Neurological Research A Journal of Progress in Neurosurgery, Neurology and Neurosciences ISSN: 0161-6412 (Print) 1743-1328 (Online) Journal homepage: https://www.tandfonline.com/loi/yner20 Local thrombolytic therapy for thrombembolic occlusion of the middle cerebral artery Elisabeth Berg-Dammer, Eckhard Möbius, Hans-Christean Nahser & Dietmar Kühne To cite this article: Elisabeth Berg-Dammer, Eckhard Möbius, Hans-Christean Nahser & Dietmar Kühne (1992) Local thrombolytic therapy for thrombembolic occlusion of the middle cerebral artery, Neurological Research, 14:2, 164-166, DOI: 10.1080/01616412.1992.11740041 To link to this article: https://doi.org/10.1080/01616412.1992.11740041 Published online: 23 Jul 2016. Submit your article to this journal View related articles Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=yner20 Local thrombolytic therapy for thrombembolic occlusion of the middle cerebral artery Elisabeth Berg-Dam mer1 , Eckhard Mobius1 , Hans-Chris.tean Nahser2 and Dietmar Kiihne2 Departments of Neurology 1 and Neuroradiologf, A/fried Krupp Krankenhaus, Essen, Germany We report on 10 patients with thrombembolic occlusion of the middle cerebral artery ( MCA ) who underwent local thrombolytic therapy. Six patients developed a MCA occlusion during. long-standing interventional neuroradiological procedures, while four had a proven or suspected cardia-embolic stroke. Streptokinase or urokinase was applied by a microcatheter placed into the thrombus within six hours of clinical onset. Complete or partial revascularization was achieved in all patients. Recovery was complete in seven and partial in three of the patients. In two patients, minor haemorrhagic trans fo rmation of the infarct occurred, which did not lead to neurological deterioration. It is concluded that in a selected group of patients with MCA occlusion, local thombolytic therap y represents a safe and effective therapy. Keywords:Middle cerebral artery; thrombolytic therapy; fibrinolytic agents INTRODUCTION The results of intravenous tissue plasminogene activator (t-PA) fibrinolysis in carotid territory have been, up to now, disappointing1 . Because of the convincing experiences with local thrombolytic therapy in acute basilar artery occlusion 2•3 , we considered that locally applied thrombolytic agents also might be beneficial in acute embolic occlusion of the middle cerebral artery (MCA). The systemic use of fibrinolytic agents, w ith the associated risk of cerebral haemorrhage is unacceptable, as arterial occlusions in the carotid territory are rarely· life-threatening. PATIENTS AND METHODS The study group consisted of ten patients in whom local thrombolytic therapy was performed between july 1986 and March 1991 . In six patients, a catheter-related embolis(ll with subsequent occlusion of t he MCA developed during interventional neuroradiologic procedures. They belonged to a group of 328 patients who underwent a total number of 125T \radiological interventions because of arterio-venous malformations, dural fistulas, surgically untreatable aneurysms or pre-operative embolisation of meningio mas. Four patients had a known or presumed cardiogenic embolism. Local fibrinolysis was used because the following prerequisites were fulfilled: (a) the patients presented with acute severe or progressive signs of hemispheric ischaemia, with an onset of disease of less than four hours, (b) there were no signs of haemorrhage, ·recent ischaemia or severe micro-angiopathy on CT or MRI, (c) there was no history of severe haemorrhagic diathesis or recent surgery. Digital subtraction angiography of the carotid territory was performed in order t o confirm the Correspondence to : D·r E. Berg-Dammer, MD, Department of Neurology, Alfried Krupp von Bohlen und Halbach-Krankenhaus, Alfried-Krupp·Str. 21, 4300 Essen, Germany. Accepted for publication December 1991. © 1992 Forefront Publishing Group 0161-6412/92/ 020164-03 164 Neurological Research, 1992, Volume 14, Suppl diagnosis of MCA occlusion and to visualize the extent of collateralization. By means of new micro-catheter systems, superselective catheterization was performed, permitting angiography distal to the occlusion site. For local thombolysis, a microcatheter was placed between the wall of the MCA and the t hrombus or within the thrombus. Up to 100,000 units of streptokinase or 750,000 units of urokinase were applied within two hours. Angiography was repeated every 30 minutes. When reperfusion was achieved, local thrombolysis was stopped and systemic heparinization was started in order to avoid secondary thrombus formation. CT was controlled on the first and third day following thrombolysis. RESULTS The study group consisted of five males and five females with a mean age of 40.9 years (range 17- 75 years). In all but one patient, the left hemisphere was affected. Digital subtraction angiography revealed a proximal occlusion of the MCA in all of them. The time interval between diagnosis and therapy ranged f rom 10 to 30 min (mean 15.8 min ) in patients with embolism caused by endovascular treatment. In the group of patients w ith cardioembolic stroke, thrombolytic therapy was started after a mean t ime of 3 h (range 1-4 h ). 