Thrombectomy Plus Intra-Arterial Thrombolysis Versus Thrombectomy for Acute Large Vessel Occlusions: a Matched-Control Study.

AIM: We conducted a matched-control analysis to compare the outcomes of large vessel occlusion (LVO) patients treated with mechanical thrombectomy (MT) plus Intra-arterial thrombolysis (IAT) versus those treated with MT alone. METHODS: The subjects of this study were chosen from ANGEL-ACT registry. All patients who received MT were identified and categorized into two groups: "MT + IAT" and "MT," based on whether or not they received additional intra-arterial medication IAT during the MT procedure. After being subjected to 1:1 propensity score matching, the outcome measures, including modified Rankin Scale (mRS) score at 90 days, successful recanalization at the final angiogram, symptomatic intracranial hemorrhage (sICH) within 36 h, and death within 90 days, were compared. RESULTS: The study encompassed a total of 1607 patients, with 641 individuals assigned to the MT + IAT group and 966 to the MT group. After applying propensity score matching, a total of 524 pairs were identified for comparison. The results indicated that there were no significant differences between the two groups with regard to the modified Rankin Scale (mRS) score (median: 3 vs. 3 points; P = 0.83), successful recanalization (89.9 vs. 88.9%; P = 0.62), sICH (8.3 vs. 8.7%; P = 0.79), and death (15.5 vs. 16.4%; P = 0.70). CONCLUSIONS: IAT during MT does not confer an elevated risk of sICH or mortality. Furthermore, the combination of MT and IAT may produce comparable functional outcomes in comparison to MT alone, when treating acute LVO patients.

Superselective Arterial Hyaluronidase Thrombolysis is an Effective Treatment for Hyaluronic Acid-Induced Retinal Artery Occlusion: Study in a Rabbit Model.

BACKGROUND: There are serious complications associated with hyaluronic acid (HA) facial injections, including vision impairment due to retinal artery ischemia. In this study, we put forth a clinically relevant model of retinal ischemia and reperfusion in rabbit. We used this to verify the efficacy of hyaluronidase intra-artery thrombolysis in the treatment of hyaluronic acid-induced retinal artery occlusion. METHODS: Retinal artery ischemia was induced by injecting HA into the ophthalmic artery (OA) of adult chinchilla rabbit, and reperfusion was achieved by intra-artery thrombolysis therapy with hyaluronidase following 60 min and 4 h of occlusion. Digital subtraction angiography (DSA) and fundus fluorescein angiography (FFA) were used to evaluate blood flow in the retina. Electroretinogram (ERG), hematoxylin and eosin staining and transmission electron microscope were used to evaluate the structure and function of the retina after ischemia and reperfusion following 60 min and 4 h of occlusion. RESULTS: DSA and FFA images confirmed occlusion of the ophthalmic and central retinal arteries, as well as reperfusion after hyaluronidase thrombolysis. ERG indicated retinal dysfunction following ischemia, and thrombolysis partially rescued its impairment following 4 h of occlusion. Hematoxylin and eosin staining and TUNEL staining revealed ischemia-induced histological damages in the retina at different time windows, and hyaluronidase thrombolysis partially mitigated these damages. CONCLUSIONS: We report a method to establish a HA-induced retinal artery occlusion animal model. Hyaluronidase intra-artery thrombolysis was used to recanalize the embolized OA at different time points. Using our method, we achieved retinal reperfusion, and an improvement was observed in the visual function of rabbits after hyaluronidase thrombolysis following 4 h of occlusion. We believe that hyaluronidase intra-artery thrombolysis is an effective method to treat HA-induced retinal artery occlusion in clinic. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Network Meta-Analysis of Different Thrombolytic Strategies for the Treatment of Central Retinal Artery Occlusion.

