Safety and Efficacy of Thrombolysis with Intravenous Alteplase in Older Stroke Patients

Drugs & Aging ◽  
2013 ◽  
Vol 30 (4) ◽  
pp. 227-234 ◽  
Author(s):  
Hakan Sarikaya
Keyword(s):  
Stroke Patients ◽  
Safety And Efficacy ◽  
Intravenous Alteplase

scholarly journals Safety and efficacy of intravenous thrombolysis in stroke patients on prior antiplatelet therapy in the WAKE-UP trial

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
Benedikt M. Frey ◽  
◽  
Florent Boutitie ◽  
Bastian Cheng ◽  
Tae-Hee Cho ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Favorable Outcome ◽  
Stroke Patients ◽  
Antiplatelet Treatment ◽  
Safety And Efficacy ◽  
History Of ◽  
Intravenous Alteplase

Abstract Background One quarter to one third of patients eligible for systemic thrombolysis are on antiplatelet therapy at presentation. In this study, we aimed to assess the safety and efficacy of intravenous thrombolysis in stroke patients on prescribed antiplatelet therapy in the WAKE-UP trial. Methods WAKE-UP was a multicenter, randomized, double-blind, placebo-controlled clinical trial to study the efficacy and safety of MRI-guided intravenous thrombolysis with alteplase in patients with an acute stroke of unknown onset time. The medication history of all patients randomized in the WAKE-UP trial was documented. The primary safety outcome was any sign of hemorrhagic transformation on follow-up MRI. The primary efficacy outcome was favorable functional outcome defined by a score of 0–1 on the modified Rankin scale at 90 days after stroke, adjusted for age and baseline stroke severity. Logistic regression models were fitted to study the association of prior antiplatelet treatment with outcome and treatment effect of intravenous alteplase. Results Of 503 randomized patients, 164 (32.6%) were on antiplatelet treatment. Patients on antiplatelet treatment were older (70.3 vs. 62.8 years, p <  0.001), and more frequently had a history of hypertension, atrial fibrillation, diabetes, hypercholesterolemia, and previous stroke or transient ischaemic attack. Rates of symptomatic intracranial hemorrhage and hemorrhagic transformation on follow-up imaging did not differ between patients with and without antiplatelet treatment. Patients on prior antiplatelet treatment were less likely to achieve a favorable outcome (37.3% vs. 52.6%, p = 0.014), but there was no interaction of prior antiplatelet treatment with intravenous alteplase concerning favorable outcome (p = 0.355). Intravenous alteplase was associated with higher rates of favorable outcome in patients on prior antiplatelet treatment with an adjusted odds ratio of 2.106 (95% CI 1.047–4.236). Conclusions Treatment benefit of intravenous alteplase and rates of post-treatment hemorrhagic transformation were not modified by prior antiplatelet intake among MRI-selected patients with unknown onset stroke. Worse functional outcome in patients on antiplatelets may result from a higher load of cardiovascular co-morbidities in these patients.

Abstract P27: Safety and Efficacy of Alteplase in Ischemic Stroke Patients > 80 Years of Age in the Extended Time Window

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Christoph Stretz ◽  
Brian C Mac Grory ◽  
Nasir Fakhri ◽  
Anusha Boyanpally ◽  
Syed Daniyal Asad ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Functional Outcome ◽  
Primary Outcome ◽  
Intravenous Thrombolysis ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Safety And Efficacy ◽  
Good Functional Outcome ◽  
Significant Difference ◽  
Intravenous Alteplase

Background: While patients > 80 years of age were originally excluded from the ECASS 3 trial showing benefit in the 3 – 4.5-hour window, recent studies have shown that intravenous alteplase is safe and benefits this population. We aimed to assess safety and efficacy of intravenous thrombolysis in stroke patients above 80 presenting both in the 3 and 3 – 4.5-hour windows. Methods: We analyzed data from 3 comprehensive stroke centers in the US of consecutive patients > 80 years of age presenting with acute ischemic stroke who received intravenous alteplase in both the 3 and 4.5-hour time windows over a 3-year period. We collected baseline demographic data, stroke severity as assessed by NIHSS scores, and use of mechanical thrombectomy (MT). Primary outcome was symptomatic intracerebral hemorrhage, as defined by ECASS 2 criteria (hemorrhagic transformation post thrombolysis with worsening of NIHSS score by ≥ 4 points). Secondary outcomes included assessment of efficacy, evaluated by good functional outcome (mRS 0 – 2) at time of discharge. Results: We identified 418 patients with ischemic stroke above 80 years (64.8% women) who received alteplase: 344 (82.3%) within 3 hour and 74 (17.7%) in the 3 to 4.5-hour window, with similar stroke severity by NIHSS scores (median [IQR] 13 [12-32] vs. 12 [6-20], p = 0.87). In addition, 147 patients received MT, 128 (37.2%) versus 19 (25.7%), (p= 0.059) in the 3 and 3-4.5-hour groups. The overall rate of sICH was 6.1% and 4.0% (p = 0.49), in the 3 and 3-4.5-hour groups, respectively. Good functional outcome was achieved in 16.7% at time of discharge, for 17.7% in the 3-hour group and for 12.2% in the 3 – 4.5-hour group (p= 0.24). Conclusions: In our multi-center cohort, the use of alteplase in patients above 80 was safe, with low sICH rates similar to the literature, irrespective of age. Given the rare occurrence of our primary outcome in a selected cohort of acute stroke patients, our study was not powered to detect a possible significant difference in sICH.

