Reperfusion Rates Following Intra-Arterial Thrombolysis for Acute Ischemic Stroke: The Influence of the Method for Alteplase Delivery

Arteriograms obtained before (A), during microcathter positioning (B−D), and following alteplase infusion (E) in a patient with occlusion at the superior division of the middle cerebral artery at the M2 segment (arrow, A) demonstrate optimization of microcatheter placement. The microcatheter tip is indicated by arrows (B−D). Arrowheads (B−D) indicate contrast distribution during microcatheter contrast injection. B, The microcatheter tip (black arrow) is located along the distal aspect of the thrombus. Contrast administration in B indicates that given this position, thrombolytic agent would only be distributed within the distal aspect of the thrombus. Contrast injection in C indicates that the thrombolytic agent is delivered to the proximal and inferior aspect of the thrombus with significant amounts of alteplase escaping into vessels proximal to the occlusion site (white arrowheads). Contrast injection in D indicates that thrombolytics are delivered around the entire thrombus (outlined by dots) and serves as an optimal position for thrombolytic infusion. Note that contrast enters 2 involved branches in D, unlike in B or C. Involved branches will demonstrate stagnant contrast opacification, whereas uninvolved branches will demonstrate brisk flow of contrast. It is intuitive that stagnant contrast would also imply that alteplase would also tend to stagnate adjacent to the thrombus during its delivery. If the RMP method was used all 3 microcatheter positions depicted in B−D would be acceptable, whereas with the OAD method, only the position in D would be acceptable.