Controversies In The Use Of Intravenous rtPA Exclusion from Therapy

Although rtPA has been shown to be beneficial in all properly selected patients, it has shown marginal positive impact in specific subgroups: the elderly, those with severe strokes, patients with extensive early ischemic changes on CT scan, and those with hyperdense artery signs. It has been suggested that the relative risk-to-benefit ratio of thrombolysis might vary among patient subgroups (40). To address these concerns, a post hoc subgroup analysis was completed using the data from the NINDS trial (16). All subgroups treated with IV rtPA had a better functional outcome at three months, including patients >75 years of age, those with early CT findings of ischemia, and those with a visible thrombus on CT scan.

Although the proportion of patients with basilar artery occlusion is much less than those with anterior circulation strokes, the functional outcome rates are much worse. Death is almost certain if recanalization is not achieved (41). Due to the uniformly poor prognosis of these patients, no placebo-controlled trial has been conducted using thrombolytics. However, some case reports do support the use of IA fibrinolytics in achieving recanalizations (24,42). Due to the high rate of rethrombosis, postprocedure anticoagulation is widely used. However, relatively few centers have the extremely specialized personnel and equipment required for this procedure. With the approval of IV use of alteplase for all ischemic strokes presenting within 3 hr, some have used this method in treating basilar artery occlusion patients (43,44). Currently, no "standard of care" in treating these complex patients has been established. The decision algorithm is based on available personnel, personal experience, severity of illness, and time of onset. A comparative trial in this subpopulation is needed to determine the best way to manage these patients.

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