Intra-arterial streptokinase in acute ischaemic stroke. A pilot study

To assess the safety and efficacy of the intra-arterial administration of streptokinase within 24 hours of acute ischaemic stroke.

Patients who presented to the Austin Hospital casualty department between 3 and 22 hours after an acute stroke were considered for the study. Eligible patients had pretreatment non-contrast computed tomographic scans of the brain to exclude haemorrhage. Streptokinase (250,000 units) was administered directly into the common carotid artery or the cervical portion of the internal carotid artery.

The incidence of symptomatic and asymptomatic cerebral haemorrhage, haemorrhagic transformation of infarction, angiographic reperfusion, clinical outcome at seven to 10 days and the frequency of other complications.

Thirteen patients were treated over a 16-month period. Major clinical improvement occurred in five patients (39%) at 48 hours. This was associated with angiographically demonstrated recanalisation of a middle cerebral artery occlusion in two patients and partial recanalisation in two others. Significant hypotension in two patients required therapy to be stopped. In five other cases mild hypotension developed but the streptokinase infusion was completed. Haemorrhagic transformation of the infarct occurred in four patients without clinical deterioration.

Intra-arterial administration of streptokinase is safe in selected patients with acute ischaemic stroke. The theoretical benefit of an increased local thrombolytic effect and reduced systemic complications, compared with the use of higher intravenous doses, justifies a randomised clinical trial. If therapies such as this are to be successful, rapid referral to an appropriate centre is necessary.