scholarly journals Thrombolysis in acute ischemic stroke in patients with dementia

Neurology ◽  
2017 ◽  
Vol 89 (18) ◽  
pp. 1860-1868 ◽  
Author(s):  
Eva Zupanic ◽  
Mia von Euler ◽  
Ingemar Kåreholt ◽  
Beatriz Contreras Escamez ◽  
Johan Fastbom ◽  
...  
Keyword(s):  
Cohort Study ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcomes ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Younger Patients ◽  
Everyday Activities ◽  
Symptomatic Intracerebral Hemorrhage ◽  
To Receive

Objective:To compare access to intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) and its outcomes in patients with and without dementia.Methods:This was a longitudinal cohort study of the Swedish dementia and stroke registries. Patients with preexisting dementia who had AIS from 2010 to 2014 (n = 1,356) were compared with matched patients without dementia (n = 6,755). We examined access to thrombolysis and its outcomes at 3 months (death, residency, and modified Rankin Scale [mRS] score). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic and ordinal logistic regression.Results:The median age at stroke onset was 83 years in both groups. IVT was administered to 94 (7.0%) patients with dementia and 639 (9.5%) patients without dementia. The OR of receiving IVT was 0.68 (95% CI 0.54–0.86) for patients with dementia. When the analysis was repeated exclusively among patients independent in everyday activities, dementia status was no longer significant (OR 0.79, 95% CI 0.60–1.06). However, differences persisted in patients ≤80 years of age (OR 0.58, 95% CI 0.36–0.94). In patients who received thrombolysis, the incidence of symptomatic intracerebral hemorrhage (sICH; 7.4% vs 7.3%) and death at 3 months (22.0% vs 18.8%) did not differ significantly between the 2 groups. However, mRS score and accommodation status were worse among patients with dementia after 3 months in adjusted analyses (both p < 0.001). Unfavorable outcomes with an mRS score of 5 to 6 were doubled in patients with dementia (56.1% vs 28.1%).Conclusions:Younger patients with dementia and AIS are less likely to receive IVT. Among patients receiving thrombolysis, there are no differences in sICH or death, although patients with dementia have worse accommodation and functional outcomes at 3 months.

scholarly journals Serum lipid level is not associated with symptomatic intracerebral hemorrhage after intravenous thrombolysis for acute ischemic stroke

PeerJ ◽  
2018 ◽  
Vol 6 ◽  
pp. e6021 ◽  
Author(s):  
Ting-Chun Lin ◽  
Yen-Kuang Lin ◽  
Chin-I Chen ◽  
Lung Chan ◽  
Nai-Fang Chi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Total Cholesterol ◽  
Functional Outcomes ◽  
Serum Lipid ◽  
Density Lipoprotein ◽  
Intravenous Thrombolysis ◽  
Lipid Levels ◽  
Nihss Score ◽  
Symptomatic Intracerebral Hemorrhage

Background This study assessed whether serum lipid levels are associated with the risk of symptomatic intracerebral hemorrhage (sICH) and functional outcomes in patients with acute ischemic stroke after receiving intravenous thrombolysis. Methods We retrospectively analyzed consecutive ischemic stroke patients who were treated with intravenous tissue plasminogen activator between January 2007 and January 2017. Lipid levels on admission, including total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride levels, as well as potential predictors of sICH were tested using univariate and multivariate analyses. Results Of the 229 enrolled patients (100 women, aged 68 ± 13 years), 14 developed sICH and 103 (45%) had favorable functional outcomes at 3 months. The patients with sICH more often had diabetes mellitus (71% vs. 26%, P = 0.01) and had more severe stroke (mean National Institutes of Health Stroke Scale [NIHSS] score of 16 vs. 13, P = 0.045). Regarding lipid subtype, total cholesterol, LDL-C, HDL-C, and triglyceride levels were not associated with sICH or functional outcomes. According to the results of multivariate analysis, the frequency of sICH was independently associated with diabetes mellitus (odds ratio [OR] = 6.04; 95% CI [1.31–27.95]; P = 0.02) and the NIHSS score (OR = 1.12; 95% CI [1.02–1.22]; P = 0.01). A higher NIHSS score was independently associated with unfavorable functional outcomes (OR = 0.86; 95% CI [0.81–0.91]; P < 0.001). Conclusions Serum lipid levels on admission, including total cholesterol, LDL-C, HDL-C, and triglyceride levels, were not associated with sICH or 3-month functional outcomes after intravenous thrombolysis for acute ischemic stroke.

