Combined Intravenous and Intraarterial Therapies

The median time from stroke onset to treatment for the PROACT trials was approximately 5.5 hr, highlighting the problem with IA management of acute stroke. The time needed to assemble all of the components required to perform the procedure is substantial. Based on data from the NINDS trial, it would be unethical to withhold IV rtPA therapy in qualified patients presenting within 3 hr of stroke onset. However, certain subgroups of patients (hyperdense artery signs, more severe deficit, and older age) benefit from IV thrombolytics to a lesser degree than the general target population. No randomized, controlled study has compared the rates of recanalization of IV versus IA thrombolysis. Wolpert et al. reported that 32 out of 93 (34%) patients had recanalization of their MCAs after the administration of IV rtPA, with most recan-alizations taking place in distal occlusions (28). In PROACT I and II, the recanalization rate was between 57.7% and 66%.

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