PURPOSE: Intravenous and intra-arterial thrombolytic strategies have been used to treat central retinal artery occlusion (CRAO); however, previous meta-analyses evaluated the efficacy of these two thrombolytic strategies separately but did not compare them. This network meta-analysis aimed to evaluate the comparative efficacy and safety of different thrombolytic methods for treating CRAO. METHODS: We searched PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfangdata to identify relevant studies published before 1 January 2023. We used the "network" command in STATA 14.0 software to perform network meta-analysis. In addition, we calculated the surface under the cumulative ranking (SUCRA) to rank all currently available thrombolytic strategies. RESULTS: We included 12 studies in the final data analysis. Results suggested that, compared with standard treatment (ST), intravenous tissue plasminogen activator (IVtPA) (OR, 5.78; 95% CI, 2.07 to 16.11) and intra-arterial urokinase (IAUK) (OR, 2.78; 95% CI, 1.10 to 7.02) and intra-arterial tPA (IAtPA) (OR, 2.45; 95% CI, 1.04 to 5.77) achieved better visual improvement. The differences in visual improvement among IVtPA, IAUK, and IAtPA are insignificant. Furthermore, compared with ST, administration of IVtPA within 4.5 hours of CRAO onset (OR, 8.87; 95% CI, 3.35 to 23.48) rather than administration after 4.5 hours of onset (OR, 3.09; 95% CI, 0.81 to 11.70) achieved better visual improvement. In addition, compared to ST, all available thrombolytic strategies we evaluated were associated with a higher risk of adverse events, but these strategies did not differ. Based on the results of SUCRA, IVtPA had the highest ranking probability in visual improvement (91.9%) but had a relatively lower ranking probability of adverse events (60.1%). CONCLUSION: Both intravenous and intra-arterial thrombolytic strategies are effective for treating CRAO, but SUCRA results show that IVtPA may be the optimal strategy for treating CRAO. Furthermore, based on the results of subgroup analysis, we further speculate that IVtPA injection within 4.5 hours of the onset of CRAO should be the optimal thrombolytic option for treating CRAO. However, due to the limitations of all eligible studies, more studies are still required in the future to validate our findings.

Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis.

BACKGROUND: There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT). METHODS: We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT. RESULTS: A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons. CONCLUSION: Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.

A Review on Adjunctive Therapies for Endovascular Treatment in Acute Ischemic Stroke.

Endovascular treatment (EVT) has revolutionized the management of acute ischemic stroke (AIS), but almost half of patients undergoing EVT do not achieve a good outcome. Adjunctive therapies have been proposed to improve the outcomes of EVT in AIS. This review aims to summarize the current evidence on the use of adjunctive therapies in EVT for AIS, including antithrombotic agents, intra-arterial thrombolytics, cerebroprotective agents, normobaric oxygen, and hypothermia. Several adjunctive therapies have shown promise in improving the outcomes of EVT in AIS, but phase 3 clinical trials are needed to establish clinical efficacy. We summarize the advantages and disadvantages of adjunctive EVT treatments and outline the challenges that each of these therapies will face before being adopted in clinical practice.

Mechanical thrombectomy with intra-arterial alteplase provided better functional outcomes for AIS-LVO: a meta-analysis.

Background: Several clinical trials have shown that intra-arterial thrombolysis using alteplase during mechanical thrombectomy (MT) has a better outcome than MT alone in ischemic stroke management. We performed the current meta-analysis to estimate the efficacy and safety of MT with intra-arterial alteplase therapy. Methods: The MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov databases were searched up to Mar. 2022 to identify the clinical trials that compared MT alone versus MT with intra-arterial alteplase therapy. STATA 16.0 was used for statistical analysis. The odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated with a random effect model. Results: Seven studies involving 1,083 participants were included. The primary outcomes were better functional outcomes, defined as a modified Rankin Scale (mRS) score between 0 and 2 at 90 days, and successful recanalization, defined as a modified thrombolysis in cerebral infarction (mTICI) score ≥ 2b. Compared to MT alone, MT with intra-arterial alteplase did not lead to higher mTICI scores (OR 1.58, 95%CI 0.94 to 2.67, p = 0.085, I2 = 16.8%) but did lead to better mRS (OR 1.37, 95%CI 1.01 to 1.86, p = 0.044). There was no increase in mortality or bleeding events in the overall or subgroup analyses. Conclusion: MT with intra-arterial alteplase did not improve the recanalization rate but provided better functional outcomes. The intervention did not increase adverse effects in any subgroup at the same time. Clinical trial registration: http://inplasy.com, identifier INPLASY202240027.

