From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
The use of tissue plasminogen activator (tPA) in spinal infarction is not routinely recommended due to limited evidence, but a recent case study suggests that intra-arterial thrombolytic therapy with tPA may be a feasible and effective treatment option for acute anterior spinal artery stroke. Unlike cerebral stroke, there are no established guidelines or large clinical trials supporting tPA use specifically for spinal cord infarction. If considered, tPA would typically follow the same protocol as for ischemic stroke: intravenous alteplase at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and the remainder infused over 60 minutes, within 4.5 hours of symptom onset 1. However, several challenges exist: spinal infarction is often diagnosed with significant delay, making patients fall outside the therapeutic window; the diagnosis can be difficult to establish quickly as MRI is required; and there are concerns about hemorrhagic complications in the confined space of the spinal canal.
Some key points to consider in the management of spinal infarction include:
- Rapid diagnosis with MRI to confirm the diagnosis and identify the location and extent of the infarction
- Consultation with both neurology and neurosurgery to discuss treatment options and determine the best course of action
- Identification and treatment of the underlying cause of the infarction, such as aortic pathology
- Blood pressure optimization to prevent further injury and promote healing
- Rehabilitation to maximize functional recovery and improve quality of life
A recent study published in the Journal of Clinical Neuroscience in 2021 reported a case of anterior spinal artery territory ischemia treated with intra-arterial thrombolytic therapy using tPA, verapamil, and eptifibatide, resulting in significant neurological improvement immediately postoperatively and at 8-month clinical follow-up 2. This study suggests that intra-arterial thrombolytic therapy with tPA may be a viable treatment option for acute spinal infarction, but more research is needed to fully understand its safety and efficacy.
In terms of anticoagulant thromboprophylaxis, a study published in the Global Spine Journal in 2017 recommends offering anticoagulant thromboprophylaxis to reduce the risk of thromboembolic events in the acute period after spinal cord injury, with either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin being suggested as options 3. However, the use of tPA in spinal infarction is not addressed in this study.
Overall, while the evidence for tPA use in spinal infarction is limited, intra-arterial thrombolytic therapy with tPA may be considered as a treatment option for acute spinal infarction, particularly in cases where the diagnosis is made promptly and the patient is a suitable candidate for thrombolytic therapy. However, more research is needed to fully understand the safety and efficacy of tPA in this context, and clinicians should prioritize rapid diagnosis and consultation with specialists before considering thrombolytic therapy.