Abstract 200: Team of Neurohospitalists, Telestroke, and Nurse Stroke Coordinator Increases the Use of Intravenous Alteplase in a Community Hospital

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
H. McCord Smith ◽  
C. Van Morris ◽  
Shelley Nichols ◽  
Joanne Lockamy ◽  
Jeffrey A Switzer ◽  
...  
Keyword(s):  
Adverse Effect ◽  
Community Hospital ◽  
Standard Of Care ◽  
Favorable Outcome ◽  
Full Time ◽  
Short Supply ◽  
Safety And Efficacy ◽  
Model Combining ◽  
Intravenous Alteplase ◽  
Iv Tpa

Background and Purpose: The FDA approved IV tPA in 1996 for the treatment of AIS. Its safety and efficacy have been demonstrated in community hospitals (CH) and it is now the standard of care; but intravenous Alteplase (IV tPA) remains underemployed. It is used in fewer than 5% of AIS patients. Short supply of neurologic manpower and concern over adverse effect contribute to this underutilization. Our hypothesis was that a combination of onsite neurohospitalists (NH), telestroke (TS), nurse stroke coordinator (NC), and education of staff and community would increase IV tPA use in a mid-sized CH PSC without compromise of safety or outcome. Methods: The hospital is a 197 bed nonprofit hospital located 60 miles from Atlanta serving a population of 350,000 in 10 counties. The hospital has been certified as a PSC since August 2004; however, the volume of AIS admissions and use of IV tPA remained low through 2008. The stroke program thus was reorganized in 2009: two full-time NH were hired to provide onsite coverage daily from 8am to 6pm, the REACH™ TS System was installed to provide the remainder of coverage, a NC was hired, and an education plan for staff and community was implemented. Patients treated with IV tPA via TS were admitted to the neuro-ICU by medical hospitalists initially with NH assuming primary care of these patients within hours. AIS admission and IV tPA use data for 2002- 2008 were compared with those for 2009 - 2012. Outcomes, assessed at discharge, 2009 - 2012 were also examined. Favorable outcome was defined as a mRS of 0 or 1. Results: From 2002-2008, 25 of 933 AIS were treated with IV tPA: 3.6 per year (2.7%). In contrast, from 2009-2012, 105 of 802 AIS received IV tPA: 26.25 per year (13%) with favorable outcome in 47 (45%). Of 64 patients treated by NH, 28 (44%) achieved favorable outcome as did 19 of 41 (46%) TS patients. These outcomes were not statistically different (p=0.92). There were 5 deaths (3 NH, 2 TS), none attributable to tPA. There were no sICH. Conclusions: A model combining NH, TS, NC, and education in a CH PSC significantly increased the use of IV tPA without compromising safety or effectiveness. Such a model may be an option where resources are limited.

Abstract TP12: The Trend of Successful First Pass in M2 Segment Stroke Thrombectomy- Insights From the STAR Collaboration

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Eyad Almallouhi ◽  
Sami Al kasab ◽  
Ali Alawieh ◽  
Reda M Chalhoub ◽  
Marios Psychogios ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Independent Predictor ◽  
Star Collaboration ◽  
Stroke Patients ◽  
First Pass ◽  
Thrombectomy Device ◽  
Intravenous Alteplase ◽  
Multicenter Registry ◽  
Over Time ◽  
Iv Tpa

Introduction: Stroke thrombectomy devices and the experience of neurointerventionists have improved significantly over the last few years making targeting distal occlusions such as of the M2 segment of the middle cerebral artery more feasible. We aimed to study the trend in the successful first pass (SFP) of M2 occlusions over time using the data from a contemporary multicenter registry. Methods: We reviewed the data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which included data from 11 thrombectomy-capable stroke centers to identify stroke patients who underwent mechanical thrombectomy of M2 segment occlusion. SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single thrombectomy device pass. We analyzed the linear trendline of the rate of SFP over time. Then, we used a logistic regression model to assess predictors of SFP of M2 segment occlusion. Results: We included 401 patients who underwent stroke thrombectomy of M2 occlusion; median age was 71 (IQR 60-80), 212 (52.9%) were females, 174 (43.4%) were white, National Institute of Health stroke scale (NIHSS) was 14 (IQR 8-19), Alberta Stroke Program Early CT (ASPECT) score on presentation was 9 (IQR 7-10) and onset wot groin time was 287 (IQR 181-454). SFP was achieved in 118 (29.4%) patients (linear trendline over time is in Figure 1). Presenting after 2014 was an independent predictor of SFP (OR 1.9, 95% CI 1.1-3.2, P=0.019) after controlling for age, sex, NIHSS on presentation, intravenous alteplase (IV-tPA), and onset to groin time. Conclusion: SFP rate of M2 segment occlusion has increased after 2014 likely secondary the improvement in stroke thrombectomy devices and neurointerventionists experience.