9 out of 10 patients presented with a global aphasia and complete motoric hemiplegia, one patient with sopor and hemiplegia on the left. Complete recanalization was obtained in 5 of the 6 patients with catheter-related embolism. In one patient distal branches of the MCA remained occluded. Restoration of normal neurologic status was observed in 4 patients. In 2 patients a slight aphasia and incomplete hemiparesis persisted. In the group of patients with suspected or proven cardiogenic embolism, co mplete recanalization was achieved in 1 patient, and a partial reperfusio n of more than 50% in 2 patients and less than 50% in the other case. Complete recovery was observed in 3 patients, while a slight motoric aphasia with an incomplet e hemiparesis remained in one. CT controls Local thrombolytic therapy for MCA occlusion: E. Berg-Dammer et al. showed ischaemic areas in the territory of the MCA in 5 patients. An asymptomatic haemorrhagic transformation of a lenticulostriate ischaemic region was demonstrated in two patients. No patient suffered from a systemic or intracranial bleeding during or after local thombolysis. REPRESENTATIVE CASE A thirty-year old female patient with a known mitral vitium was referred to our hospital three hours after the onset of a right-sided complete hemiplegia and global aphasia. Angiography revealed a proximal occlusion of the MCA with collaterals via leptomeningeal anastomoses from the anterior cerebral artery (ACA). A microcatheter was positioned within the embolus. Local thrombolysis was started and during a period of 1.5 h 600,000 units of urokinase were administered with subsequent complete recanalization (see Figures 1a-1d). Despite a haemorrhagic transformation of a small infarcted area in the MCA territory on CT after 24 hours, neurological signs completely resolved within ten days. a b c d Figure 1: (a) Complete proximal MCA occlusion including the lenticulostriate arteries. There is beginning collateralization v ia ACA branches and the artery of Heubner. (b) The catheter tip of a microcatheter was placed within the thrombus. (c) After perfusion of 300,000 units of urokinase there is recanalization of the lenticulostriate arteries and onset of flow to middle cerebral branches. (d After administration of 600,000 units of urokinase follow up control exhibited complete revascularization Neurological Research, 1992, Volume 14, Suppl 165 Local thrombolytic therapy for MCA occlusion: E. Berg-Oammer et al. DISCUSSION The aim of thrombolyti c therapy is to enhance and accelerate the natural process of recanalization in acute stroke. Encouraged by the favourable results of local fibrinolysis in acute embolic basilar artery occlusion 2•3 , we have instituted thrombolyti c therapy in 10 patients with acute middle cerebral artery (MCA) occlusion. Patients with catheter-rel ated embolism were considered an ideal group because there was no significant time delay between diagnosis and initiation of therapy. Indeed, we could achieve sufficient recanalization in all of them. The in vitro studies of Matsumoto and Satoh showed that fresh clots responded well to the thrombolyti c action of urokinase supported by piercing of the thrombus 4 . This can explain the observed clinical improvemen t in our studies. The earlier unsatisfactory experiences in three patients with embolic complication of intervention al angiographic procedures 5 , could be due to more extensive embolism. The internal carotid artery siphon was involved in one patient and MCA branches in the other ones, whereas in our patients, the embolism was confined only to the proximal MCA. Our good results with acute middle cerebral artery occlusion in patients with suspected or proven cardiofenic embolism are confirmed by other clinical trials6 • • The developmen t of haemorrhagic transformations in two patients with small infarctions in the lenticulostria te area underlines the importance of a short interval between diagnosis and initiation of local thrombolysi s. The vulnerability of the lenticulostria te arteries possessing only a small amount of collateralization 8 is increased with time after successful recanalizati on. In our patients, local thrombolysis was terminated within 6 hours after the 166 Neurological Research, 1992, Volume 14, Suppl onset of symptoms and we did not observe any intracranial bleeding in them. Because spontaneous clot lysis often occurs too late to prevent irreversible damage of brain tissue9 , we particularly recommend local infusion of fibrinolytic agents when an embolic MCA occlusion affects the dominant hemisphere. REFERENCES 2 3 4 5 6 7 8 9 The t-PA Acute Stroke Study Group. An open multicenter study of the safety and effiacy of various doses of t-PA in patients with acute stroke. Stroke 1990; 21 : 181 Zeumer H, Hacke W , Kolmann HL, Poeck K. Lokale Fibrinolysethe rapie bei Basilaris-Throm bose. Dtsch Med Wochenschr 1982; 107: 728-731 Mobius E, Berg-Dammer E, Kuhne D, Kunitsch G, Nahser HC. Local intraarterial fibrinolysis in acute basilar occlusion with progressive brainstem damage. Akt Neurol1989; 16: 184-190 Matsumoto K, Satoh K. In vitro thrombus lysis by urokinase in preparation for patient studies. In: Hacke, et a/., eds. Thrombolytic Therapy in Acute Ischemic Stroke. 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