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Ann Thorac Surg 2002;74:2227-2228
© 2002 The Society of Thoracic Surgeons
a Department of Surgery 1, Hirosaki University School of Medicine 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
b Department of Radiology, Tsukuba Medical Center Hospital 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558, Japan
e-mail: ikuofuku{at}cc.hirosaki-u.ac.jp
To the Editor:
We read with great interest the recent article by Dr Moazami and colleagues [1]. They reported successful outcome of intraarterial thrombolysis for an acute intracranial arterial occlusion after cardiac operation. Thrombolysis is an effective but potentially deleterious therapy and therefore, should be limited to patients with acute intracerebral vessel occlusion and salvageable tissue. The essential challenge of this approach for postcardiotomy stroke is adverse effects due to thrombolysis. Generally, major operation within the previous 14 to 30 days is considered a contraindication to fibrinolytic therapy because of incremental risk for surgical site bleeding. Hemorrhagic transformation of the infarction is another concern.
We used the same strategies for postoperative stroke after cardiac operation for 3 patients with a recanalization rate of 100% [2]. In our experience, 2 of 3 patients improved significantly and 1 patient improved moderately. Our patients had delayed thromboembolism closely related to atrial fibrillation or mechanical valve, but radiologic and clinical improvement was striking. One patient had a small hemorrhagic cerebral infarction at the core of the ischemic area, yet bleeding complications due to use of fibrinolytic agents were minimal. Although early recanalization within 3 hours after stroke onset is universally safe, some patients show complete recovery treated several hours after the onset of stroke.
Recently diffusion- and perfusion-weighed magnetic resonance imaging became available for early assessment of acute ischemic stroke [3]. Using this method, the differential diagnosis between complete cerebral infarct and reversible ischemia is possible. Selection of patients for reperfusion therapy will become clearer in the near future. However, organization of a stroke care team and immediate assessment of cerebral ischemia is necessary because the therapeutic window for cerebral reperfusion is still narrow.
Compared to intravenous administration of tissue plasminogen activator, which is easy to perform, there are several benefits from intraarterial administration of fibrinolytic agents. First, because the local concentration of fibrinolytic agent may be higher by intraarterial administration, the required dose of the fibrinolytic agent can be minimized by real-time monitoring of cerebral perfusion with angiography. In the Prolyse in Acute Cerebral Thromboembolism (PROACT) study, partial recanalization was significantly greater after local administration in a pro-urokinase group than in the placebo group, whereas the incidence of intracranial hemorrhagic deterioration was the same [4]. Several large case series of treatment by intraarterial thrombolysis with urokinase or tissue plasminogen activator report complete or partial recanalization in 74% of the patients, which is higher than that achieved by intravenous administration, and the incidence of symptomatic intracranial hematoma is lower than that reported for intravenous thrombolysis [5, 6]. Second, additional intervention is possible for residual stenosis or thrombosis of an intracerebral artery. As for surgical site bleeding, none of the patients who received lytic therapy experienced bleeding in their operative sites in our series. Local intraarterial administration of fibrinolytic agents seems to be more effective than systemic administration of fibrinolytic agents. These results suggest potential benefits and acceptable safety of local thrombolysis.
Although use of a thrombolytic agent after cardiac operation is controversial, we support Dr Moazami’s aggressive approach for ischemic stroke after cardiac operation.
References
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