scholarly journals No Increased Risk of Symptomatic Intracerebral Hemorrhage After Thrombolysis in Patients With European Cooperative Acute Stroke Study (ECASS) Exclusion Criteria

Stroke ◽  
2012 ◽  
Vol 43 (6) ◽  
pp. 1684-1686 ◽  
Author(s):  
Carolyn A. Cronin ◽  
Nikeith Shah ◽  
Tanya Morovati ◽  
Lisa D. Hermann ◽  
Kevin N. Sheth
Keyword(s):  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Exclusion Criteria ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Study ◽  
Increased Risk

scholarly journals Preventive Ceftriaxone in Patients with Stroke Treated with Intravenous Thrombolysis: Post Hoc Analysis of the Preventive Antibiotics in Stroke Study

2016 ◽  
Vol 42 (5-6) ◽  
pp. 361-369 ◽  
Author(s):  
Jan-Dirk Vermeij ◽  
Willeke F. Westendorp ◽  
Yvo B. Roos ◽  
Matthijs C. Brouwer ◽  
Diederik van de Beek ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Intravenous Thrombolysis ◽  
Control Group ◽  
P Value ◽  
Post Hoc Analysis ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Study ◽  
Increased Risk ◽  
Post Hoc

Background: The Preventive Antibiotics in Stroke Study (PASS), a randomized open-label masked endpoint trial, showed that preventive ceftriaxone did not improve functional outcome at 3 months in patients with acute stroke (adjusted common OR 0.95; 95% CI 0.82-1.09). Post-hoc analyses showed that among patients who received intravenous thrombolysis (IVT), patients who received ceftriaxone had a significantly better outcome as compared with the control group. This study aimed to gain more insight into the characteristics of these patients. Methods: In PASS, 2,550 patients were randomly assigned to preventive antibiotic treatment with ceftriaxone or standard care. In current post-hoc analysis, 836 patients who received IVT were included. Primary outcome included functional status on the modified Rankin Scale, analyzed with adjusted ordinal regression. Secondary outcomes included infection rate and symptomatic intracerebral hemorrhage (sICH) rate. Results: For all patients in PASS, the p value for the interaction between IVT and preventive ceftriaxone regarding functional outcome was 0.03. Of the 836 IVT-treated patients, 437 were administered ceftriaxone and 399 were allocated to the control group. Baseline characteristics were similar. In the IVT subgroup, preventive ceftriaxone was associated with a significant reduction in unfavorable outcome (adjusted common OR 0.77; 95% CI 0.61-0.99; p = 0.04). Mortality at 3 months was similar (OR 0.75; 95% CI 0.48-1.18). Preventive ceftriaxone was associated with a reduction in infections (OR 0.43; 95% CI 0.28-0.66), and a trend towards an increased risk for sICH (OR 3.09; 95% CI 0.85-11.31). Timing of ceftriaxone administration did not influence the outcome (aOR 1.00; 95% CI 0.98-1.03; p = 0.85). Conclusions: According to the post-hoc analysis of PASS, preventive ceftriaxone may improve the functional outcome in IVT-treated patients with acute stroke, despite a trend towards an increased rate of post-IVT-sICH.

Abstract 119: Risk of Intracerebral Hemorrhage with Combined Antiplatelet and Anticoagulant Use

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Matthew L Flaherty ◽  
Lili Ding ◽  
Jessica G Woo ◽  
Lisa Martin ◽  
Mary Haverbusch ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Antiplatelet Agents ◽  
Population Based ◽  
Careful Consideration ◽  
Antiplatelet Drug ◽  
Treatment Groups ◽  
Stroke Study ◽  
Increased Risk ◽  
Anticoagulant Drugs ◽  
Increase Risk

