Intravenous thrombolysis in patients with chronic kidney disease

Neurology ◽  
2020 ◽  
Vol 95 (2) ◽  
pp. e121-e130
Author(s):  
Konark Malhotra ◽  
Aristeidis H. Katsanos ◽  
Nitin Goyal ◽  
Ashis Tayal ◽  
Henrik Gensicke ◽  
...  
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Stroke Study ◽  
Symptomatic Intracranial Hemorrhage ◽  
Favorable Functional Outcome

ObjectiveTo determine the association of chronic kidney disease (CKD) with the safety and efficacy of IV thrombolysis (IVT) among patients with acute ischemic stroke (AIS).MethodsA systematic review and pairwise meta-analysis of studies involving patients with CKD undergoing IVT for AIS were conducted to evaluate the following outcomes: symptomatic intracranial hemorrhage (sICH), asymptomatic and any intracranial hemorrhage (ICH), in-hospital and 3-month mortality, 3-month favorable functional outcome (FFO; modified Rankin Scale [mRS] score 0–1), and 3-month functional independence (FI, mRS score 0–2). CKD was defined with estimated glomerular filtration rate (eGFR) ranging from mild (eGFR 60–89 mL/min) to moderate (eGFR 30–59 mL/min) to severe (eGFR 15–29 mL/min).ResultsWe identified 20 studies comprising 60,486 patients with AIS treated with IVT. In unadjusted analyses, CKD was associated with sICH according to the National Institute of Neurological Disorders and Stroke (NINDS) (7 studies; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19–1.67) and European Cooperative Acute Stroke Study (ECASS) II (9 studies; OR 1.37, 95% CI 1.01–1.85) definitions, any ICH (8 studies; OR 1.42, 95% CI 1.18–1.70), 3-month mortality (9 studies; OR 2.20, 95% CI 1.72–2.81), 3-month FFO (8 studies; OR 0.58, 95% CI 0.47–0.72), and 3-month FI (8 studies; OR 0.57, 95% CI 0.46–0.71). In adjusted analyses, CKD was associated with sICH according to NINDS (4 studies; ORadj 1.34, 95% CI 1.01–1.79) and ECASS II (3 studies; ORadj 2.08, 95% CI 1.27–3.43) definitions, any ICH (6 studies; ORadj 1.41, 95% CI 1.01–1.97), in-hospital mortality (2 studies; ORadj 1.19, 95% CI 1.09–1.30), and 3-month FFO (6 studies; ORadj 0.80, 95% CI 0.70–0.92).ConclusionsAfter adjustment for confounders in this pairwise meta-analysis, moderate to severe CKD is associated with increased risks of ICH and worse functional outcomes among patients with AIS treated with IVT.

Abstract WP103: Re-Examining the Exclusion Criterion of Early Recurrent Ischemic Stroke in Intravenous Thrombolysis: A Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Katrina Hannah Ignacio ◽  
Jose Danilo Diestro ◽  
Adrian Espiritu ◽  
Julian Spears ◽  
Maria Cristina San Jose
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Exclusion Criterion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage

Background: Current guidelines for intravenous tissue plasminogen activator for acute ischemic stroke preclude the administration of the drug in patients with a history of recent stroke. Objectives: Our meta-analysis aims to determine the safety and efficacy of thrombolysis in patients with early recurrent ischemic stroke (within 3 months of initial stroke). Methods: Pubmed, Cochrane, Scopus, Embase, Clinicaltrials.gov , and HERDIN were searched for studies comparing the outcomes of acute stroke patients undergoing intravenous thrombolysis between those with early recurrent stroke (ERS) and those without. Random-effects meta-analysis was used to evaluate the outcomes in terms of symptomatic intracranial hemorrhage, mortality and good functional outcomes at 3 months (modified Rankin Score < 2 ) Results: Three observational studies with a total of 48,459 thrombolysed patients (824 with ERS and 47,635 without) were included in the study. There was no significant difference between patients with ERS and those without in terms of symptomatic intracranial hemorrhage (OR 1.39, 95% Confidence Interval [CI] 0.75-2.58), mortality (OR 1.36, 95% CI 0.60-3.09) and good functional outcomes at 3 months (OR 0.74, 95% CI 0.47-1.16). Conclusion: Our meta-analysis suggests that there is insufficient evidence to substantiate excluding patients with ERS from receiving thrombolysis. Further studies to re-examine ERS as an exclusion criterion for receiving thrombolysis are warranted.

