Early Local Intra-Arterial Thrombolysis for Severe Middle Cerebral Artery Stroke

Nineteen patients selected for acute hemispheric stroke, severe and stable motor impairment and angiographically proven occlusion of middle cerebral artery trunk or internal carotid artery siphon within 6 h from symptoms onset were treated with graded local urokinase injections using a superselective approach. Eleven of them (58%) displayed partial or subcomplete reperfusion after 900,000 units of urokinase. On follow-up computed tomography, mass effect was severe in 12 patients and moderate in 3 patients. Only 1 patient developed a brain hematoma with clinical deterioration. Good or fair outcome correlated with the presence of collateral blood flow (p < 0.003) and reperfusion (p < 0.007). All patients with collaterals demonstrated immediate recanalization. Local superselective arterial thrombolysis led to a relatively high reperfusion rate, although needing unexpectedly large doses of urokinase. The study emphasizes the central importance of leptomeningeal blood flow for both the likelihood of immediate reperfusion and prognosis.