Based on the results cited and other anecdotal evidence (and before publication of the NINDS stroke trial), the EMS-bridging trial was initiated to combine the purported advantages of both IV rtPA (timeliness and relative ease of administration) and IA administration (higher recanalization rates and decreased dose) (29). This was a Phase 1 pilot study of IV rtPA or placebo followed by immediate cerebral arteriography and local IA administration of rtPA. The goal was to test the feasibility, efficacy, and safety of this combined therapy in acute stroke within 3 hr of onset. Thirty-five patients were enrolled. The 17 patients who received IV rtPA were given a dose of 0.6 mg/kg (maximum of 60 mg), 10% bolus, with remainder administered over 30 min. Of the 35 patients enrolled, 34 were taken for cerebral angiography. If an occlusion was found, a very specific protocol was followed for attempted recanalization: 1 mg of rtPA was administered beyond the thrombus and then 1 mg was infused directly into the thrombus, followed by infusion at the rate of 10 mg/hr until complete recanaliza-tion or 2 hr.
Of the 22 patients who had an occlusion on angiography, those who received combined therapy (IV/IA) had better recanalization rates (54%) versus those who received only IA therapy (10%; p = 0.03). However, essentially no difference in clinical outcomes was observed between the two groups. The rates of symptomatic ICH were similar also.
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