Acute Myocardial Infarction after Intravenous Thrombolysis for Acute Ischemic Stroke: Case Series and Systematic Review

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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Faculty Opinions recommendation of Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717953732.793459347 ◽

2012 ◽

Author(s):

Mark Wainwright

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Internal Carotid ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Carotid Artery Occlusion

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Importance of perioperative management for emergency carotid artery stenting within 24 h after intravenous thrombolysis for acute ischemic stroke: Case report

International Journal of Surgery Case Reports ◽

10.1016/j.ijscr.2016.07.027 ◽

2016 ◽

Vol 26 ◽

pp. 108-112 ◽

Cited By ~ 2

Author(s):

Akihiro Inoue ◽

Kanehisa Kohno ◽

Shinya Fukumoto ◽

Saya Ozaki ◽

Satoko Ninomiya ◽

...

Keyword(s):

Ischemic Stroke ◽

Case Report ◽

Carotid Artery ◽

Acute Ischemic Stroke ◽

Carotid Artery Stenting ◽

Perioperative Management ◽

Intravenous Thrombolysis ◽

Stroke Case

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Abstract P536: Impact of the Covid-19 Pandemic on the Volumes and Outcomes of Acute Ischemic Stroke and Myocardial Infarction

Stroke ◽

10.1161/str.52.suppl_1.p536 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Raul Nogueira ◽

Katherine Etter ◽

Thanh Nguyen ◽

Shelly Ikeme ◽

Michael R Frankel ◽

...

Keyword(s):

Myocardial Infarction ◽

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Clinical Severity ◽

Hospital Length Of Stay ◽

Healthcare Database ◽

Hospitalization Costs

Introduction: The COVID-19 pandemic has wreaked havoc on the presentation, care and outcomes of patients with acute cerebrovascular and cardiovascular conditions. We sought to measure the national impact of COVID-19 on the care for acute ischemic stroke (AIS) and acute myocardial infarction (AMI). Methods: In this retrospective, observational study, we used the Premier Healthcare Database to evaluate the changes in the volume of care and hospital outcomes for AIS and AMI in relation to the pandemic. The pandemic months were defined from March 1, 2020- April 30, 2020 and compared to the same period in the year prior. Outcome measures were volumes of hospitalization and reperfusion treatment for AIS and AMI (including intravenous thrombolysis [IVT] and/or mechanical thrombectomy [MT] for AIS and percutaneous coronary interventions [PCI] for AMI) as well as in-hospital mortality, hospital length of stay (LOS) and hospitalization costs were compared across a 2-month period at the height of the pandemic versus the corresponding period in the prior year. Results: There were 95,453 AIS patients across 145 hospitals and 19,744 AMI patients across 126 hospitals. There was a significant nation-wide decline in the absolute number of hospitalizations for AIS (-38.94%;95%CI,-34.75% to -40.71%) and AMI (-38.90%;95%CI,-37.03% to -40.81%) as well as IVT (-30.32%;95%CI,-27.02% to -33.83%), MT (-23.54%;95%CI,-19.84% to -27.70%), and PCI (-35.05%;95%CI,-33.04% to -37.12%) during the first two months of the pandemic. This occurred across low-, mid-, and high-volume centers and in all geographic regions. Higher in-hospital mortality was observed in AIS patients (5.7% vs.4.2%, p=0.0037;OR 1.41,95%CI 1.1-1.8) but not AMI patients. A shift towards an increase in the proportion of admitted AIS and AMI patients receiving reperfusion therapies suggests a greater clinical severity among patients that were hospitalized for these conditions during the pandemic. A shorter length of stay (AIS: -17%, AMI: -20%), and decreased hospitalization costs (AIS: -12%, AMI: -19%) were observed. Conclusions: Our findings shed light on the combined health outcomes and economic impact the COVID-19 pandemic has had on acute stroke and cardiac emergency care.

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Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis

Implementation Science ◽

10.1186/s13012-020-01054-3 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Md Golam Hasnain ◽

John R. Attia ◽

Shahinoor Akter ◽

Tabassum Rahman ◽

Alix Hall ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Publication Bias ◽

Behaviour Change ◽

Intravenous Thrombolysis ◽

Intervention Strategies ◽

Therapeutic Window ◽

Behaviour Change Wheel ◽

Meta Analyses

Abstract Background Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates—mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. Method The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. Results Results from 77 studies were included. Five behaviour change wheel interventions, ‘Education’, ‘Persuasion’, ‘Training’, ‘Environmental restructuring’ and ‘Enablement’, were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. Conclusion There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.

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