Predictors of futile recanalization after endovascular treatment in acute ischemic stroke: a meta-analysis

2021 ◽  
pp. neurintsurg-2021-017963
Author(s):  
Gang Deng ◽  
Jun Xiao ◽  
Haihan Yu ◽  
Man Chen ◽  
Ke Shang ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Systolic Blood Pressure ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Serum Glucose ◽  
Female Sex ◽  
Symptomatic Intracerebral Hemorrhage

BackgroundDespite successful recanalization after endovascular treatment, many patients with acute ischemic stroke due to large vessel occlusion still show functional dependence, namely futile recanalization.MethodsPubMed and Embase were searched up to April 30, 2021. Studies that reported risk factors for futile recanalization following endovascular treatment of acute ischemic stroke were included. The mean difference (MD) or odds ratio (OR) and 95% confidence interval (95% CI) of each study were pooled for a meta-analysis.ResultsTwelve studies enrolling 2138 patients were included. The pooled analysis showed that age (MD 5.81, 95% CI 4.16 to 7.46), female sex (OR 1.40, 95% CI 1.16 to 1.68), National Institutes of Health Stroke Scale (NIHSS) score (MD 4.22, 95% CI 3.38 to 5.07), Alberta Stroke Program Early CT Score (ASPECTS) (MD −0.71, 95% CI −1.23 to –0.19), hypertension (OR 1.73, 95% CI 1.43 to 2.09), diabetes (OR 1.78, 95% CI 1.41 to 2.24), atrial fibrillation (OR 1.24, 95% CI 1.01 to 1.51), admission systolic blood pressure (MD 4.98, 95% CI 1.87 to 8.09), serum glucose (MD 0.59, 95% CI 0.37 to 0.81), internal carotid artery occlusion (OR 1.85, 95% CI 1.17 to 2.95), pre-treatment intravenous thrombolysis (OR 0.67, 95% CI 0.55 to 0.83), onset-to-puncture time (MD 16.92, 95% CI 6.52 to 27.31), puncture-to-recanalization time (MD 12.37, 95% CI 7.96 to 16.79), and post-treatment symptomatic intracerebral hemorrhage (OR 6.09, 95% CI 3.18 to 11.68) were significantly associated with futile recanalization.ConclusionThis study identified female sex, comorbidities, admission systolic blood pressure, serum glucose, occlusion site, non-bridging therapy, and post-procedural complication as predictors of futile recanalization, and also confirmed previously reported factors. Further large-scale prospective studies are needed.

Abstract TMP25: Effects of Age and Ethnicity on the Benefits and Risks of Low- versus Standard-dose Alteplase in Acute Ischemic Stroke Patients: The Enchanted Trial

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Xia Wang ◽  
Thompson Robinson ◽  
Hisatomi. Arima ◽  
Joseph Broderick ◽  
Andrew Demchuk ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Effects ◽  
Low Dose ◽  
Standard Dose ◽  
Intravenous Thrombolysis ◽  
Open Label ◽  
Poor Outcome ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Study

Background and Purpose: As lower doses of alteplase reduce the risk of symptomatic intracerebral hemorrhage (sICH), older and Asian people may benefit more from low-dose alteplase than other patients with acute ischemic stroke (AIS). Methods: Data from the ENhanced Control of Hypertension ANd Thrombolysis strokE study (ENCHANTED), an international, multi-center, prospective, randomized, open-label, blinded-endpoint trial, were analyzed to assess effects of low- (0.6mg/kg body weight) vs. standard-dose (0.9mg/kg) alteplase in AIS patients, by age and ethnicity (Asian vs. non-Asian), pre-specified subgroup analyses, on key efficacy and safety outcomes. Results: 3297 patients (1248 female), mean age 67 years were included. After adjusting for baseline characteristics and management variables over the first seven days, increasing age was associated with poor outcome, defined by ordinal analysis of the modified Rankin score (mRS) (shift to a less favorable outcome, P trend <0.0001). In the comparison between low- and standard-dose alteplase, no significant differences were observed for 90-day poor outcome by age deciles and ethnicity. Less sICH was observed with low-dose alteplase, and this was consistent for age and ethnicity. There was no ethnic difference in the treatment effects by age, severity, and time to treatment. Conclusions: Increasing age predicts poor outcome in thrombolysis-treated AIS patients. There was no heterogeneity in the treatment effects of low- vs. standard-dose alteplase. Decisions about intravenous thrombolysis should be based on variables other than age and ethnicity.

