Treatment of Medial Medullary Syndrome When Intravenous rtPA Did Not Work
This protocol covers patients with medial medullary syndrome — an ischaemic brainstem stroke — who received intravenous thrombolysis as first-line treatment but did not achieve the required neurological response.
Prior Treatment — Failure Condition
First-line therapy was intravenous rtPA. The goal was neurological improvement at 24 hours — defined as complete neurological recovery or an improvement of at least 4 points on the NIHSS — and this was not reached. This protocol defines the next clinical step.
Next-Line Approach — Partial Overview
The escalation strategy involves endovascular reperfusion. Options are available both for patients who did not respond to intravenous thrombolysis and for those who were not candidates for it in the first place. Eligibility depends on time from symptom onset and individual patient criteria — the full selection and procedural guidance is in the protocol.
References
DOI: 10.1161/STR.0b013e318284056a
- Intra-arterial fibrinolysis is beneficial for treatment of carefully selected patients with major ischemic strokes of <6 hours' duration caused by occlusions of the MCA who are not otherwise candidates for intravenous rtPA (Class I; Level of Evidence B).
- When mechanical thrombectomy is pursued, stent retrievers such as Solitaire FR and Trevo are generally preferred to coil retrievers such as Merci (Class I; Level of Evidence A).
- The Merci, Penumbra System, Solitaire FR, and Trevo thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis in carefully selected patients (Class IIa; Level of Evidence B).
- Rescue intra-arterial fibrinolysis or mechanical thrombectomy may be reasonable approaches to recanalization in patients with large-artery occlusion who have not responded to intravenous fibrinolysis.
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