Intravenous Thrombolytic Treatment in the Oldest Old

Background and Purpose.Intravenous thrombolysis using tissue plasminogen activator is safe and probably effective in patients >80 years old. Nevertheless, its safety has not been specifically addressed for the oldest old patients (≥85 years old, OO). We assessed the safety and effectiveness of thrombolysis in this group of age.Methods.A prospective registry of patients treated with intravenous thrombolysis. Patients were divided in two groups (<85 years and the OO). Demographic data, stroke aetiology and baseline National Institute Health Stroke Scale (NIHSS) score were recorded. The primary outcome measures were the percentage of symptomatic intracranial haemorrhage (SICH) and functional outcome at 3 months (modified Rankin Scale, mRS).Results.A total of 1,505 patients were registered. 106 patients were OO [median 88, range 85–101]. Female sex, hypertension, elevated blood pressure at admission, cardioembolic strokes and higher basal NIHSS score were more frequent in the OO. SICH transformation rates were similar (3.1% versus 3.7%,P=1.00). The probability of independence at 3 months (mRS 0–2) was lower in the OO (40.2% versus 58.7%,P=0.001) but not after adjustment for confounding factors (adjusted OR, 0.82; 95% CI, 0.50 to 1.37;P=0.455). Three-month mortality was higher in the OO (28.0% versus 11.5%,P<0.001).Conclusion.Intravenous thrombolysis for stroke in OO patients did not increase the risk of SICH although mortality was higher in this group.

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Primary acute stroke thrombectomy within 3 h for large artery occlusion (PAST3-LAO): a pilot study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012172 ◽

2016 ◽

Vol 9 (4) ◽

pp. 352-356 ◽

Cited By ~ 1

Author(s):

Yahia Lodi ◽

Varun Reddy ◽

Gorge Petro ◽

Ashok Devasenapathy ◽

Anas Hourani ◽

...

Keyword(s):

Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Artery Occlusion ◽

Large Artery ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Nihss Score ◽

Tissue Plasminogen ◽

Poor Outcomes

Background and purposeIn recent trials, acute ischemic stroke (AIS) from large artery occlusion (LAO) was resistant to intravenous thrombolysis and adjunctive stent retriever thrombectomy (SRT) was associated with better perfusion and outcomes. Despite benefit, 39–68% of patients had poor outcomes. Thrombectomy in AIS with LAO within 3 h is performed secondary to intravenous thrombolysis, which may be associated with delay. The purpose of our study is to evaluate the safety, feasibility, recanalization rate, and outcome of primary SRT within 3 h without intravenous thrombolysis in AIS from LAO.MethodsBased on an institutionally approved protocol, stroke patients with LAO within 3 h were offered primary SRT as an alternative to intravenous recombinant tissue plasminogen activator. Consecutive patients who underwent primary SRT for LAO within 3 h from 2012 to 2014 were enrolled. Outcomes were measured using the modified Rankin Scale (mRS).Results18 patients with LAO of mean age 62.83±15.32 years and median NIH Stroke Scale (NIHSS) score 16 (10–23) chose primary SRT after giving informed consent. Near complete (TICI 2b in 1 patient) or complete (TICI 3 in 17 patients) recanalization was observed in all patients. Time to recanalization from symptom onset and groin puncture was 188.5±82.7 and 64.61±40.14 min, respectively. NIHSS scores immediately after thrombectomy, at 24 h and 30 days were 4 (0–12), 1 (0–12), and 0 (0–4), respectively. Asymptomatic perfusion-related hemorrhage developed in four patients (22%). 90-day outcomes were mRS 0 in 50%, mRS 1 in 44.4%, and mRS 2 in 5.6%.ConclusionsOur study demonstrates that primary SRT in AIS from LAO is safe and feasible and is associated with complete recanalization and good outcome. Further study is required.

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Thrombolytic treatment in the oldest-old patient with acute ischemic stroke: an update on current evidence

Italian Journal of Medicine ◽

10.4081/itjm.2013.160 ◽

2013 ◽

pp. 160-165

Author(s):

Fabiola Maioli ◽

Gaetano Procaccianti ◽

Valeria Nativio ◽

Giorgia Arnone ◽

Roberto Nardi ◽

...

