Pre-procedural predictive factors of symptomatic intracranial hemorrhage after thrombectomy in stroke

2021 ◽  
Author(s):  
Laura Venditti ◽  
Olivier Chassin ◽  
Claire Ancelet ◽  
Nicolas Legris ◽  
Mariana Sarov ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Predictive Factors ◽  
Symptomatic Intracranial Hemorrhage

Abstract MP34: Retrospective Analysis on Predictive Factors and Timeline for Early Neurologic Decline and Symptomatic Intracranial Hemorrhage Following Administration of Intravenous Recombinant Tissue Plasminogen Activator for Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Alexander Clark ◽  
Kavit Shah ◽  
Shashvat Desai ◽  
Ashutosh Jadhav
Keyword(s):  
Ischemic Stroke ◽  
Retrospective Analysis ◽  
Intracranial Hemorrhage ◽  
Predictive Factors ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Care ◽  
Serum Glucose ◽  
Vessel Occlusion ◽  
Symptomatic Intracranial Hemorrhage ◽  
Iv Tpa

Introduction: Current guidelines recommend that patients given intravenous tPA (IV tPA) for acute ischemic stroke (AIS) receive comprehensive stroke care for 24 hours post-treatment to monitor key physiologic variables. 1,2,3 Early de-escalation of monitoring is likely feasible in a particular subset of patients, which may have implications in the post-COVID era. 4 In this study, we examined when patients with AIS are susceptible to early neurologic decline (END) and symptomatic intracranial hemorrhage (sICH) after IV tPA and whether those at low clinical risk of neurologic deterioration may be suitable for earlier transition to lower level of care. Methods: We performed a retrospective analysis of AIS receiving IV tPA based on AHA/ASA guidelines. We included those that presented within 4.5 hours of last seen well (LSW) without large vessel occlusion (LVO) or flow-limiting stenosis (FLS) on non-invasive angiographic imaging. Outcomes included END (≥4-point worsening of NIHSS at 24 hours) from any cause, parenchymal hemorrhage (PH1 or PH2), and/ or symptomatic intracranial hemorrhage (sICH; ≥4-point NIHSS worsening with presence of hemorrhage). Results: 1238 patients were included from 1/2013 - 6/2019. END and ICH occurred in 7.4% (91) and 9.4% (116), respectively. 63.7% of patients with END did not have ICH within 24 hours. In those with NIHSS <12, 82% had END within 12 hours and most occurred within 5 hours. Predictive factors included older patients (72.6 ±16.1 vs 69.1 ±14.8, p=0.03), history of tobacco use (OR-2.1 [1.1-4.3], p = 0.04) and hyperlipidemia (OR-1.7 [1.1-2.8] p = 0.02). ICH occurred within 12 hours in 30% of patients, predictors included older age (74.6 ± 12.4 vs 68.8 ± 15.1, p ≤ 0.01), higher NIHSS (14.6 ± 7.3 vs 10.8 ± 7.9, p ≤ 0.01), and higher presentation serum glucose levels (155.1 ± 87.5 vs 140.4 ± 70.5, p = 0.04). Overall, only 2.7% (33) of patients developed sICH. There were no independent predictive factors for delayed ICH (≥ 12 hours). Conclusion: In our selected post-IV tPA patients, a relatively small proportion suffered sICH and END; most often within 12 hours of tPA administration. These findings may support earlier de-escalation of higher acuity monitoring for clinically stable post-IV tPA patients.

scholarly journals Tenecteplase Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (11) ◽  
pp. 3440-3451
Author(s):  
Steven J. Warach ◽  
Adrienne N. Dula ◽  
Truman J. Milling
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Time Window ◽  
Large Vessel ◽  
Bolus Administration ◽  
Phase 2 ◽  
Qualitative Synthesis ◽  
Phase 3 ◽  
Symptomatic Intracranial Hemorrhage ◽  
Meta Analyses

Tenecteplase is a fibrinolytic drug with higher fibrin specificity and longer half-life than the standard stroke thrombolytic, alteplase, permitting the convenience of single bolus administration. Tenecteplase, at 0.5 mg/kg, has regulatory approval to treat ST-segment–elevation myocardial infarction, for which it has equivalent 30-day mortality and fewer systemic hemorrhages. Investigated as a thrombolytic for ischemic stroke over the past 15 years, tenecteplase is currently being studied in several phase 3 trials. Based on a systematic literature search, we provide a qualitative synthesis of published stroke clinical trials of tenecteplase that (1) performed randomized comparisons with alteplase, (2) compared different doses of tenecteplase, or (3) provided unique quantitative meta-analyses. Four phase 2 and one phase 3 study performed randomized comparisons with alteplase. These and other phase 2 studies compared different tenecteplase doses and effects on early outcomes of recanalization, reperfusion, and substantial neurological improvement, as well as symptomatic intracranial hemorrhage and 3-month disability on the modified Rankin Scale. Although no single trial prospectively demonstrated superiority or noninferiority of tenecteplase on clinical outcome, meta-analyses of these trials (1585 patients randomized) point to tenecteplase superiority in recanalization of large vessel occlusions and noninferiority in disability-free 3-month outcome, without increases in symptomatic intracranial hemorrhage or mortality. Doses of 0.25 and 0.4 mg/kg have been tested, but no advantage of the higher dose has been suggested by the results. Current clinical practice guidelines for stroke include intravenous tenecteplase at either dose as a second-tier option, with the 0.25 mg/kg dose recommended for large vessel occlusions, based on a phase 2 trial that demonstrated superior recanalization and improved 3-month outcome relative to alteplase. Ongoing randomized phase 3 trials may better define the comparative risks and benefits of tenecteplase and alteplase for stroke thrombolysis and answer questions of tenecteplase efficacy in the >4.5-hour time window, in wake-up stroke, and in combination with endovascular thrombectomy.

