebral hemorrhage after intravenous thrombolysis or intra-arterial thrombolysis

Table 2

Summary of major clinical trials of intravenous thrombolysis for acute ischemic stroke

NIHSS, national institute of health stroke scale; rt-PA, recombinant tissue plasminogen activator; mRS, modified Rankin Scale; GCS, Glasgow coma scale; NA, non-applicable; PH, parenchymal hemorrhage.

^*Comparison between treatment group and placebo group, statistical significance at P < 0.05.

Table 3

Characteristics of patients with ischemic stroke who could be treated with rt-PA

INR indicates international normalized ratio; aPTT, activated partial thromboplastin time.

Table 4

Summary of major prospective trials for combined intravenous/intra-arterial thrombolysis and endovascular treatment of acute ischemic stroke

NIHSS: National Institute of Health Stroke Scale, mRS: modified Rankin Scale, TIMI: Thrombolysis in myocardial infarction, ICH: Intracerebral hemorrhage.

^*Comparison between treatment group and placebo group, statistical significance at P < 0.05.

References

1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995. 333:1581–1587.

2. Kwiatkowski TG, Libman RB, Frankel M, Tilley BC, Morgenstern LB, Lu M, Broderick JP, Lewandowski CA, Marler JR, Levine SR, Brott T. Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med. 1999. 340:1781–1787.

3. The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke. 1997. 28:2109–2118.

4. Tanne D, Kasner SE, Demchuk AM, Koren-Morag N, Hanson S, Grond M, Levine SR. Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the Multicenter rt-PA Stroke Survey. Circulation. 2002. 105:1679–1685.

5. Derex L, Hermier M, Adeleine P, Pialat JB, Wiart M, Berthezene Y, Philippeau F, Honnorat J, Froment JC, Trouillas P, Nighoghossian N. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator. J Neurol Neurosurg Psychiatry. 2005. 76:70–75.

6. Hemorrhage in the Interventional Management of Stroke study. Strok. 2006. 37:847–851.

7. Selim M, Fink JN, Kumar S, Caplan LR, Horkan C, Chen Y, Linfante I, Schlaug G. Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume. Stroke. 2002. 33:2047–2052.

8. Neumann-Haefelin T, Hoelig S, Berkefeld J, Fiehler J, Gass A, Humpich M, Kastrup A, Kucinski T, Lecei O, Liebeskind DS, Rother J, Rosso C, Samson Y, Saver JL, Yan B. Leukoaraiosis is a risk factor for symptomatic intracerebral hemorrhage after thrombolysis for acute stroke. Stroke. 2006. 37:2463–2466.

9. Engelter ST, Fluri F, Buitrago-Tellez C, Marsch S, Steck AJ, Ruegg S, Lyrer PA. Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke. J Neurol. 2005. 252:1167–1170.

10. Lyden P. Thrombolytic Therapy for Acute Stroke. 2005. 2nd ed. Totowa, NJ: Humana Press.

11. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, Trouillas P. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998. 352:1245–1251.

12. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Hoxter G, Mahagne MH, et al. The European Cooperative Acute Stroke Study (ECASS). Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. Jama. 1995. 274:1017–1025.

13. Steiner T, Bluhmki E, Kaste M, Toni D, Trouillas P, von Kummer R, Hacke W. ECASS Study Group. European Cooperative Acute Stroke Study. The ECASS 3-hour cohort Secondary analysis of ECASS data by time stratification. Cerebrovasc Dis. 1998. 8:198–203.

14. Albers GW, Bates VE, Clark WM, Bell R, Verro P, Hamilton SA. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. Jama. 2000. 283:1145–1150.

15. Hill MD, Buchan AM. Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study. Cmaj. 2005. 172:1307–1312.

16. Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007. 369:275–282.

17. Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR, Alvarez-Sabin J, Montaner J, Saqqur M, Demchuk AM, Moye LA, Hill MD, Wojner AW. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004. 351:2170–2178.

18. Tsivgoulis G, Alexandrov A. Ultrasound-enhanced thrombolysis: from bedside to bench. Stroke. 2008. 39:1404–1405.

19. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007. 38:1655–1711.

20. Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Jama. 1999. 282:2019–2026.

21. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, Brott T, Frankel M, Grotta JC, Haley EC Jr, Kwiatkowski T, Levine SR, Lewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC, Albers G, Bluhmki E, Wilhelm M, Hamilton S. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004. 363:768–774.

22. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008. 359:1317–1329.

23. Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC, Broderick JP, Levine SR, Frankel MP, Horowitz SH, Haley EC Jr, Lewandowski CA, Kwiatkowski TP. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology. 2000. 55:1649–1655.

24. Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial-Italy (MAST-I) Group. Lancet. 1995. 346:1509–1514.

25. Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial-Europe Study Group. N Engl J Med. 1996. 335:145–150.

26. Donnan GA, Hommel M, Davis SM, McNeil JJ. Streptokinase in acute ischaemic stroke Steering Committees of the ASK and MAST-E trials. Australian Streptokinase Trial. Lancet. 1995. 346:56.

27. Hommel M, Boissel JP, Cornu C, Boutitie F, Lees KR, Besson G, Leys D, Amarenco P, Bogaert M. MAST Study Group. Termination of trial of streptokinase in severe acute ischaemic stroke. Lancet. 1995. 345:57.

28. Haley EC Jr, Lyden PD, Johnston KC, Hemmen TM. A pilot dose-escalation safety study of tenecteplase in acute ischemic stroke. Stroke. 2005. 36:607–612.

29. Furlan AJ, Eyding D, Albers GW, Al-Rawi Y, Lees KR, Rowley HA, Sachara C, Soehngen M, Warach S, Hacke W. Dose Escalation of Desmoteplase for Acute Ischemic Stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke. 2006. 37:1227–1231.

30. Hacke W, Furlan AJ, Al-Rawi Y, Davalos A, Fiebach JB, Gruber F, Kaste M, Lipka LJ, Pedraza S, Ringleb PA, Rowley HA, Schneider D, Schwamm LH, Leal JS, Sohngen M, Teal PA, Wilhelm-Ogunbiyi K, Wintermark M, Warach S. Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurol. 2009. 8:141–150.

31. Hacke W. FA, for the DIAS-2 Investigators. Results from the phase III study of desmoteplase in acute ischemic stroke trial, 2 (DIAS 2). Cerebrovasc Dis. 2007. 23:suppl 2. 54.

32. Adams HP Jr, Effron MB, Torner J, Davalos A, Frayne J, Teal P, Leclerc J, Oemar B, Padgett L, Barnathan ES, Hacke W. Emergency administration of abciximab for treatment of patients with acute ischemic stroke: results of an international phase III trial: Abciximab in Emergency Treatment of Stroke Trial (AbESTT-II). Stroke. 2008. 39:87–99.

33. Darby DG, Barber PA, Gerraty RP, Desmond PM, Yang Q, Parsons M, Li T, Tress BM, Davis SM. Pathophysiological topography of acute ischemia by combined diffusion-weighted and perfusion MRI. Stroke. 1999. 30:2043–2052.

34. Albers GW, Thijs VN, Wechsler L, Kemp S, Schlaug G, Skalabrin E, Bammer R, Kakuda W, Lansberg MG, Shuaib A, Coplin W, Hamilton S, Moseley M, Marks MP. Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol. 2006. 60:508–517.

35. Davis SM, Donnan GA, Parsons MW, Levi C, Butcher KS, Peeters A, Barber PA, Bladin C, De Silva DA, Byrnes G, Chalk JB, Fink JN, Kimber TE, Schultz D, Hand PJ, Frayne J, Hankey G, Muir K, Gerraty R, Tress BM, Desmond PM. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurol. 2008. 7:299–309.

36. Hacke W, Albers G, Al-Rawi Y, Bogousslavsky J, Davalos A, Eliasziw M, Fischer M, Furlan A, Kaste M, Lees KR, Soehngen M, Warach S. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke. 2005. 36:66–73.

37. Adams HP Jr, Leira EC, Torner JC, Barnathan E, Padgett L, Effron MB, Hacke W. Treating patients with 'wake-up' stroke: the experience of the AbESTT-II trial. Stroke. 2008. 39:3277–3282.

38. Cho AH, Sohn SI, Han MK, Lee DH, Kim JS, Choi CG, Sohn CH, Kwon SU, Suh DC, Kim SJ, Bae HJ, Kang DW. Safety and efficacy of MRI-based thrombolysis in unclear-onset stroke. A preliminary report. Cerebrovasc Dis. 2008. 25:572–579.

39. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007. 38:967–973.

40. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke. 2004. 35:904–911.

