Unitat Neurovascular, Servei de Neurologia, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
J Neuroimaging. 2010 Jul;20(3):224-7. doi: 10.1111/j.1552-6569.2008.00357.x. Epub 2009 Feb 13.
Microbubbles (MB) and ultrasound have been shown to enhance thrombolysis. We sought to evaluate safety and efficacy on middle cerebral artery (MCA) recanalization of local MB administration during intra-arterial (IA) thrombolysis and continuous transcranial Doppler (TCD) monitoring.
Patients with acute M1-MCA occlusion were treated with intravenous tissue plasminogen activator (iv-tPA) and continuously monitored with TCD. If recanalization was not achieved during first-hour bridging IA-rescue was adopted: MB + tPA direct intraclot microcatheter infusion. TCD flow monitoring allowed continuous insonation at clot location. Recanalization was angiographically assessed (thrombolysis in cerebral infarction [TICI] score) and compared with simultaneous TCD data. IA procedures were stopped at 6 hours. Recanalization was reassessed at 12 hours (TCD). Neurological status was repeatedly assessed (National Institutes of Health Stroke Scale [NIHSS]). At three months, patients were considered independent if mRS <or= 2.
Of the 18 included patients (mean age 72), 16 received standard iv-tPA (.9 mg/kg). Nine patients were recanalized during tPA infusion and 9 patients underwent IA-rescue procedures. Median pre-IA NIHSS score: 20. Median time to IA initiation was 175 +/- 63 minutes. Mean IA doses were tPA = 10 +/- 3 mg and MB = 3 +/- 1 mL. TCD monitoring allowed direct visualization of massive MB arrival during every administration. In-procedure recanalization was observed in 78% (n= 7): complete-TICI3 in 22% (n= 2), partial-TICI2 in 56% (n= 5). Perfect correlation was observed between TICI and TCD scores. At 12 hours complete recanalization increased to 56%, partial to 22%. One patient (11%) experienced symptomatic intracranial hemorrhage accounting for the only death. Median NIHSS evolution was 12 at 24 hours and 10 at discharge. At 3 months 4 patients (44%) were independent.
The combination of ultrasound and IA MB and tPA may be a strategy to enhance the thrombolytic effect and increase recanalization rates.
微泡（MB）和超声已被证明可以增强溶栓作用。我们旨在评估在经动脉（IA）溶栓和连续经颅多普勒（TCD）监测期间局部 MB 给药对大脑中动脉（MCA）再通的安全性和疗效。
急性 M1-MCA 闭塞患者接受静脉组织型纤溶酶原激活剂（iv-tPA）治疗，并连续接受 TCD 监测。如果在第一小时的桥接 IA 抢救中未实现再通，则采用 MB+tPA 直接血栓内微导管输注：TCD 流量监测允许在血栓位置进行连续照射。通过血管造影评估再通情况（血栓溶解脑梗死 [TICI] 评分），并与同时的 TCD 数据进行比较。IA 程序在 6 小时停止。在 12 小时（TCD）重新评估再通情况。反复评估神经状态（国立卫生研究院卒中量表 [NIHSS]）。三个月时，如果 mRS<or=2，则患者被认为是独立的。
18 例纳入患者（平均年龄 72 岁）中，16 例接受标准 iv-tPA（0.9mg/kg）。9 例患者在 tPA 输注期间再通，9 例患者接受 IA 抢救。IA 前 NIHSS 评分中位数：20。IA 开始的中位时间为 175+/-63 分钟。IA 平均剂量为 tPA=10+/-3mg 和 MB=3+/-1mL。TCD 监测允许在每次给药时直接观察到大量 MB 的到达。78%（n=7）的患者观察到术中再通：完全 TICI3 占 22%（n=2），部分 TICI2 占 56%（n=5）。TICI 和 TCD 评分之间观察到完美的相关性。在 12 小时时，完全再通增加到 56%，部分再通增加到 22%。1 例（11%）患者发生症状性颅内出血，是唯一的死亡病例。24 小时和出院时 NIHSS 中位数分别为 12 和 10。3 个月时，4 例（44%）患者独立。
超声联合 IA MB 和 tPA 可能是增强溶栓效果和提高再通率的一种策略。
