Who Can Perform Sonothrombolysis?
Sonothrombolysis should only be performed by endoscopists or physicians who have undergone specific training and have experienced interventional radiologists available in case of complications. 1
Current Status and Recommendations
Sonothrombolysis refers to the use of ultrasound waves to enhance clot breakdown, typically as an adjunctive therapy to intravenous thrombolysis in acute ischemic stroke. However, its clinical utility is limited by current evidence and guidelines:
The American Heart Association/American Stroke Association explicitly recommends against the use of sonothrombolysis as adjuvant therapy with IV thrombolysis (Class III: No Benefit; Level of Evidence B-R) 1, 2
Despite some promising early studies showing increased recanalization rates, larger subsequent trials like NOR-SASS found no statistically significant difference in neurological improvement or functional outcomes 2
Technical Requirements and Expertise
For those centers that may still be investigating sonothrombolysis in research settings:
- Requires specialized training in ultrasound techniques and interpretation
- Necessitates understanding of cerebrovascular anatomy and stroke pathophysiology
- Demands familiarity with thrombolytic medications and their complications
- Requires access to immediate neurointerventional support
Multidisciplinary Approach
An integrated, multidisciplinary approach is essential when considering any interventional treatment for stroke, including experimental approaches like sonothrombolysis:
- Stroke physician
- Interventional cardiologist
- Internist
- Coagulation specialist
- Neurologist
- Radiologist
- Anesthesiologist 1
Current Standard of Care
Instead of sonothrombolysis, the current standard of care for acute ischemic stroke includes:
IV thrombolysis with alteplase for eligible patients within 4.5 hours of symptom onset 1
Endovascular thrombectomy for patients with large vessel occlusion, particularly within 6 hours of symptom onset (but can be extended to 24 hours in selected patients) 1
Mechanical clot extraction using approved devices like stent retrievers or primary thrombus aspiration 1
Safety Concerns
While sonothrombolysis continues to be studied, safety concerns include:
- Risk of symptomatic intracranial hemorrhage, particularly with low-frequency ultrasound 2
- Technical factors such as frequency of ultrasound waves and skull transmittance variability affecting efficacy and safety 2
- Potential for embolization of clot fragments to distal territories
Conclusion
While sonothrombolysis shows some promise in research settings, particularly in patients with middle cerebral artery occlusions 3, it is not currently recommended as standard clinical practice by major stroke guidelines. Any application of this technique should be limited to specialized centers with appropriate expertise and preferably within the context of clinical trials.