Effect of intra-arterial thrombolysis following successful endovascular thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke: A post-CHOICE meta-analysis.

INTRODUCTION: Endovascular thrombectomy (EVT) is the standard treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although > 70% of patients in the trials assessing EVT for AIS-LVO had successful recanalization, only a third ultimately achieved favorable outcomes. A "no-reflow" phenomenon due to distal microcirculation disruption might contribute to such suboptimal outcomes. Combining intra-arterial (IA) tissue plasminogen activator (tPA) and EVT to reduce the distal microthrombi burden was investigated in a few studies. We present a pooled-data meta-analysis of the existing evidence of this combinatorial treatment. METHODS: We followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) recommendations. We aimed to include all original studies investigating EVT plus IA tPA in AIS-LVO patients. Using R software, we calculated pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI). A fixed-effects model was adopted to evaluate pooled data. RESULTS: Five studies satisfied the inclusion criteria. Successful recanalization was comparable between the IA tPA and control groups at 82.9% and 82.32% respectively. The 90-day functional independence was similar between both groups (OR= 1.25; 95% CI= 0.92-1.70; P= 0.154). Symptomatic intracranial hemorrhage (sICH) was also comparable between both groups (OR= 0.66; 95% CI= 0.34-1.26; P= 0.304). CONCLUSION: Our current meta-analysis does not show significant differences between EVT alone and EVT plus IA tPA in terms of functional independence or sICH. However, with the limited number of studies and included patients, more randomized controlled trials (RCTs) are needed to further investigate the benefits and safety of combined EVT and IA tPA.

Efficacy and safety of intra-arterial thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis.

PURPOSE: To investigate the efficacy and safety of intra-arterial thrombolysis (IAT) in patients with central retinal artery occlusion (CRAO). METHODS: PubMed and EMBASE were searched for potentially eligible studies that reported IAT in CRAO patients from inception to Nov 8, 2021. Standard mean difference (SMD) was pooled to compare visual acuity (VA) at baseline with final in IAT patients. The rates and odds ratios (OR) were meta-analyzed to compare VA improvement in IAT with non-IAT patients, stratified to different times from onset to procedure, different definitions of VA improvement, and three CRAO stages. Adverse effects were recorded. RESULTS: Fifteen studies were included, enrolling 507 CRAO patients who received IAT and 296 CRAO patients who did not. VA was significantly improved from baseline to final VA in IAT patients (SMD [LogMAR] 0.70, 95% CI [0.51, 0.90]). VA improvement rate was higher in IAT patients than that in non-IAT (56% vs 32%, OR 3.55, 95%CI [1.74, 7.24]), with greater OR in IAT within 6 h from onset to procedure (OR 4.60, 95%CI [1.24, 16.99]) than that beyond 6 h (OR 3.36, 95%CI [1.43, 7.85]). The benefit remained consistent when VA improvement was defined as ≥ 3 lines on the Snellen chart (OR 4.68, 95%CI [2.10, 10.41]) and was even greater when CRAO was incomplete. Five patients had a symptomatic intracranial hemorrhage and 21 patients had ischemic stroke or transient ischemic attack after IAT. CONCLUSIONS: IAT treatment has certain potential in ameliorating VA in CRAO patients, which should be balanced against cerebral complications.

Research progress on intra-arterial thrombolysis for the treatment of central retinal artery occlusion / 国际眼科杂志(Guoji Yanke Zazhi)

Central retinal artery occlusion(CRAO), also known as eye stroke, always results in acute and painless visual loss. At present, conservative treatments, such as eye massage, lowering intraocular pressure and vasodilators have little effect on reducing visual loss. Intra-arterial thrombolysis(IAT)has significantly improved prognosis in patients with acute ischemic stroke, thus IAT has been gradually applied in the treatment of CRAO. IAT injects fibrinolytic drugs directly into the ophthalmic artery by a microcatheter, and dissolves the emboli that block the central retinal artery to restore the blood flow of the retina. Theoretically, IAT may be effective for CRAO as what has been found for stroke, but existing clinical studies exhibited inconsistent results. This paper summarizes the feasibility, efficacy, and safety of IAT treatment in CRAO. It will also analyze related factors that affect the prognosis, putting forward potential development directions and providing insights for the further clinical application of IAT.

