Intra-arterial cerebral thrombolysis for acute ischemic stroke in a community hospital.

BACKGROUND AND PURPOSE: Advances in thrombolytic therapy, brain imaging, and neurointerventional techniques provide new therapeutic options for acute stroke. Intra-arterial thrombolysis has proved to be a potent therapeutic tool. To show that this procedure can be performed in community hospitals, we describe our experience with a group of 11 patients treated for middle cerebral artery occlusions. METHODS: Twenty-two patients seen during a period of 1 year with clinical findings of acute major-vessel stroke met screening criteria and were evaluated under an institutional review board-approved protocol. After CT scanning, 17 of those patients met strict criteria, gave informed consent, and underwent angiography. Eleven patients had M1 and M2 middle cerebral artery occlusions and received local thrombolytic therapy with urokinase. Recanalization efficacy, complications, and outcome data were compiled. RESULTS: The average score on the National Institutes of Health Stroke Scale was 22.2 at the onset of treatment and 12.5 after therapy, with 91% of patients showing neurologic improvement. Complete (TIMI 3) recanalization occurred in 73% of cases and partial recanalization (TIMI 2) in 18%. At the 90-day follow-up evaluation, 56% of patients had good outcomes (modified Rankin score, 0 to 1). One intracranial hemorrhage occurred. CONCLUSION: Intra-arterial thrombolysis can be performed in a community hospital by radiologists with interventional and neuroradiologic skills given appropriate institutional preparation.

Vasospasm and thrombus formation as possible mechanisms of stroke related to alkaloidal cocaine.

BACKGROUND: "Crack" cocaine (alkaloidal cocaine) induces ischemic stroke. However, the mechanisms by which this occurs are not well documented in humans. We present pertinent information on three patients whose ischemic strokes involved the territory of the internal carotid artery and were associated with crack use. CASE DESCRIPTIONS: These patients were investigated clinically, radiologically, intraoperatively, and/or histopathologically at the same institution, and the diagnostic evaluations did not reveal a definite cardiac or hematologic cause of stroke. Large filling defects were noted on conventional carotid angiography in two of these patients; in the third patient, the histopathological changes were compatible with vasospasm. To our knowledge, these changes have not been previously documented in human arteries. CONCLUSIONS: We suggest that some brain infarcts among crack cocaine users may result from vasospasm of large arteries and secondary intravascular thrombosis.