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Oldest Old ◽

Intravenous Thrombolysis ◽

Cognitive Status ◽

Screening Tools ◽

Current Evidence ◽

Thrombolytic Treatment ◽

Old Patients

The incidence of ischemic stroke rises exponentially with age, with a steep increase in the age interval between 75 and 85 years. Thrombolytic therapy restores cerebral blood flow in patients with acute ischemic stroke of any etiology by using drugs that dissolve blood clots. Infusion for 1 h of alteplase at the dose of 0.9 mg/kg within 3 h of the start of the symptoms is associated to a 30% increase in the likelihood of gaining a favorable outcome with respect to placebo. There is strong evidence that selected patients with ischemic stroke may benefit from intravenous thrombolysis when treated within 3 h. The aim of the study was to evaluate available evidence for the efficacy and safety of thrombolytic therapy in patients with ischemic stroke aged 80 years and over. Compared to younger stroke patients treated with thrombolytic therapy, those aged 80 years and over have higher acute mortality due to symptomatic intracranial hemorrhage. However, functional outcome at six months is significantly better for over-80-year-olds than younger patients. There is a need for screening tools that take into account pre-stroke functional and cognitive status that are able to identify those over-80-year-old patients with ischemic stroke who can most benefit from thrombolytic treatment. Available evidence supports further recruitment of oldest-old patients into ongoing trials of thrombolysis.

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Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis

The Neuroradiology Journal ◽

10.1177/19714009211009112 ◽

2021 ◽

pp. 197140092110091

Author(s):

Hanna Styczen ◽

Matthias Gawlitza ◽

Nuran Abdullayev ◽

Alex Brehm ◽

Carmen Serna-Candel ◽

...

Keyword(s):

Clinical Outcome ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Intracranial Haemorrhage ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

Background Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience. Methods A retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010–September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded. Results In total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up. Conclusion Mechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.

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Clinical profile of patients with acute ischemic stroke receiving intravenous thrombolysis (rtPA-alteplase)

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20180078 ◽

2018 ◽

Vol 5 (1) ◽

pp. 164

Author(s):

Shiva Prasad Jagini ◽

Suresh I.

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Prospective Observational Study ◽

Primary Outcome ◽

Intravenous Thrombolysis ◽

Clinical Profile ◽

Favorable Outcome ◽

Nihss Score ◽

The Mean ◽

Centre Hospital

Background: Stroke patients are at highest risk death in the first few weeks after the event, and between 20-50% die within first month depending on type, severity, age, co-morbidities and effectiveness of treatment of complications. Objective of this study was to clinical profile of patients with acute ischemic stroke receiving intravenous thrombolysis (rtPA-alteplase).Methods: Prospective Observational study of 26 cases of acute ischemic stroke receiving IV thrombolysis using rtPA-alteplase at Kovai Medical Centre Hospital, Coimbatore over a period of 1 year 9 months.Results: 21 cases had NIHSS score of range 10 to 22. The mean NIHSS score at admission is 13.5. 15 subjects (57.7%) had achieved primary outcome in this study. MRS Score of 0 to 2 is considered as favorable outcome. In this study 20 subjects (76.92 %) had favorable outcome at the end of 3 months.Conclusions: Majority of the patients receiving rtPA-alteplase had favorable outcome.

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Thrombolytic treatment in stroke mimic, inevitable but fortunately safe: An observational study from Iran

Iranian Journal of Neurology ◽

10.18502/ijnl.v18i4.2188 ◽

2020 ◽

Author(s):

Sara Esmaeili ◽

Motahareh Afrakhteh ◽

Maryam Bahadori ◽

Seyedeh Fahimeh Shojaei ◽

Rezan Ashayeri ◽

...

Keyword(s):