41. The Interventional Management of Stroke (IMS) II Study. Stroke. 2007. 38:2127–2135.

42. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke. 2005. 36:869–871.

43. Lee KY, Han SW, Kim SH, Nam HS, Ahn SW, Kim DJ, Seo SH, Kim DI, Heo JH. Early recanalization after intravenous administration of recombinant tissue plasminogen activator as assessed by pre- and post-thrombolytic angiography in acute ischemic stroke patients. Stroke. 2007. 38:192–193.

44. Zeumer H, Hacke W, Ringelstein EB. Local intraarterial thrombolysis in vertebrobasilar thromboembolic disease. AJNR Am J Neuroradiol. 1983. 4:401–401.

45. Choi JH, Bateman BT, Mangla S, Marshall RS, Prabhakaran S, Chong J, Mohr JP, Mast H, Pile-Spellman J. Endovascular recanalization therapy in acute ischemic stroke. Stroke. 2006. 37:419–424.

46. Janjua N, Brisman JL. Endovascular treatment of acute ischaemic stroke. Lancet Neurol. 2007. 6:1086–1093.

47. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999. 282:2003–2011.

48. Ogawa A, Mori E, Minematsu K, Taki W, Takahashi A, Nemoto S, Miyamoto S, Sasaki M, Inoue T. Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic intervention trial (MELT) Japan. Stroke. 2007. 38:2633–2639.

49. Becker KJ, Monsein LH, Ulatowski J, Mirski M, Williams M, Hanley DF. Intraarterial thrombolysis in vertebrobasilar occlusion. AJNR Am J Neuroradiol. 1996. 17:255–262.

50. Brandt T, von Kummer R, Muller-Kuppers M, Hacke W. Thrombolytic therapy of acute basilar artery occlusion. Variables affecting recanalization and outcome. Stroke. 1996. 27:875–881.

51. Macleod MR, Davis SM, Mitchell PJ, Gerraty RP, Fitt G, Hankey GJ, Stewart-Wynne EG, Rosen D, McNeil JJ, Bladin CF, Chambers BR, Herkes GK, Young D, Donnan GA. Results of a multicentre, randomised controlled trial of intra-arterial urokinase in the treatment of acute posterior circulation ischaemic stroke. Cerebrovasc Dis. 2005. 20:12–17.

52. Mahon BR, Nesbit GM, Barnwell SL, Clark W, Marotta TR, Weill A, Teal PA, Qureshi AI. North American clinical experience with the EKOS MicroLysUS infusion catheter for the treatment of embolic stroke. AJNR Am J Neuroradiol. 2003. 24:534–534.

53. Brekenfeld C, Remonda L, Nedeltchev K, Arnold M, Mattle HP, Fischer U, Kappeler L, Schroth G. Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke: assessment of 294 patients treated with urokinase. J Neurol Neurosurg Psychiatry. 2007. 78:280–285.

54. Christoforidis GA, Karakasis C, Mohammad Y, Caragine LP, Yang M, Slivka AP. Predictors of hemorrhage following intra-arterial thrombolysis for acute ischemic stroke: the role of pial collateral formation. AJNR Am J Neuroradiol. 2009. 30:165–170.

55. Kase CS, Furlan AJ, Wechsler LR, Higashida RT, Rowley HA, Hart RG, Molinari GF, Frederick LS, Roberts HC, Gebel JM, Sila CA, Schulz GA, Roberts RS, Gent M. Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial. Neurology. 2001. 57:1603–1610.

56. Kidwell CS, Saver JL, Carneado J, Sayre J, Starkman S, Duckwiler G, Gobin YP, Jahan R, Vespa P, Villablanca JP, Liebeskind DS, Vinuela F. Predictors of hemorrhagic transformation in patients receiving intra-arterial thrombolysis. Stroke. 2002. 33:717–724.

57. Vora NA, Gupta R, Thomas AJ, Horowitz MB, Tayal AH, Hammer MD, Uchino K, Wechsler LR, Jovin TG. Factors predicting hemorrhagic complications after multimodal reperfusion therapy for acute ischemic stroke. AJNR Am J Neuroradiol. 2007. 28:1391–1394.

58. Mandava P, Kent TA. Intra-arterial therapies for acute ischemic stroke. Neurology. 2007. 68:2132–2139.

59. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, Lutsep HL, Nesbit GM, Grobelny T, Rymer MM, Silverman IE, Higashida RT, Budzik RF, Marks MP. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005. 36:1432–1438.