scholarly journals Safety of Glycoprotein IIb-IIIa Inhibitors Used in Stroke-Related Treatment: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 26 ◽  
pp. 107602962094259
Author(s):  
Xiaolin Zhu ◽  
Genmao Cao
Keyword(s):  
Intracranial Hemorrhage ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Antiplatelet Agents ◽  
National Institutes Of Health ◽  
Randomized Controlled ◽  
Tissue Plasminogen ◽  
Treatment Administration ◽  
Symptomatic Intracranial Hemorrhage

Background: Endovascular therapy and intravenous thrombolysis with recombinant tissue plasminogen activator are the 2 most recommended treatments for acute ischemic stroke (AIS). Glycoprotein (GP) IIb-IIIa inhibitors are short-acting selective reversible antiplatelet agents that emerged as promising therapeutic agents for AIS about 10 years ago. Given the unclear safety profile and application coverage of GP inhibitors, we conducted this meta-analysis to explore the same. Methods: We used GP IIb-IIIa inhibitors, intracranial hemorrhage, and mortality as the key words on Medline, Web of Science, and the Embase databases. Randomized controlled trials, prospective literatures, and retrospective studies in English published between 1990 and 2020 were screened. The outcomes were relative risk (RR) of death and 90-day intracerebral hemorrhage (ICH). We pooled the results in 2 categories and conducted a subgroup analysis stratified by different drugs. The choice of the effects model depended on the value of I 2. Results: In all, 3700 patients from 20 studies were included. No GP IIb-IIIa inhibitors were found to have a remarkable influence on the ICH rate. The RR values of symptomatic ICH for abciximab and eptifibatide were 4.26 (1.89, 9.59) and 0.17 (0.04, 0.69), respectively. Both tirofiban and abciximab could decrease the mortality rate within 90 days. Age > 70 years, National Institutes of Health Stroke Scale > 15, and overall dose > 10 mg are risk factors for ICH events with tirofiban usage. Thrombectomy combined with tirofiban was safe for arterial reocclusion prevention. Conclusions: In stroke-related treatment, administration of GP IIb-IIIa inhibitors could be safe, but care should be taken regarding drug species and doses. Abciximab can increase the risk of symptomatic intracranial hemorrhage. Tirofiban and eptifibatide can be considered safe in low doses. Suitable patients should be selected using strict criteria.

scholarly journals Tenecteplase versus alteplase for acute ischemic stroke thrombolysis: a systematic review and meta-analysis

2021 ◽  
Vol 26 (4) ◽  
pp. 671-683
Author(s):  
YinQin Hu ◽  
YangBo Hou ◽  
Zhen Chen ◽  
Qian Xiao ◽  
Huixia Chen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Cochrane Library ◽  
Nihss Score ◽  
Thrombolytic Drug ◽  
Symptomatic Intracranial Hemorrhage