Alcohol Intoxication ◽

Intravenous Thrombolysis ◽

Treatment Decision ◽

National Institutes Of Health ◽

Nihss Score ◽

Number Of Patients ◽

Acute Cerebral Ischemia ◽

Tissue Plasminogen ◽

Baseline Characteristics ◽

Stroke Mimic

Background: A number of patients with symptoms of acute cerebral ischemia may have other causes called stroke mimics (SM). The prevalence of SM can be as high as 31% in some reports, and these patients are potentially at the risk of intravenous thrombolysis (IVT) therapy and its complications. This study was designed to determine the prevalence of our center’s SM (Firoozgar Hospital) among patients who received IVT, their baseline characteristics, final diagnoses, and outcomes. Methods: We reviewed the medical records of all patients who received IVT between June 2015 and May 2018. The following variables were collected: demographic characteristics, past medical history, onset-to-needle (OTN) time, door-to-needle (DTN) time, National Institutes of Health Stroke Scale (NIHSS) score at admission, brain imaging, and all paraclinic findings. Functional outcome at discharge based on modified Rankin Scale (mRS) was also assessed. Results: 10 out of 165 (6.0%) patients including 8 men and 4 women were finally diagnosed with SM. The median age and NIHSS score at presentation were 60 years and 7, respectively. Final diagnoses were seizure (n = 6), hemiplegic migraine (n = 2), conversion (n = 1), and alcohol intoxication (n = 1). All patients were discharged with a mRS score of 0 and 1 without experiencing any thrombolytic adverse effects. Conclusion: None of the patients with SM experienced any adverse effect of tissue plasminogen activator (tPA) including hemorrhage and all of them reached good mRS score. This shows that tPA is generally safe and the risk of treating patients with SM is very low and making a vital treatment decision may outweigh the risk of neglected cases in a time-sensitive setting.

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Initial Stroke Severity Is the Major Outcome Predictor for Patients Who Do Not Receive Intravenous Thrombolysis due to Mild or Rapidly Improving Symptoms

ISRN Neurology ◽

10.5402/2011/947476 ◽

2011 ◽

Vol 2011 ◽

pp. 1-3 ◽

Cited By ~ 5

Author(s):

Mu-Chien Sun ◽

Tien-Bao Lai

Keyword(s):

Independent Predictor ◽

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Unfavorable Outcome ◽

Stroke Severity ◽

Outcome Predictor ◽

Nihss Score ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Favorable Group

Intravenous tissue plasminogen activator thrombolysis for stroke is still under use. A substantial proportion of excluded patients for mild or improving symptoms are dependent at discharge. We prospectively recruited 49 patients who did not receive thrombolysis because of mild or improving symptoms. 32 had favorable outcome (mRS ≤ 2) and 17 had unfavorable outcome (mRS > 2) at discharge. Comparisons were made between the two groups. Age was older (72.5 ± 10.0 versus 64.7 ± 13.2 years, P = 0.037), and initial National Institutes of Health Stroke Scale (NIHSS) score (5.7 ± 4.0 versus 2.2 ± 2.1, P < 0.001) was higher in the unfavorable group. Diastolic blood pressure was higher in the favorable group (98 ± 15 versus 86 ± 18 mmHg; P = 0.018). Atrial fibrillation (3.1 versus 23.5%; P = 0.043) and ipsilateral artery stenosis (21.9 versus 58.8%; P = 0.012) were more frequently found in the unfavorable group. Percentage of patients excluded from thrombolysis due to improving symptoms was higher in the unfavorable group (40.6 versus 82.4%; P = 0.005). Initial NIHSS score, but not other factors, was identified by logistic regression analysis as a major independent predictor for unfavorable outcome (OR 1.44; 95%CI, 1.03–2.02).

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Clinical comparison of intravenous thrombolysis and bridging artery thrombectomy in hyperacute ischemic stroke with unknown time of onset

Archives of Medical Science ◽

10.5114/aoms/143513 ◽

2021 ◽

Vol 17 (6) ◽

pp. 1804-1810

Author(s):

Bai Qingke ◽

Zheng Ping ◽

Zhang Jianying ◽

Zhao Zhenguo

Keyword(s):

Ischemic Stroke ◽

Adverse Events ◽

Cerebral Infarction ◽

Clinical Efficacy ◽

Onset Time ◽

Intravenous Thrombolysis ◽

Modified Rankin Scale ◽

Efficacy And Safety ◽

Nihss Score ◽

Clinical Comparison

IntroductionThe aim of the study was to explore the clinical efficacy and safety of intravenous thrombolysis and bridging artery thrombectomy for hyperacute ischemic stroke with unknown onset time.Material and methodsOne hundred and twenty-eight patients with hyperacute cerebral infarction and without a clear time of onset were randomly divided into intravenous thrombolysis (n = 66) and bridging artery thrombectomy groups (n = 62).ResultsIn the intravenous thrombolysis group, 37 patients’ vessels had recanalization, 32 patients’ 24-hour National Institute of Health Stroke Scale (NIHSS) score improved, and 42 patients’ 90-day modified Rankin Scale (mRS) score was good. In the bridging artery thrombectomy group, 62 patients’ vessels had recanalization, 28 patients’ 24-hour NIHSS score improved, and 38 patients’ 90-day mRS score was good.ConclusionsThe benefits and adverse events between intravenous thrombolysis and bridging artery thrombectomy for ischemic stroke with unknown time of onset are similar.

