Clinical Briefing:
Catheter-Based Therapy for Acute Ischemic Stroke
November / December 2005
Intravenous tissue plasminogen activator (tPA)
is the standard of care for treating patient with acute ischemic
stroke who present within three hours of symptom onset. However,
patients often have medical conditions which contraindicate
IV tPA, such as recent surgery, or fail to achieve vessel
recanalization despite this therapy.
Such patients may be
effectively treated with catheter based approaches to restore
cerebral perfusion, either in lieu of or in addition to
IV tPA. Intra-arterial administration of tPA directly into
the occluded vessel, use of mechanical devices to disrupt
and extract clot, and acute angioplasty are all in use at
our center, and we have been involved in a number of studies
evaluating the safety and effectiveness of these therapies.
Scott
E. Kasner, MD,
Associate Professor of Neurology,
Director of the Comprehensive
Stroke Center
Case Study
Mr. G is a 53-year-old man who presented
to a local community hospital 30 minutes after the abrupt
onset of left hemiplegia, left visual field loss, left sensory
impairment, and dense neglect consistent with a major right
hemispheric stroke. Emergent head CT showed no evidence of
hemorrhage. He underwent an inguinal hernia repair the day
prior to this stroke, which contraindicated the use of intravenous
thrombolytic therapy. He also had a history of neck cancer
that was successfully treated five years earlier with surgery
and focused radiation therapy to the neck.
Given his major deficit and contraindication for intravenous
thrombolysis, his local neurologist immediately contacted
the Penn Stroke Team to discuss other treatment options.
He was transferred by helicopter to the Hospital of the University
of Pennsylvania and taken to the interventional neuroradiology
suite where a rapid assessment by one of our stroke neurologists
confirmed a severe right hemispheric stroke with a poor prognosis
for functional recovery without aggressive therapy. Immediate
angiography revealed a near-occlusion of the right internal
carotid artery, likely due to accelerated atherosclerosis
from prior neck radiation, and an abrupt embolic occlusion
of the right middle cerebral artery.
 A catheter could not be passed to the affected intracranial
artery for direct intraclot administration of thrombolytic
agent given the severe carotid stenosis. Our interventional
neuroradiologist, therefore, dilated the vessel with carotid
angioplasty, followed by introduction of low-dose tissue
plasminogen activator (tPA) into the occluded intracranial
artery. The artery rapidly and completely recanalized with
restoration of flow to the entire right hemisphere.
Immediately
post-procedure, the patient had dramatic neurologic recovery.
He was admitted to our Stroke Unit and received intensive
monitoring and measures to maintain optimal cerebral perfusion.
Follow-up neuroimaging revealed a very small area of infarction.
He was discharged to home two days later with complete
recovery except for mild loss of sensation in his left face
and hand.
Clinical Trials
- Neuroprotective agents (for
both ischemic stroke and intracerebral hemorrhage)
- Alternative
reperfusion strategies
- Antiplatelet agents for
stroke prevention
- Procoagulation for hemorrhagic
strokes
- Patent foramen ovale closure for stroke
prevention
- Novel diagnostic imaging modalities
- Blood markers
and stroke mechanism
- Risk stratification for transient
ischemic attack
- Prevention of epilepsy after
intracerebral hemorrhage
Our Team
The Penn Comprehensive Stroke Center has
fellowship-trained stroke neurologists on call 24 hours a
day, 7 days a week for evaluation and management of patients
with acute stroke. Numerous clinical trials evaluating experimental
neuroprotective and reperfusion agents are available, and
offer the possibility of benefit to patients ineligible for
conventional therapy.
Fully-equipped neuroimaging (including
MRI, MR angiography, MR perfusion, CT angiography, CT perfusion,
xenon CT, and catheter angiography), interventional neuroradiology,
a dedicated Stroke Unit, in-house neurologic and neurosurgical
staff, and specialized rehabilitation personnel and facilities
provide a breadth of expertise to optimize the chance of
maximal recovery following acute stroke.
Scott E. Kasner, MD
Associate Professor of Neurology
Director of the Comprehensive Stroke Center
Hospital of the
University of Pennsylvania
Brett L. Cucchiara, MD
Assistant Professor of Neurology
Hospital of the University
of Pennsylvania
John A. Detre, MD
Associate Professor of Neurology
Hospital of the University
of Pennsylvania
Robert W. Hurst, MD
Professor of Radiology (Neuroradiology)
Hospital of the
University of Pennsylvania
Joshua Levine, MD
Assistant Professor of Neurology
Hospital of the University
of Pennsylvania
Jean Luciano, CRNP
Hospital of the University of
Pennsylvania
Michael L. McGarvey, MD
Assistant Professor of
Neurology
Hospital of the University of Pennsylvania
Steven R. Messe, MD
Assistant Professor of Neurology
Hospital of the University
of Pennsylvania
Michele Sellers, RN
Hospital of the University
of Pennsylvania
John B. Weigele, MD, PhD
Assistant Professor of
Radiology (Neuroradiology)
Hospital of the University of
Pennsylvania
Richard D. Zorowitz, MD
Associate Professor of
Physical Medicine and Rehabilitation
Hospital of the University
of Pennsylvania
Access
For information about how to contact the Penn Stroke Team,
please call the PENNHealth at 1-800-789-PENN.
Hospital of the University of Pennsylvania
9th
floor, Silverstein Building
3400 Spruce Street, Philadelphia
To refer a patient and/or consult with a doctor:
Please contact your UPHS physician liaison with any concerns
or problems you may experience when referring your patient.
Location
|
|
Referring Physicians: To speak with a Penn physician
or refer a patient, contact PennHealth through the secure online
referral form or by calling
1-800-789-PENN
(7366). |
 |
|
|
|