Context: Intracranial bleeding is the most feared complication of antithrombotic use. Antiplatelet and anticoagulant drugs increase risk of intracerebral hemorrhage (ICH), yet in some instances, combinations of antiplatelet agents and anticoagulants are used without firm evidence of efficacy. Few studies have compared the risks of different agents and their combinations in a single population. We determined the risk of ICH associated with the most commonly used antiplatelet and anticoagulant drugs and their combinations in a population-based case-control study. Methods: This report includes data from subjects recruited from the Greater Cincinnati/Northern Kentucky area by the Genetic and Environmental Risk Factors for Hemorrhagic Stroke Study from 1997 to 2009. We compared individuals in different treatment groups to identify any differences in baseline covariates that could be associated with treatment assignment. As there were a number of statistically significant differences, we used multivariate matching to analyze risk for ICH conferred by different antithrombotic agents. Treatment effects on ICH were estimated using the matched samples while accounting for the dependence between matched individuals. Results: There were 733 subjects with ICH and 2555 controls included in this study period. Results are shown in the table. Use of aspirin, clopidogrel, or their combination was associated with a trend toward increased risk. Warfarin increased risk compared with no antithrombotic use (OR 3.98, p < 0.0001). The combination of warfarin and either aspirin or clopidogrel produced the greatest risk, compared with no antithrombic therapy (OR 4.92 p<0.001) or compared with warfarin alone (OR 3.00 p=0.009). Conclusions: The combination of warfarin and an antiplatelet drug significantly increases risk of ICH compared with no antithrombotic therapy or warfarin monotherapy. The use of combination therapy requires careful consideration in clinical practice.

scholarly journals Low-dose versus standard-dose alteplase in acute ischemic stroke in Asian stroke registries: an individual patient data pooling study

2019 ◽  
Vol 14 (7) ◽  
pp. 670-677
Author(s):  
Xia Wang ◽  
Jingwei Li ◽  
Tom J Moullaali ◽  
Keon-Joo Lee ◽  
Beom Joon Kim ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Low Dose ◽  
Standard Dose ◽  
Stroke Registry ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Intravenous Alteplase

Objective To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. Methods Individual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the individual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. Results Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85–1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63–1.19), except for lower death with borderline significance, 0.77 (0.59–1.01). Conclusions The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.

scholarly journals Short- and Long-Term Reduction of Door-to-Needle Time in Thrombolysis for Acute Stroke

2016 ◽  
Vol 44 (3) ◽  
pp. 255-260 ◽  
Author(s):  
Bing Yu Chen ◽  
Aimen Moussaddy ◽  
Mark R. Keezer ◽  
Yan Deschaintre ◽  
Alexandre Y. Poppe
Keyword(s):  
Computed Tomography ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Hospital Treatment ◽  
Long Term Effects ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference ◽  
Clinical Benefits ◽  
Short And Long Term

AbstractBackground: More timely administration of tissue plasminogen activator (alteplase) for patients with acute ischemic stroke yields greater clinical benefits. We implemented door-to-needle (DTN) time reduction strategies at our center and evaluated their short- and long-term effects on in-hospital treatment delays and clinical outcomes. Methods: Strategies, including stroke team prenotification, direct computed tomography transfer, not routinely waiting for laboratory results and alteplase delivery on the computed tomography table, were implemented in June 2013. We included all thrombolysed patients admitted directly to our hospital between January 2012 and March 2015. In-hospital delays and symptomatic intracerebral hemorrhage rates were compared between patients pre- and postmodification, and the latter period was divided into early (first 6 months) and late (beyond 6 months) phases to assess the durability of our modifications. Results: Forty-eight individuals were treated premodification compared with 58 postmodification. The median DTN time was reduced from 75 to 46 minutes (p<0.0001). The median DTN time in the early and late postmodification phases was not significantly different (41 vs 46 minutes, p=0.4085). There was no significant difference in rates of symptomatic intracerebral hemorrhage (4.2 vs 1.7%, p=0.361) or stroke mimics (2.1 ves 5.2%, p=0.625) Conclusions: We were able to decrease our DTN time for acute stroke thrombolysis by implementing relatively simple modifications and these improvements persisted over time.

