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26. Who should be considered for IA therapy?

. Patients who have received IV TPA for a distal ICA, M1 segment of MCA, proximal M2 segment of MCA, or basilar lesion on TCD, MRA, or CTA, who have not recanalized by the time they get to the angio suite, and who still have a disabling deficit.

 

Even if patients have received full-dose IV TPA, we have found that following IV therapy with IA therapy is safe in most patients. However, this must still be done while the tissue is still alive, i.e., before there are extensive ischemic CT changes or while the MRI still shows mismatch.

. Patients who qualify for IV TPA within 3 hours but have certain exclusions that would increase bleeding risk, such as recent major surgery or INR>1.6, and who have a  devastating stroke. However, IA thrombolysis has been associated with up to 10% rates of symptomatic ICH, so IA lytics should not be considered a ‘‘safer’’ alternative to IV TPA. But IA therapy allows the use of mechanical clot disruption rather than pharmacologic clot lysis, and these mechanical approaches might be associated with less bleeding risk in such patients.

. Patients outside the 3-hour window but within 9 hours of onset of symptoms, with a severe stroke (NIHSS>10), limited or no ischemic changes on CT, significant perfusion/ diffusion mismatch on MRI, with no other contraindication. In these cases, we consider either IV TPA or IA therapy depending on whether we can identify a large artery occlusion on TCD, MRA, or CTA, and the availability of the endovascular team to mobilize quickly. We often push the time window for starting IA therapy beyond 9 hours if the patient has a suspected basilar occlusion, because doing nothing would be uniformly fatal.

Next: Unproven therapies - Neurological deterioration in acute ischemic stroke 

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