Successful intra-arterial thrombolysis beyond the accepted 6-hour time window in two young patients

Two young women with ischemic stroke successfully underwent intra-arterial thrombolysis (IAT) 10 and 11h, respectively after stroke onset. A 23-year-old (case 1) and a 22-year-old woman (case 2) who developed severe neurological deficits (NIHSS 20 and 13, respectively) were presented to our hospital 9h after onset of the symptoms. In case 1 a CT angiography (CTA) revealed an occlusion of the left middle cerebral artery (MCA) and in case 2 CTA showed a large embolus at the left carotid bifurcation, almost entirely occluding the internal carotid artery. We decided to apply IAT beyond the generally accepted 6-hour time window. Case 1 was treated with 2mg rtPA administered locally in the occluded MCA followed by 70 mg rtPA (1 mg/min) and case 2 was treated with 100,000 IU urokinase in the left common carotid artery followed by 200,000 IU during 2h and 10mg abciximab. In case 1 IAT resulted in complete recanalisation of the MCA within 3h and complete resolution of symptoms in the following six weeks. In case 2 IAT resulted in an initial 50% reduction of the thrombus. After nine days CTA showed complete lysis and the patient had completely recovered. Both patients suffered from Anti-Phospholipid-Syndrome. The results show that IAT may be beneficial to young patients with a severe stroke, even beyond the 6-hour time window.