Nomogram to Predict Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke in an Asian Population.

2021 ◽  
Vol 19 ◽  
Author(s):  
Xiaohua Xie ◽  
Jie Yang ◽  
Lijie Ren ◽  
Shiyu Hu ◽  
Wancheng Lian ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Calibration Curve ◽  
Intravenous Thrombolysis ◽  
Asian Population ◽  
Individual Risk ◽  
Clinical Effects ◽  
Symptomatic Intracranial Hemorrhage

Background: Symptomatic intracranial hemorrhage (sICH) is a serious hemorrhagic complication after intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients. Most existing predictive scoring systems were derived from Western countries Objective: To develop a nomogram to predict the possibility of sICH after IVT in an Asian population. Methods: This retrospective cohort study included AIS patients treated with recombinant tissue plasminogen activator (rt-PA) in a tertiary hospital in Shenzhen, China, from January 2014 to December 2020. The end point was sICH within 36 hours of IVT treatment. Multivariable logistic regression was used to identify risk factors of sICH, and a predictive nomogram was developed. Area under the curve of receiver operating characteristic curves (AUC), calibration curve, and decision curve analyses were performed. The nomogram was validated by bootstrap resampling Results: Data on a total of 462 patients were collected, of whom 20 patients (4.3%) developed sICH. In the multivariate logistic regression model, the National Institute of Health stroke scale scores (NIHSS) (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.06–1.23, P < 0.001), onset to treatment time (OTT) (OR, 1.02; 95% CI, 1.01–1.03, P < 0.001), neutrophil to lymphocyte ratio (NLR) (OR, 1.22; 95% CI, 1.09–1.35, P < 0.001), and cardioembolism (OR, 3.74; 95% CI, 1.23–11.39, P = 0.020) were independent predictors for sICH and were used to construct a nomogram. Our nomogram exhibited favorable discrimination ability [AUC, 0.878; specificity, 87.35%; and sensitivity, 73.81%]. Bootstrapping for 500 repetitions was performed to further validate the nomogram. The AUC of the bootstrap model was 0.877 (95% CI: 0.823–0.922). The calibration curve exhibited good fit and calibration. The decision curve revealed good positive net benefits and clinical effects Conclusion: The nomogram consisted of the predictors NIHSS, OTT, NLR, and cardioembolism could be used as an auxiliary tool to predict the individual risk of sICH in Chinese AIS patients after IVT. Further external verification among more diverse patient populations is needed to demonstrate the accuracy of the model’s predictions.

Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000013049
Author(s):  
Aristeidis H Katsanos ◽  
Konark Malhotra ◽  
Niaz Ahmed ◽  
Georgios Seitidis ◽  
Eva A. Mistry ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Individual Patient Data ◽  
Patient Data ◽  
Neurological Deterioration ◽  
Endovascular Thrombectomy ◽  
Early Neurological Deterioration ◽  
Symptomatic Intracranial Hemorrhage

Objective:To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).Methods:A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.Results:A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.Conclusion:Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.

Abstract 183: Time to Alteplase and Symptomatic Intracranial Hemorrhage Complication Rates

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Muhammad U Farooq ◽  
Kathie Thomas
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
American Heart ◽  
Phase Iii ◽  
P Value ◽  
Complication Rates ◽  
Stroke Patients ◽  
Number Of Patients ◽  
Symptomatic Intracranial Hemorrhage ◽  
Get With The Guidelines

Background/Objective: The American Heart Association’s Target Stroke initiative focuses on reducing door-to-needle time for faster treatment with Alteplase and improved patient outcomes. The concern for reducing door-to-needle time is that there will be an increase in complication rates, specifically the rate of symptomatic intracranial hemorrhage (ICH). This study sought to review whether reduced door-to-needle times were associated with increased rates of complications in Midwest hospitals. Methods: A retrospective review of acute ischemic stroke patients treated with Alteplase was conducted from 2010-2018 in 13 Midwestern states (IN, IL, KS, KY, MI, MN, NO, ND, OH, SD, and WI) using the American Stroke Association’s Get With The Guidelines (GWTG) Stroke database. Percentage of eligible patients treated with Alteplase, treatment times, and complication rates were reviewed. Results: From 2010-2018 the rate of ischemic stroke patients treated with Alteplase in the approved 3-hour window increased from 68.9% to 88.5%. The number of patients treated with Alteplase in 60 minutes increased from 24.1% in 2010 to 74.9% in 2018. The median time to treatment for Alteplase was reduced from 80 minutes in 2010 to 46 minutes in 2018. The rate of complications associated with thrombolytics was 6.5% in 2010 and dropped to 4.5% in 2018. This is statistically significant at a p-value of .05. Conclusions: In the Midwest Region, a reduction in door-to-needle times was not associated with increased complication rates. Interestingly, a reduction in door-to-needle times was associated with a reduction in complication rates. This supports the American Heart Association’s new Target Stroke Phase III initiative which seeks to further reduce door-to-needle times.

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