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Endovascular reperfusion of M2 occlusions in acute ischemic stroke reduced disability and mortality: ETIS Registry results

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017380 ◽

2021 ◽

pp. neurintsurg-2021-017380

Author(s):

Patricio Muszynski ◽

Mohammad Anadani ◽

Sébastien Richard ◽

Gaultier Marnat ◽

Romain Bourcier ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Primary Outcome ◽

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Favorable Outcome ◽

Nihss Score ◽

Excellent Outcome ◽

Procedural Complications

BackgroundThe predictors of successful reperfusion and the effect of reperfusion after endovascular treatment (EVT) for M2 occlusions have not been well studied. We aimed to identify predictors of successful reperfusion and the effect of reperfusion on outcomes of EVT for M2 occlusions in current practice.MethodsPatients with acute ischemic stroke due to isolated M2 occlusions who were enrolled in the prospective multicenter Endovascular Treatment in Ischemic Stroke (ETIS) Registry in France between January 2015 and March 2020 were included. The primary outcome was a favorable outcome, defined as modified Rankin Scale (mRS) score of 0–2 at 90 days. Successful reperfusion was defined as an improvement of ≥1 points in the modified Thrombolysis In Cerebral Infarction score between the first and the last intracranial angiogram.ResultsA total of 458 patients were included (median National Institutes of Health Stroke Scale (NIHSS) score 14; 61.4% received prior intravenous thrombolysis). Compared with the non-reperfused patients, reperfused patients had an increased rate of excellent outcome (OR 2.3, 95% CI 0.98 to 5.36; p=0.053), favorable outcome (OR 2.79, 95% CI 1.31 to 5.93; p=0.007), and reduced 90-day mortality (OR 0.39, 95% CI 0.19 to 0.79; p<0.01). Admission NIHSS score was the only predictor of successful reperfusion. First-line strategy was not a predictor of successful reperfusion or favorable outcome, but the use of a stent retriever, alone or with an aspiration catheter, was associated with higher rates of procedural complications and 90-day mortality.ConclusionsSuccessful reperfusion of M2 occlusions reduced disability and mortality. However, safety is a concern, especially if the procedure failed.

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Intra-Arterial vs Intra-Venous Thrombolysis for Anterior Cerebral Occlusion

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100009999 ◽

2010 ◽

Vol 37 (2) ◽

pp. 240-244 ◽

Cited By ~ 6

Author(s):

Bin Zhang ◽

Xiaojiang Sun ◽

Minghua Li ◽

Feng Wang ◽

Dan Xu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Circulation ◽

Intracranial Haemorrhage ◽

Intravenous Thrombolysis ◽

Modified Rankin Scale ◽

Arterial Thrombolysis

Background:The safety and effectiveness of intra-arterial thrombolysis (IAT) in comparison to intravenous thrombolysis (IVT) for the treatment of ischemic stroke is uncertain. Our study aims to assess and compare IAT to IVT for clinically relevant outcomes in patients with occlusion of the anterior cerebral circulation.Methods:Patients with acute ischemic stroke were enrolled for either treatment; those whose symptoms occurred within 4.5 hrs after stroke were treated with IVT, whereas those who presented <4.5 hrs but had contraindications to IVT or presented between 4.5 and 6 hrs were treated with IAT. Evaluated endpoints included: disability at 90 days as measured by the modified Rankin Scale (mRS), incidence of mortality, and incidence of symptomatic intracranial haemorrhage.Results:78 patients with anterior cerebral circulation occlusion were included in the study (55 in IVT, 23 in IAT). After 90 days, 82.6% patients treated with IAT reached independence in comparison to 56.4% in the IVT group (P=0.028, RR=2.66, 95% CI: 1.10-7.04). The incidence of all intracranial haemorrhages in the IAT and IVT groups respectively were 30.4% and 12.7% (P=0.103, RR=2.391, 95% CI: 0.946-6.047); symptomatic intracranial haemorrhage occurred in 8.7% and 9.1% of patients (P=1.00, RR= 0.957, 95% CI: 0.200-4.579), and mortality in 8.7% and 16.4% (P=0.492, RR=1.882, 95% CI: 0.440-8.045).Conclusion:Results suggest that IAT is more effective than IVT in allowing patients to achieve independence. While inconclusive, the safety of IAT within 6 hrs is comparable to IVT within 4.5 hrs.

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