Tenecteplase versus alteplase before endovascular thrombectomy (EXTEND-IA TNK): A multicenter, randomized, controlled study

2017 ◽  
Vol 13 (3) ◽  
pp. 328-334 ◽  
Author(s):  
Bruce CV Campbell ◽  
Peter J Mitchell ◽  
Leonid Churilov ◽  
Nawaf Yassi ◽  
Timothy J Kleinig ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Stroke Onset ◽  
Large Vessel ◽  
Controlled Study ◽  
Modified Rankin Scale ◽  
Open Label ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage

Background and hypothesis Intravenous thrombolysis with alteplase remains standard care prior to thrombectomy for eligible patients within 4.5 h of ischemic stroke onset. However, alteplase only succeeds in reperfusing large vessel arterial occlusion prior to thrombectomy in a minority of patients. We hypothesized that tenecteplase is non-inferior to alteplase in achieving reperfusion at initial angiogram, when administered within 4.5 h of ischemic stroke onset, in patients planned to undergo endovascular therapy. Study design EXTEND-IA TNK is an investigator-initiated, phase II, multicenter, prospective, randomized, open-label, blinded-endpoint non-inferiority study. Eligibility requires a diagnosis of ischemic stroke within 4.5 h of stroke onset, pre-stroke modified Rankin Scale≤3 (no upper age limit), large vessel occlusion (internal carotid, basilar, or middle cerebral artery) on multimodal computed tomography and absence of contraindications to intravenous thrombolysis. Patients are randomized to either IV alteplase (0.9 mg/kg, max 90 mg) or tenecteplase (0.25 mg/kg, max 25 mg) prior to thrombectomy. Study outcomes The primary outcome measure is reperfusion on the initial catheter angiogram, assessed as modified treatment in cerebral infarction 2 b/3 or the absence of retrievable thrombus. Secondary outcomes include modified Rankin Scale at day 90 and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0–1) at day 3. Safety outcomes are death and symptomatic intracerebral hemorrhage. Trial registration ClinicalTrials.gov NCT02388061

scholarly journals Flexible Versus Rigid Methods Of Intravenous Thrombolysis In Iran

2017 ◽  
pp. 6
Author(s):  
Kavian Ghandehari
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Tertiary Care ◽  
Intravenous Thrombolysis ◽  
Recent Decade ◽  
Recombinant Tissue Plasminogen Activator ◽  
Limiting Factor ◽  
Standard Protocol ◽  
Exclusion Criteria ◽  
Symptomatic Intracerebral Hemorrhage

Thrombolysis with administration of intravenous (IV) recombinant tissue plasminogen activator (rtPA) has been performed in some tertiary care hospitals in Iran in recent decade. Mininstery of Health and Medical Education of Iran approved a new management strategy which covers the cost of Alteplase since 2015. This is a great advance in increasing chance for Iranian stroke patients to get the treatment. Delay in performing triage and CT and laboratory tests is another limiting factor which can be decreased by defining special team members for thrombolysis. Most of the Iranian neurologists are not expert for performing the management. This limitation can be managed by continous thrombolysis work shops. However many of the Neurologists may not be interested to do the thrombolysis due to its risks and lack of financial benefits for responsible doctor.  Most of the contraindications for thrombolysis with tPA originated as exclusion criteria in famous clinical trials. These were derived from expert consensus for the National Institute of Neurological Disorders and Stroke (NINDS) trial. Despite the fact that the safety and efficacy of IV rtPA has been repeatedly confirmed in large international observational studies over the past 20 years, most patients with acute ischemic stroke  still do not receive thrombolytic treatment. Some of the original exclusion criteria have proven to be unnecessarily restrictive in real-world clinical practice. It has been suggested that application of relaxed exclusion criteria might increase the IV thrombolysis rate up to 20% with comparable outcomes to thrombolysis with more conventional criteria. We review the absolute and relative contraindications to IV rtPA for acute ischemic stroke, discussing the underlying rationale and evidence supporting these exclusion criteria. There are two therapeutic strategies for selecting the contraindications and exclusion criteria. Flexible method is ignoring some absolute or partial exclusion critera as illustrated above. This method will increase the probability of symptomatic intracerebral hemorrhage and death and may increase  numbers of legal condemnations for treating physician. Rigid method is prohibition of violations from standard protocols of thrombolysis which decreases both numbers of managed patients and thrombolysis contraindications. Physicians who prefer the first therapeutic strategy refer to data of published articles and guidelines of American and European stroke societies. There are two points of view; first, the Iranian neurologists do not have thrombolysis experience as well as western neurologusts. For instance very limited number of Iranian neurologists have enough experience for detection of ASPECT score. Second, due to some social factors number of legal condemnations  due to medical malpractice has been hugely increased in recent two decades in Iran. Based on these points second strategy is more wise for Iranian neurologists. The speaker has made a standard protocol of thrombolysis based on international gudelines and his experience. This standard protocol which is designed according to the rigid method is available by search in Google engine and is provided in Persian language.  