Efficacy and safety of intra-arterial thrombolysis for retinal artery occlusion based on the green channel for eye stroke / 中华眼底病杂志

Objective:To explore the short-term efficacy and safety of intra-arterial thrombolysis (IAT) in the treatment of retinal artery occlusion (RAO) with the assistance of the rescue green channel in the eye stroke center.Methods:A prospective, interventional, single-center study. Thirty-eight eyes from 38 RAO patients who received IAT treatment in Guangdong Provincial People’s Hospital were enrolled. All the patients were rescued via the green channel in our eye stroke center. Data from comprehensive ocular examinations including best-corrected visual acuity (BCVA) and optical coherence tomography angiography (OCTA) were collected. BCVA was measured with Snellen chart and converted to the logarithmic minimum angle of resolution (logMAR) unit for statistical analysis. RTVue XR OCTA was used to measure vascular densities (VD) of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and radial peripapillary capillary (RPC), and central retinal thickness (CRT). All RAO eyes attempted IAT treatment and 34 eyes were successful. Four eyes failed to complete IAT because of the occlusion of internal or common carotid arteries on the same side with the RAO eyes. Ocular examinations in post-operative 1-3 days were performed with the same devices and methods as those before surgery. Parameters measured before and after surgery include BCVA, VD of SCP, DCP, RPC, and CRT. Data of the green channel collected include the time intervals from onset of RAO to first presentation in local hospitals, and from onset of RAO to our eye stroke center. Comparisons of VD and CRT between the RAO eyes and contralateral healthy eyes were performed with independent samples Mann-Whitney U test; comparisons of VD and CRT in RAO eyes before and after IAT surgery were performed with paired samples Wilcoxon Rank Sum test. Results:Among the 34 RAO patients who had successful IAT surgery, 18 (52.9%, 18/34) were males and 16 (47.1%, 16/34) were females; the mean age was (51.0±12.9) years old. There were 30 and 4 eyes diagnosed as central RAO and branch RAO respectively. The logMAR BCVA before and after IAT surgery was 2.52±0.61 and 2.18±0.85 respectively, and the difference was statistically significant ( Z=-3.453, P=0.002). Before surgery, VD of SCP, DCP and RPC were significantly decreased and CRT was significantly increased in the affected eye compared with the contralateral healthy eyes, with the statistical significance ( P<0.001). Compared with those before surgery, the VD of SCP and DCP were significantly improved after surgery ( Z=-2.523, -2.427; P=0.010, 0.014), while there was no difference in VD of RPC and CRT ( Z=-1.448, -1.454; P=0.150, 0.159). The time interval between onset of RAO and first visit to the hospital was (6.56±6.73) hours; the time interval between onset of RAO and the arrival at our hospital was (24.11±19.90) hours. No cerebral stroke was observed in the early postoperative period and no cerebrocardiovascular events were observed later. he time interval between onset of RAO and the arrival at our hospital was (24.11±19.90) hours. No cerebral stroke was observed in the early postoperative period and no cerebrocardiovascular events were observed later. Conclusions:The short-term efficacy and safety of IAT in the treatment of RAO were satisfactory. The rescue time window might be prolonged.

Intra-Arterial Thrombolysis Vs. Mechanical Thrombectomy in Acute Minor Ischemic Stroke Due to Large Vessel Occlusion.

