Robert J. Ernst

Combined Intravenous and Intra-Arterial Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke

Background and Purpose A retrospective analysis was performed on 20 consecutive patients who presented with severe acute ischemic stroke and were evaluated for a combined intravenous (IV) and local intra-arterial (IA) recombinant tissue plasminogen activator (rtPA) thrombolytic approach within 3 hours of onset. Methods Twenty consecutive patients with carotid artery distribution strokes were evaluated and treated using a combined IV and IA rtPA approach over a 14-month period (September 1998 to October 1999). rtPA (0.6 mg/kg) was given intravenously (maximum dose 60 mg); 15% of the IV dose was given as bolus, followed by a continuous infusion over 30 minutes. A maximal IA dose, up to 0.3 mg/kg or 24 mg, whichever was less, was given over a maximum of 2 hours. IV treatment was initiated within 3 hours in 19 of 20 patients. All 20 patients underwent angiography, and 16 of 20 patients received local IA rtPA. Results The median baseline National Institutes of Health Stroke Scale (NIHSS) score for the 20 patients was 21 (range 11 to 31). The median time from stroke onset to IV treatment was 2 hours and 2 minutes, and median time to initiation of IA treatment was 3 hours and 30 minutes. Ten patients (50%) recovered to a modified Rankin Scale (mRS) of 0 or 1; 3 patients (15%), to an mRS of 2; and 5 patients (25%), to an mRS of 4 or 5. One patient (5%) developed a symptomatic intracerebral hemorrhage and eventually died. One other patient (5%) expired because of complications from the stroke. Conclusions We believe that the greater-than-expected proportion of favorable outcomes in these patients with severe ischemic stroke reflects the short time to initiation of both IV and IA thrombolysis.

Spinal Dural Arteriovenous Fistulas: Recognizing the Spectrum of Magnetic Resonance Imaging Findings

Spinal dural arteriovenous fistulas are the most common type of vascular malformation to involve the spinal cord. In this report, we describe and analyze the various magnetic resonance imaging (MRI) findings of spinal dural arteriovenous fistulas in order to increase awareness and prompt timely diagnosis. We reviewed 14 patients evaluated and treated for spinal dural arteriovenous fistulas over a seven year period, with special attention to findings on MRI. All patients had regions of increased cord signal on T2-weighted MRI, with corresponding hypointense signal on T1-weighted images in 11 patients (79 percent). Thirteen (93 percent) of 14 patients had focal increased cord caliber and eight (57 percent) had prominent intradural vessels. Cord enhancement was observed in all seven patients who were administered contrast and two patients had enhancement of intradural vessels. These imaging findings are relatively nonspecific, but should lead to further investigation with myelography or arteriography in the appropriate clinical setting.