scholarly journals MEAN PLATELET VOLUME DI STROK

2016 ◽  
Vol 19 (1) ◽  
pp. 37
Author(s):  
Besse Rosmiati ◽  
Sulina Y Wibawa ◽  
Darmawaty ER
Keyword(s):  
Cohort Study ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mean Platelet Volume ◽  
Modified Rankin Scale ◽  
Platelet Activity ◽  
Stroke Patients ◽  
Platelet Volume ◽  
P Values ◽  
The Mean

Ischemic stroke is the cause of most cases which occur due to obstruction, this pathogenesis can be caused by the formation of thrombus in the cerebrum blood vessels. Platelet aggregation plays a role in the pathogenesis of thromboembolic cerebrovascular disease. Platelets size, measured as Mean Platelet Volume (MPV) is a marker of platelet function and is associated with the indicator of platelet activity. Several studies have found that there was an increased of MPV in acute ischemic stroke while the correlation with the severity and outcome of stroke was still controversial. The aim of study is to determine the MPV and their association with outcomes in acute ischemic stroke patients. A cohort study during May up to July 2010 was carried out, the researchers measured MPV and analyze their correlation with its outcome using modified Rankin scale score 10 days after the onset in 33 acute ischemic stroke patients. The mean of MPV for the first three days of the onset was 8.9 fl, on the 5th day was increased up to 9.4 but at the 10th day of onset the MPV remains the same value as the 5th day. The MPV of first three days and 5th day have a positive correlation, but insignificant with their outcome, with p values 0.158 and 0.06, respectively. From this study can be concluded that the increased of MPV on the fifth day onset did not have any significant correlation with the outcome of acute ischemic stroke illness.

scholarly journals Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results.

2019 ◽  
Author(s):  
Massimo Gamba ◽  
Nicola Gilberti ◽  
Enrico Premi ◽  
Angelo Costa ◽  
Michele Frigerio ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Safety Profile ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage

Abstract Background and Purpose endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients is still unclear. The present study aims to test whether IVT plus ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS by LVO. Methods we performed a single center retrospective observational study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. The patients were divided in 2 groups based on the treatment they received: CoT and, if IVT contraindicated, direct ET. We compared functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up infarct volume (EFIV) (for recanalized patients only) as well as safety profile, defined as symptomatic intracerebral hemorrhage (sICH) and 3-month mortality, between groups. Results 145 subjects were included in the study, 70 in direct ET group and 75 in CoT group. Patients who received CoT presented more frequently a functional independence at 3-months follow-up compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P<0.001. mRS score 0-2: 67.1% vs 37.3%; P<0.001), higher first-pass success rate (62.7% vs 38.6%, P<0.05), higher recanalization rate (84.3% vs 65.3%; P=0.009) and, in recanalized subjects, smaller EFIV (16.4ml vs 62.3ml; P=0.003). The safety profile was similar for the 2 groups. In multivariable regression analysis, low baseline NIHSS score (P<0.05), vessel recanalization (P=0.05) and CoT (P=0.03) were indipendent predictors of 3-month favorable outcome. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

scholarly journals Adiposity and Outcome After Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 144-151
Author(s):  
Zuolu Liu ◽  
Nerses Sanossian ◽  
Sidney Starkman ◽  
Gilda Avila-Rinek ◽  
Marc Eckstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Odds Ratio ◽  
Functional Outcomes ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Related Quality ◽  
Severely Obese

Background and Purpose: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. Methods: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2–6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. Results: Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival ( P =0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6–4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5–1.4]), obese (0.5, [CI, 0.3–1.0]), and severely obese (0.4 [CI, 0.2–0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2–6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. Conclusions: Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients’ adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

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