Background: The efficacy and safety of mechanical thrombectomy (MT) in acute large vessel occlusion (LVO) patients with minor stroke (NIHSS ≤ 5) remains undetermined. We aimed to compare the efficacy and safety of intra-arterial thrombolysis (IAT) alone vs. MT for LVO patients with minor stroke. Methods: Patients were selected from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry, a prospective multicenter registry study, and divided into MT and IAT alone groups. We compared the outcome measures between the two groups, including 90-day functional outcome evaluated by the modified Rankin Scale (mRS), the final recanalization level, intracranial hemorrhage, and mortality within 90-days by logistic regression models with adjustment. Besides the conventional multivariable analysis, we performed a sensitivity analysis by adjusting the propensity score to confirm our results. The propensity score was derived using a logistic regression model. Results: Of the 120 patients, 63 received IAT alone and 57 received MT as the first-line treatment strategy. As compared to MT group, patients in the IAT alone group were associated with a higher chance of 90-day mRS 0-2 [93.7% vs. 71.9%, odds ratio (OR) = 4.75, 95% confidence interval (CI): 1.20-18.80, P = 0.027], a high chance of 90-day mRS 0-3 (96.8% vs. 86.7%, OR = 11.35, 95% CI: 1.93-66.86, P = 0.007), a shorter median time from puncture to recanalization (PTR) (60 min vs. 100 min, ß = -63.70, 95% CI: -81.79- -45.61, P < 0.001), a lower chance of any intracranial hemorrhage (ICH) within 48 h (3.2% vs. 19.3%, OR = 0.15, 95% CI: 0.03-0.79, P = 0.025), and a lower chance of mortablity within 90 days (1.6% vs. 9.2%, OR = 0.05, 95% CI: 0.01-0.57, P = 0.016). Similarly, the sensitivity analysis showed the robustness of the primary analysis. Conclusions: Compared with MT, IAT may improve 90-day clinical outcomes with decreased ICH rate and mortality in LVO patients with minor stroke.

Early Onset of Neovascular Glaucoma After Intra-Arterial Thrombolysis for Central Retinal Artery Occlusion: A Possible Complication?

Purpose: To report on four cases of central retinal artery occlusion (CRAO) treated with intra-arterial thrombolysis with early onset neovascular glaucoma in the further disease course. Patients and Methods: Retrospective analysis of the medical records of six consecutive patients treated with intra-arterial thrombolysis for CRAO of which four developed neovascular glaucoma. Results: All six patients were diagnosed with acute CRAO and treated with intra-arterial thrombolysis 4.5-6 hours after symptom onset. The patients had no significant carotid artery stenosis and unremarkable ophthalmic history. No visual improvement could be achieved after treatment. Four to seven weeks after CRAO onset, four of these patients developed severe painful neovascular glaucoma. Conclusion: Early onset of aggressive neovascular glaucoma following intra-arterial thrombolysis for CRAO might be a complication of CRAO itself, still possible association with intra-arterial thrombolysis in our patients should be discussed.

Contrast-Associated Acute Kidney Injury in Patients with and without Diabetes Mellitus Undergoing Computed Tomography Angiography and Local Thrombolysis for Acute Lower Limb Ischemia.

PurposeRepetitive iodinated contrast media exposure may be harmful for the kidneys. The aim of the present study was to evaluate if patients with diabetes mellitus (DM) undergoing CT angiography (CTA) and local continuous thrombolysis for acute lower limb ischemia (ALI) had an increased risk of developing contrast-associated acute kidney injury (CA-AKI) compared to patients without DM. Methods: This is a retrospective study of patients undergoing CTA and local continuous thrombolysis due to ALI between 2001 and 2018. CA-AKI was defined as a 25% increase in serum creatinine within 72 hours after latest contrast administration. Results: There was no difference (P = .30) in the frequency of CA-AKI between patients with (27.9%; n = 43) and without DM (20.6%; n = 170). Among patients with CA-AKI, patients with DM had a lower (P < .001) estimated glomerular filtration rate (eGFR) at discharge (55 ml/min/1.73 m2) than at admission (70 ml/min/1.73 m2), while no such difference was found in the group without DM (P = .20). The gram-iodine dose/eGFR ratio was higher (P < .001) in patients with CA-AKI (median 1.49, [IQR 1.34-1.81]) than in those who did not develop CA-AKI (median 1.05 [IQR 1.00-1.13]). There was a trend that gram-iodine dose/eGFR ratio (OR 1.42/standard deviation increment, 95% CI 1.00-2.02; P = .050) was associated with an increased risk of CA-AKI, after adjusting for DM, age, and gender. Conclusions: The frequency of CA-AKI was high after CTA and local continuous thrombolysis for ALI without shown increased frequency for the DM group. Among patients with CA-AKI, however, patients with DM had worse renal function at discharge than those without DM. The gram-iodine dose/eGFR ratio in these patients needs to be lower to improve renal outcomes, particularly in patients with DM.