Abstract NS 4: Non-Invasive Oscillometric Blood Pressure Monitoring in tPA Treated Patients: Is Mean Arterial Pressure Associated with Patient Outcomes?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Anne W Alexandrov ◽  
Asad A Chaudhary ◽  
April Sisson ◽  
Kara Sands ◽  
Pawan Rawal ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
National Standard ◽  
Stroke Patients ◽  
Non Invasive ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Center

Background: Blood pressure (BP) parameters for management of tPA treated patients are well known among experienced stroke clinicians, and violation of systolic and diastolic BP limits have previously been shown to be associated with symptomatic intracerebral hemorrhage (sICH) in tPA treated patients. Non-invasive oscillometric BP monitoring measures a “true” mean arterial pressure (MAP), and then algorithmically defines what systolic and diastolic pressure "might" be. Because this form of BP monitoring has become the national standard, we examined the occurrence of MAP BP elevations to determine their association with sICH and treatment outcome in acute ischemic stroke patients that received systemic tPA. Methods: Two-years of consecutive systemic tPA cases were retrieved from our Stroke Center database and arterial blood pressures for the first 24 hours from time of bolus were entered from auto-recordings in our electronic medical records. Protocol violations in MAP were defined as greater than 120 mm Hg at any point in the first 24 hours from time of bolus. Off-label treatment with intravenous tPA beyond 4.5 hours from symptom onset was identified a priori as a potential counfounder to stroke outcome. Symptomatic intracerebral hemorrhage was defined as an increase in the NIHSS of ≥ 4 points. Spearman’s correlation was used to assess the relationship between MAP and post-tPA NIHSS score. Results: 191 tPA cases were identified for inclusion in the analysis with 150 (79%) receiving their tPA at our Comprehensive Stroke Center and another 41 (21%) administered as a telephone-consult supported drip and ship. Patients were 65.5±16 years of age with median admission NIHSS scores of 12 (IQR=7-17). All patients had normal CT scans or minor changes consistent with acute stroke without hypo-attenuation. A total of 77 (40%) patients experienced a MAP violation overall. There were 11 isolated systolic BP violations, 4 isolated diastolic BP violations, and 21 isolated MAP violations that were otherwise not detectable by a violation in systolic or diastolic parameters, averaging 123.3±2 mm Hg. A total of 2 (1%) sICHs occurred in the sample, and of these 1 was associated with on-label peri-treatment BP protocol violations affecting systolic, diastolic and MAP parameters. An increased reduction in post-tPA NIHSS points was significantly associated with higher MAPs (r=.92; p=.008). Conclusions: Evidence-based guidelines are silent on MAP limits, and MAP is rarely monitored clinically in tPA treated patients despite dependence on the MAP for assignment of systolic and diastolic pressures in oscillometric BP monitoring. Our findings suggest that an improved understanding of the contribution of MAP-dependent oscillometric methods to BP monitoring in acute stroke patients is warranted.

scholarly journals Leukoaraiosis Is a Risk Factor for Symptomatic Intracerebral Hemorrhage After Thrombolysis for Acute Stroke

Stroke ◽  
2006 ◽  
Vol 37 (10) ◽  
pp. 2463-2466 ◽  
Author(s):  
Tobias Neumann-Haefelin ◽  
Silke Hoelig ◽  
Joachim Berkefeld ◽  
Jens Fiehler ◽  
Achim Gass ◽  
...  
Keyword(s):  
Risk Factor ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Symptomatic Intracerebral Hemorrhage

Abstract P37: A Novel Emergency Stroke Alert System Reduces Door-to-CT And Door-to-Needle Time in Patients With Acute Ischemic Stroke

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
Muhammad A Pervez ◽  
Joshua N Goldstein ◽  
Natalia S Rost ◽  
Joyce Mclntyre ◽  
Joseph Fay ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Stroke Care ◽  
National Guidelines ◽  
Alert System ◽  
Acute Stroke Care ◽  
Post Intervention ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Increased Risk ◽  
Iv Tpa