Abstract WP53: Safety and Efficacy of Mechanical Thrombectomy in Acute Stroke Patients on New Oral Anticoagulants

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nurose Karim ◽  
Alicia C Castonguay ◽  
Hisham Salahuddin ◽  
Julie Shawver ◽  
Syed Zaidi ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Oral Anticoagulants ◽  
National Institutes Of Health ◽  
New Oral Anticoagulants ◽  
Limited Data ◽  
Stroke Patients ◽  
Safety And Efficacy ◽  
Nihss Score ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Symptomatic Intracranial Hemorrhage

Background: Limited data exists on the benefits of mechanical thrombectomy (MT) in acute ischemic stroke patients on new oral anticoagulants (NOAC). The aim of our study is to examine the safety and efficacy of MT in NOAC patients at our center. Methods: A retrospective review of our prospective MT database was performed for this study. Baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) score, revascularization rate, symptomatic intracranial hemorrhage rate (sICH), and 90-day mortality and favorable outcomes were compared in MT patients on NOAC (MT-NOAC) versus those who were not on NOAC (MT). Results: From July 2012 to December 2018, 553 AIS patients underwent treatment with MT, with 36 patients on NOAC (6.5%). Median age was similar (73 versus 74), with 52.8% and 52.0% (p=0.8) female in the MT-NOAC and MT groups, respectively. Median baseline NIHSS score (17 IQR10-21 versus 17 IQR 12-21, p=0.75) and ASPECTS (9 IQR 8-9, p=0.80) were similar between the groups. Atrial fibrillation was more prevalent in the MT-NOAC group (80.6% versus 37.7%, p=<0.0001). No difference was seen in occlusion site between the group, with M1 occlusions the most common site (44.4% versus 43.3%, p=0.9). Median onset to revascularization times did not differ between the cohorts (146 minutes versus 206, p=0.61). Successful revascularization (mTICI≥2b) was 87.5% and 81.8% in the MT NOAC and MT groups, respectively. Rates of symptomatic intracerebral hemorrhage per ECASS III criteria were similar between the two groups (5.5% versus 4.6%, p=0.68). No difference was seen in 90-day favorable outcomes (mRS 0-2) (48.3% versus 41.1%, p=0.44) or mortality (27.6% versus 27.1%, 0.95). Conclusion: MT in patients on NOAC appears to be safe and efficacious. As our study is limited by sample size, larger prospective studies are needed to understand the safety and efficacy of MT in AIS patients on NOAC.

Epileptic manifestations in stroke patients treated with intravenous alteplase

2017 ◽  
Vol 24 (6) ◽  
pp. 755-761 ◽  
Author(s):  
C. Bentes ◽  
H. Martins ◽  
A. R. Peralta ◽  
C. Morgado ◽  
C. Casimiro ◽  
...  
Keyword(s):  
Stroke Patients ◽  
Intravenous Alteplase

scholarly journals Influence of recent direct-to-EVT trials on practical decision-making for the treatment of acute ischemic stroke patients

2021 ◽  
pp. 159101992110579
Author(s):  
Rosalie McDonough ◽  
Johanna Ospel ◽  
Nima Kashani ◽  
Manon Kappelhof ◽  
Jianmin Liu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Strategies ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Randomized Controlled ◽  
Intravenous Alteplase ◽  
Short Time ◽  
Current Guidelines

Background Current guidelines recommend that eligible acute ischemic stroke (AIS) patients receive intravenous alteplase (IVT) prior to endovascular treatment (EVT). Six randomized controlled trials recently sought to determine the risks of administering IVT prior to EVT, five of which have been published/presented. It is unclear whether and how the results of these trials will change guidelines. With the DEBATE survey, we assessed the influence of the recent trials on physicians’ IVT treatment strategies in the setting of EVT for large vessel occlusion (LVO) stroke. Methods Participants were provided with 15 direct-to-mothership case-scenarios of LVO stroke patients and asked whether they would treat with IVT  +  EVT or EVT alone, a) before publication/presentation of the direct-to-EVT trials, and b) now (knowing the trial results). Logistic regression clustered by respondent was performed to assess factors influencing the decision to adopt an EVT-alone paradigm after publication/presentation of the trial results. Results 289 participants from 37 countries provided 4335 responses, of which 13.5% (584/4335) changed from an IVT  +  EVT strategy to EVT alone after knowing the trial results. Very few switched from EVT alone to IVT  +  EVT (8/4335, 0.18%). Scenarios involving a long thrombus (RR 1.88, 95%CI:1.56–2.26), cerebral micro-hemorrhages (RR 1.78, 95%CI:1.43–2.23), and an expected short time to recanalization (RR 1.46 95%CI:1.19–1.78) had the highest chance of participants switching to an EVT-only strategy. Conclusion In light of the recent direct-to-EVT trials, a sizeable proportion of stroke physicians appears to be rethinking IVT treatment strategies of EVT-eligible mothership patients with AIS due to LVO in specific situations.

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