Significant Vision Recovery from Filler-Induced Complete Blindness with Combined Intra-Arterial Injection of Hyaluronidase and Thrombolytic Agents.

With the increase of cosmetic injectable hyaluronic acid (HA), there have been more cases with serious complications, including skin necrosis, blindness, and cerebral embolism. Patients who have recovered from HA filler-induced total vision loss are extremely rare. We report a case of a 27-year-old female who developed severe ocular pain on the right side and total vision loss following a 1.0 ml HA filler injection in the nasal dorsum. She arrived at our hospital 4 hours later. Her visual acuity was no light perception (NLP), and she exhibited eyelid ptosis, ophthalmoplegia, and frontal and nasal ecchymosis. She was promptly treated with subcutaneous and retrobulbar hyaluronidase injections, as well as intra-arterial 1500 IU hyaluronidase injections into the right ophthalmic artery with DSA assistance. Her vision improved from NLP to counting fingers at 1.0 meters. Unfortunately, 13 hours later, she felt an intense headache, and her vision again decreased to NLP. We immediately performed an injection of 1500 IU hyaluronidase combined with 8 mg alteplase for intra-arterial thrombolysis (IAT) into the right ophthalmic artery. Her vision improved immediately afterward. After 3 months, her visual acuity had significantly recovered from NLP (admission vision status) to 20/50 (Snellen chart with glasses). Similarly, skin, conjunctival, eye movement, and ptosis symptoms completely recovered. This case demonstrates that reversal of complete blindness due to embolism of the ophthalmic and central retinal arteries could be accomplished through multidisciplinary therapies, especially IAT using fibrinolytic agents combined with hyaluronidase followed by an anticoagulant regimen.Level of evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Better late than never: initial experience of intra-arterial pulsed-urokinase-injection as a salvage therapy for refractory sudden sensorineural hearing loss.

BACKGROUND AND PURPOSE: Cochlear vascular micro-thrombosis has been hypothesized as one of the pathogenic mechanisms for sudden sensorineural hearing loss (SSNHL) refractory to regular management. This study aimed to evaluate the feasibility and safety of intra-arterial pulsed-injection urokinase (IAPU) as a salvage therapy for SSNHL after the failure of conventional therapy. METHODS: We retrospectively reviewed our patient database to identify refractory SSNHL patients between November 2017 and July 2020. Study outcomes before and after the IAPU therapy were compared between IAPU and conventional therapy groups. RESULTS: Sixty-seven moderate-profound SSNHL patients (29 in IAUP group, 38 in control group) were included in this study. Compared to the control group, patients in the IAPU group showed more significant improvement in pure tone average (PTA) (34.2 ± 23.5 vs. 10.7 ± 13.1, p < 0.001) and degree of hearing recovery (total: 20.7% vs. 5.3%, partial: 24.1% vs. 10.5%, mild: 27.6% vs. 13.2% and non: 27.6% vs. 71.1%) 2 weeks after admission. In the IAPU group, a significant improvement of PTA (86.6 ± 11.5 vs. 54.6 ± 20.1 dB, p < 0.005) was observed on the first day after IAPU treatment. CONCLUSION: In carefully selected SSNHL cases with a highly suspected vascular origin, IAPU is a safe and effective therapy when conventional treatments have failed. Despite the encouraging findings of our work, large studies are needed to better investigate the strengths and limitations of this salvage therapy.

Intra-arterial thrombolysis for early hepatic artery thrombosis after liver transplantation.