Background: National guidelines recommend eligible acute stroke patients undergo neuroimaging within 25 min and IV tPA within 60 min. In order to reduce door-to-needle time, we implemented an “ED2CT” virtual group pager which allows ED staff to simultaneously activate the Stroke Team, neuroradiologists, CT technologists, nursing supervisors and pharmacists. Methods: We performed an IRB approved retrospective review of a prospectively acquired cohort of consecutive patients with ischemic stroke presenting to a single tertiary stroke center using our Get With the Guidelines Stroke (GWTG-S) database. We compared patients who received IV tPA within 3 hours of symptom onset pre- (March 2006-April 2008) to post-intervention (September 2008-December 2009) by Wilcoxon or Fisher's exact as appropriate. Results: Overall, there were 56 patients in the pre-intervention and 53 in the post-intervention groups. Patients were 50.5% male, median age was 76 [IQR 63, 85] years, median time to presentation was 50 [IQR 33, 87] min, and median initial NIHSS was 14 [IQR 8, 20]. None of these variables were significantly different between the pre- and post-intervention groups. Implementation of the ED2CT alert was associated with a reduction of 31% in door-to-CT time (29 [22, 40] vs. 20 [16, 29] min; p=<0.001) and 13.5% in door-to needle time (59 [42, 78] vs. 51 [35, 62] min; p=0.02). In addition, there was an increase of 55% in the proportion of patients undergoing CT within 25 min (42.9% vs.66.7 % p=0.01) and 39% in door-to needle within 60 min (51.8% vs. 72.0% p=0.03). Symptomatic intracerebral hemorrhage (sICH) was infrequent among patients receiving IV tPA with or without rescue IA reperfusion (n=109, 8.3%) and those with IV tPA only (n=83, 6.0%); there was a trend in reduced sICH rate post intervention (11.6% vs. 0%; p=0.06). Conclusions: A novel emergency alert system with which the ED attending directly activates multiple members of the acute stroke clinical and imaging team was associated with an improved door-CT time and improved door-tPA time without an increased risk of sICH. This approach aligns acute stroke care activation with trauma and emergency cardiac care and suggests that team-based approaches may be better than specialty -specific responses.

Thrombectomy in Extensive Stroke May Not Be Beneficial and Is Associated With Increased Risk for Hemorrhage

Stroke ◽  
2021 ◽  
Author(s):  
Lukas Meyer ◽  
Matthias Bechstein ◽  
Maxim Bester ◽  
Uta Hanning ◽  
Caspar Brekenfeld ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Cerebral Infarction ◽  
Medical Treatment ◽  
Scale Score ◽  
Odds Ratio ◽  
Modified Rankin Scale ◽  
Anterior Circulation ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Best Medical Treatment ◽  
Increased Risk

Background and Purpose: This study evaluates the benefit of endovascular treatment (EVT) for patients with extensive baseline stroke compared with best medical treatment. Methods: This retrospective, multicenter study compares EVT and best medical treatment for computed tomography (CT)–based selection of patients with extensive baseline infarcts (Alberta Stroke Program Early CT Score ≤5) attributed to anterior circulation stroke. Patients were selected from the German Stroke Registry and 3 tertiary stroke centers. Primary functional end points were rates of good (modified Rankin Scale score of ≤3) and very poor outcome (modified Rankin Scale score of ≥5) at 90 days. Secondary safety end point was the occurrence of symptomatic intracerebral hemorrhage. Angiographic outcome was evaluated with the modified Thrombolysis in Cerebral Infarction Scale. Results: After 1:1 pair matching, a total of 248 patients were compared by treatment arm. Good functional outcome was observed in 27.4% in the EVT group, and in 25% in the best medical treatment group ( P =0.665). Advanced age (adjusted odds ratio, 1.08 [95% CI, 1.05–1.10], P <0.001) and symptomatic intracerebral hemorrhage (adjusted odds ratio, 6.35 [95% CI, 2.08–19.35], P <0.001) were independently associated with very poor outcome. Mortality (43.5% versus 28.9%, P =0.025) and symptomatic intracerebral hemorrhage (16.1% versus 5.6%, P =0.008) were significantly higher in the EVT group. The lowest rates of good functional outcome (≈15%) were observed in groups of failed and partial recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 0/1–2a), whereas patients with complete recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 3) with recanalization attempts ≤2 benefitted the most (modified Rankin Scale score of ≤3:42.3%, P =0.074) compared with best medical treatment. Conclusions: In daily clinical practice, EVT for CT–based selected patients with low Alberta Stroke Program Early CT Score anterior circulation stroke may not be beneficial and is associated with increased risk for hemorrhage and mortality, especially in the elderly. However, first- or second-pass complete recanalization seems to reveal a clinical benefit of EVT highlighting the vulnerability of the low Alberta Stroke Program Early CT Score subgroup. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03356392.

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