Use of Intra-Arterial Tissue Plasminogen Activator in Acute Stroke: Video Case

This video illustrates access to tortuous distal intracranial vasculature and the use of intra-arterial (IA) tissue plasminogen activator (tPA) for the revascularization of small vessel occlusion. IA tPA is a reasonable approach for distal arterial occlusion resistant to intravenous tPA or mechanical thrombectomy. In this video, the patient had a posterior circulation stroke with elevated time-to-peak in the cerebellar hemispheres. He had received intravenous tPA in the emergency room but ataxia and dysarthria symptoms persisted. Cerebral angiography showed right superior cerebellar artery (SCA) occlusion. Although his NIHSS score was low, his symptoms were disabling. While not standard of care, discussion with patients about potential options is crucial; and we believe that mechanical and localized therapies in these circumstances may be beneficial. A Velocity microcatheter (Penumbra, Alameda, California) was initially used to attempt SCA access but was unsuccessful. A second attempt was made with a Headway Duo (MicroVention, Aliso Viejo, California)-a smaller, more pliant microcatheter better suited to the acute turn in the SCA. A 2 mg IA tPA dose was administered at the occlusion site. A direct aspiration first-pass technique (ADAPT) and stent retriever were thought to be too aggressive in a small SCA. The proximal vessel was recanalized, and the microcatheter was advanced to the distal occlusion site before IA administration of another 2 mg of tPA. Post-tPA runs showed excellent SCA revascularization. For occlusion of small intracranial vessels where IV tPA is ineffective and mechanical thrombectomy is unsafe, local administration of IA tPA can be an effective therapy. Consent was obtained from the patient prior to performing the procedure. Institutional review board approval is not required for the report of a single case.