BACKGROUND: Early hepatic artery thrombosis (E-HAT) is a serious complication after liver transplantation (LT), which often results in graft failure and can lead to patient deaths. Treatments such as re-transplantation and re-anastomosis are conventional therapeutic methods which are restricted by the shortage of donors and the patient's postoperative intolerance to re-laparotomy. Due to the advances in interventional techniques and thrombolytics, endovascular treatments are increasingly being selected by more and more centers. This study reviews and reports our single-center experience with intra-arterial thrombolysis as the first choice therapy for E-HAT after deceased donor LT. AIM: To evaluate the feasibility and reasonability of intra-arterial thrombolysis for E-HAT after deceased donor LT. METHODS: A total of 147 patients who underwent deceased donor LT were retrospectively reviewed in our hospital between September 2011 and December 2016. Four patients were diagnosed with E-HAT. All of these patients underwent intra-arterial thrombolysis with alteplase as the first choice therapy after LT. The method of arterial anastomosis and details of the diagnosis and treatment of E-HAT were collated. The long-term prognosis of E-HAT patients was also recorded. The median follow-up period was 26 mo (range: 23 to 30 mo). RESULTS: The incidence of E-HAT was 2.7% (4/147). E-HAT was considered when Doppler ultrasonography showed no blood flow signals and a definite diagnosis was confirmed by immediate hepatic arterial angiography when complete occlusion of the hepatic artery was observed. The patients were given temporary thrombolytics (mainly alteplase) via a 5-Fr catheter which was placed in the proximal part of the thrombosed hepatic artery followed by continuous alteplase using an infusion pump. Alteplase dose was adjusted according to activated clotting time. The recanalization rate of intra-arterial thrombolysis in our study was 100% (4/4) and no thrombolysis-related mortality was observed. During the follow-up period, patient survival rate was 75% (3/4), and biliary complications were present in 50% of patients (2/4). CONCLUSION: Intra-arterial thrombolysis can be considered first-line treatment for E-HAT after deceased donor LT. Early diagnosis of E-HAT is important and follow-up is necessary even if recanalization is successful.

Postcardiac Surgery Acute Stroke Therapies: A Systematic Review.

OBJECTIVE: To identify interventions for the treatment of acute ischemic stroke after cardiac surgery and to report the efficacy of these treatments. DESIGN: Systematic review and narrative synthesis PARTICIPANTS: Patients with ischemic stroke after cardiac surgery. INTERVENTIONS: Treatment efficacy of intra-arterial thrombolysis (IAT) and/or endovascular mechanical thrombectomy (EMT). METHODS AND MAIN RESULTS: The MEDLINE (Ovid), Embase (Ovid), Scopus (Elsevier), and Cochrane Central Register of Controlled Trials (Wiley) databases were searched from January 1, 1990, until September 20, 2018. After reviewing 5,231 records, 8 case reports/series and 2 retrospective studies were included (n = 33). Three of these reports (n = 19) published between 2001 and 2003 described IAT, and 6 studies (n = 14) published between 2015 and 2019 reported the use of EMT. In the 19 patients who received IAT, 3 (16%) had good, 8 (42%) had moderate, and 8 (42%) had poor neurologic outcomes. In the 14 patients who received EMT, 7 (50%) had good, 5 (36%) had moderate, and 2 (14%) had poor neurologic outcomes. CONCLUSIONS: Endovascular thrombectomy, with or without IAT, is being used increasingly with success in patients presenting with postcardiac surgery stroke. However, the number of patients reported is too small to confidently understand its overall effect on neurologic outcomes in this setting.

Large Vessel Occlusion in the Acute Stroke Patient: Identification, Treatment, and Management.

Acute ischemic stroke is a major cause of death and disability in the United States. Historically, acute stroke patients were treated with intravenous (IV) thrombolysis. Patients with large vessel occlusions (LVOs) should be offered mechanical thrombectomy, with or without IV thrombolysis, in an extended window up to 24 hours of last known well. Both treatment options are the standard of care for a patient with an LVO. It is critical that the intensive care unit nurse understand new treatment indications for LVO strokes, and the priorities of nursing care with medical and endovascular intervention.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis.

OBJECTIVE: Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding. METHODS: A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality. RESULTS: After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group. CONCLUSION: The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.