60. Smith WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol. 2006. 27:1177–1182.

61. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, Lutsep HL, Rymer MM, Higashida RT, Starkman S, Gobin YP, Frei D, Grobelny T, Hellinger F, Huddle D, Kidwell C, Koroshetz W, Marks M, Nesbit G, Silverman IE. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008. 39:1205–1212.

62. Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A, Branca V, Sit SP. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol. 2008. 29:1409–1413.

63. Sorimachi T, Fujii Y, Tsuchiya N, Nashimoto T, Harada A, Ito Y, Tanaka R. Recanalization by mechanical embolus disruption during intra-arterial thrombolysis in the carotid territory. AJNR Am J Neuroradiol. 2004. 25:1391–1402.

64. Ringer AJ, Qureshi AI, Fessler RD, Guterman LR, Hopkins LN. Angioplasty of intracranial occlusion resistant to thrombolysis in acute ischemic stroke. Neurosurgery. 2001. 48:1282–1288.

65. Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke. 2002. 33:2872–2876.

66. Levy EI, Ecker RD, Horowitz MB, Gupta R, Hanel RA, Sauvageau E, Jovin TG, Guterman LR, Hopkins LN. Stent-assisted intracranial recanalization for acute stroke: early results. Neurosurgery. 2006. 58:458–463.

67. Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D, Woo HH, Albuquerque FC, Jovin TG, Horowitz MB, Hopkins LN. Self-expanding stents for recanalization of acute cerebrovascular occlusions. AJNR Am J Neuroradiol. 2007. 28:816–822.

68. Bae GY, Hong JH, Sohn SI, Sohn CH, Chang HW. Emergent Carotid Stenting in Acute Stroke Patients with Steno-Occlusion of Proximal Internal Carotid Artery. J Korean Neurol Assoc. 2008. 26:177–185.

69. Suh DC, Kim JK, Choi CG, Kim SJ, Pyun HW, Ahn C, Yang DH, Lim KS, Leem JG, Hahm KD, Lee JH, Kwon SU, Kim JS. Prognostic factors for neurologic outcome after endovascular revascularization of acute symptomatic occlusion of the internal carotid artery. AJNR Am J Neuroradiol. 2007. 28:1167–1171.

70. Abou-Chebl A, Bajzer CT, Krieger DW, Furlan AJ, Yadav JS. Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis. Stroke. 2005. 36:2286–2288.

71. Gupta R, Vora NA, Horowitz MB, Tayal AH, Hammer MD, Uchino K, Levy EI, Wechsler LR, Jovin TG. Multimodal reperfusion therapy for acute ischemic stroke: factors predicting vessel recanalization. Stroke. 2006. 37:986–990.

72. Shi HB, Suh DC, Lim SM, Lee JH, Kim JK, Jeong AK, Choi CG, Lee HK, Lim TW, Auh YH. Outcome evaluation of intra-arterial infusion of urokinase for acute ischemic stroke. J Korean Radiol Soc. 2000. 42:897–904.

73. Song JM, Yoon W, Kim JK, Seo JJ, Heo SH, Park JG, Jeong YY, Kang HK. Influential factors of clinical outcome of local intra-arterial thrombolysis using urokinase in patients with hyperacute ischemic stroke. J Korean Radiol Soc. 2002. 47:340–350.

74. Lee DH, Na DG, Ihn YK, Kim DJ, Kim EY, Kim YS, Lim SM, Roh HG, Sohn CH. Review of the current status of intra-arterial thrombolysis for treating acute cerebral infarction: a retrospective analysis of the data from multiple centers in Korea. Korean J Radiol. 2007. 8:87–93.

75. Cho AH, Kim JS, Kim SJ, Yun SC, Choi CG, Kim HR, Kwon SU, Lee DH, Kim EK, Suh DC, Kang DW. Focal fluid-attenuated inversion recovery hyperintensity within acute diffusion-weighted imaging lesions is associated with symptomatic intracerebral hemorrhage after thrombolysis. Stroke. 2008. 39:3424–3426.

76. Lewandowski CA, Frankel M, Tomsick TA, Broderick J, Frey J, Clark W, Starkman S, Grotta J, Spilker J, Khoury J, Brott T. Combined intravenous and intra-arterial r-TPA versus intraarterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke. 1999. 30:2598–2605.

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