Background: Intravenous thrombolysis is the preferred clinical treatment for acute ischemic stroke. Alteplase is an intravenous thrombolytic drug used in clinical practice. Recently, studies have shown the efficacy of another intravenous thrombolytic drug, tenecteplase, and have reported that the risk of bleeding is low. However, at present, Chinese and international research has yielded controversial results regarding the efficacy and risks of tenecteplase. Therefore, this systematic review and meta- analysis of the efficacy and safety of tenecteplase were performed. Methods: PubMed, the Cochrane Library, MEDLINE, the Wanfang Database and CNKI were searched for all studies on the thrombolytic treatment of acute ischemic stroke. All studies published in English prior to March 2021 were retrieved. The studies were screened and selected based on the inclusion and exclusion criteria. Then, the data were extracted and recorded by trained researchers. RevMan 5.4 statistical software was used to analyze the data on the 24h recanalization rate, early neurological improvement (24h reduction in the National Institutes of Health Stroke Scale [NIHSS] score of at least 8 points or 24 h NIHSS score of 0~1 point), mRS score at 90 days, intracranial hemorrhage, symptomatic intracranial hemorrhage and mortality in the tenecteplase group and alteplase group. Results: A total of 565 related studies were identified through the initial searches in each database. The citations of meta-analyses and related reviews were screened for additional eligible articles. Eventually, 9 high-quality English-language articles that included 2149 patients with acute ischemic stroke (including 1035 in the tenecteplase group and 1046 in the alteplase group)were included in this meta-analysis. The meta-analysis results were as follows: (1) Efficacy: The 24 h recanalization rate with regard to vascular recanalization was significantly better in the tenecteplase group than in the alteplase group(OR = 1.83, 95% CI: 1.23~2.72, z = 2.97, P = 0.003). There was significantly greater improvement in early neurological function in the tenecteplase group than in the alteplase group (OR= 1.34, 95% CI: 1.11~1.63, Z=3.00, P =0.003). There were no significant differences in 90-day mRS scores between the two groups (mRS score =0-1, OR = 1.20, 95% CI: 0.99~1.46, z = 1.82, p = 0.07; mRS score =0-2, OR = 1.17, 95% CI: 0.94~1.45, z = 1.38, p = 0.17). However, the subgroup analysis showed that the 90-day mRS score of the 0.25 mg/kg tenecteplase group was significantly different from that of groups treated with other doses of tenecteplase (OR = 1.48, 95% CI: 1.01~2.03, z = 2.03, p = 0.04). (2) Safety: The incidences of any intracranial hemorrhage (OR = 0.91, 95% Ci: 0.55~1.49, z = 0.39, p = 0.70), symptomatic intracranial hemorrhage (OR = 1.21, 95% CI: 0.63~2.32, z = 0.56 P = 0.57), and mortality (OR = 0.85, 95% CI: 0.57~1.26, z = 0.82, p = 0.41) were not significantly different between the tenecteplase and alteplase groups. Conclusions: Tenecteplase can significantly increase the 24-hour vascular recanalization rate and improve the neurological prognosis of patients with acute ischemic stroke and it does not increase the risk of intracranial hemorrhage or mortality.

Abstract 234: Prior Warfarin Treatment and Intracranial Hemorrhage among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator: A Meta-analysis

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Huijuan Li ◽  
Ying Xian ◽  
Daniel Laskowitz ◽  
Eric Peterson
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
International Normalized Ratio ◽  
Bleeding Complications ◽  
Intravenous Tissue Plasminogen Activator ◽  
Increased Risk ◽  
Symptomatic Intracranial Hemorrhage ◽  
Risk For Bleeding

Background and Purpose: The risk for bleeding complications after intravenous thrombolysis for ischemic stroke in patients on warfarin with international normalized ratio [INR] ≤1.7) remains unclear. The aim of the current study is to perform a meta-analysis to determine whether there is an association between warfarin and risk of symptomatic intracranial hemorrhage (sICH). Methods: We searched MEDLINE, Web of Science and EBSCO databases for articles published through Jul 2012. A random-effects model was used to compute the pooled risk estimate. Results: Overall, 11 observational studies were identified that met our study inclusion criteria. This included 29,283 stroke participants treated with tPA; of which 2129 (7.3%) patients were on home warfarin prior treatment. Warfarin pretreatment was associated with an increased crude OR for symptomatic intracranial hemorrhage (sICH) (combined OR=1.77; 95% CI, 1.07~2.93;P=0.03).Of these studies, 7 studies had conducted a multivariate adjusted analyses, which demonstrated no association between warfarin use and increased risk of sICH following tPA use (combined adjusted OR=1.73; 95% CI, 0.91-3.28; p=0.10). Conclusions: These data suggested that the risk of sICH after thrombolytic therapy is not increased in patients using warfarin with sub therapeutic INR levels.

scholarly journals Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials

2021 ◽  
pp. neurintsurg-2021-017667
Author(s):  
Chun-Hsien Lin ◽  
Jeffrey L Saver ◽  
Bruce Ovbiagele ◽  
Wen-Yi Huang ◽  
Meng Lee
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Randomized Trials ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Risk Difference ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage

ObjectiveTo conduct a meta-analysis of randomized trials to comprehensively compare the effect of endovascular thrombectomy (EVT) versus intravenous thrombolysis (IVT) plus EVT on functional independence (modified Rankin Scale (mRS) 0–2) after acute ischemic stroke due to large vessel occlusions (AIS-LVO).MethodsWe searched Pubmed, EMBASE, CENTRAL, and clinicaltrials.gov from January 2000 to February 2021 and abstracts presented at the International Stroke Conference in March 2021 to identify trials comparing EVT alone versus IVT plus EVT in AIS-LVO. Five non-inferiority margins established in the literature were assessed: −15%, −10%, −6.5%, −5%, and −1.3% for the risk difference for functional independence at 90 days.ResultsFour trials met the selection criteria, enrolling 1633 individuals, with 817 participants randomly assigned to EVT alone and 816 to IVT plus EVT. Crude cumulative rates of 90-day functional independence were 46.0% with EVT alone versus 45.5% with IVT plus EVT. Pooled results showed the risk difference of functional independence was 1% (95% CI −4% to 5%) between EVT alone versus IVT plus EVT. The lower 95% CI bound of −4% fell within the non-inferiority margins of −15%, −10%, −6.5%, and −5%, but not −1.3%. Pooled results also showed the risk difference between EVT alone versus IVT plus EVT was 1% (95% CI −3% to 5%) for mRS 0–1, and 1% (95% CI −1% to 3%) for symptomatic intracranial hemorrhage.ConclusionsThis meta-analysis suggests that EVT alone is non-inferior to IVT plus EVT for several, but not the most stringent, non-inferiority margins.

scholarly journals Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke

Stroke ◽  
2022 ◽  
Author(s):  
Fouzi Bala ◽  
Ilaria Casetta ◽  
Stefania Nannoni ◽  
Darragh Herlihy ◽  
Mayank Goyal ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Early Time ◽  
Functional Independence ◽  
Late Time ◽  
Individual Patient Level ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: Sex-related differences exist in many aspects of acute stroke and were mainly investigated in the early time window with conflicting results. However, data regarding sex disparities in late presenters are scarce. Therefore, we sought to investigate differences in outcomes between women and men treated with endovascular treatment in the late time window. Methods: Analyses were based on the SOLSTICE Consortium (Selection of Late-Window Stroke for Thrombectomy by Imaging Collateral Extent), which was an individual-patient level analysis of seven trials and registries. Baseline characteristics, 90-day functional independence (modified Rankin Scale score ≤2), mortality, and symptomatic intracranial hemorrhage were compared between women and men. Effect of sex on the association of age and successful reperfusion (final Thrombolysis in Cerebral Infarction 2b–3) with outcomes was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, time from onset to puncture, occlusion location, intravenous thrombolysis, and successful reperfusion, with interaction terms. Results: Among 608 patients treated with endovascular treatment, 50.5% were women. Women were older than men (median age of 72 versus 68 years, P =0.02) and had a lower prevalence of tandem occlusions (14.0% versus 22.9%, P =0.005). Workflow times were similar between sexes. Adjusted outcomes did not differ between women and men. Functional independence at 90 days was achieved by 127 out of 292 women (43.5%) and 135 out of 291 men (46.4%). Mortality at 90 days (54 [18.5%] versus 48 [16.5%]) and symptomatic intracranial hemorrhage (37 [13.3%] versus 33 [11.6%]) were similar between women and men. There was no sex-by-age interaction on functional outcomes. However, men had higher likelihood of mortality ( P interaction =0.003) and symptomatic intracranial hemorrhage ( P interaction =0.017) with advancing age. Sex did not influence the relation between successful reperfusion and outcomes. Conclusions: In this multicenter analysis of late patients treated with endovascular treatment, sex was not associated with functional outcome. However, sex influenced the association between age and safety outcomes, with men experiencing worse outcomes with advancing age.

Abstract TP69: Association Between DWI-FLAIR Mismatch and Functional Outcomes in Patients Undergoing Mechanical Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Fumihiro Sakakibara ◽  
Kazutaka Uchida ◽  
Soichiro Numa ◽  
Shinichi Yoshimura ◽  
Takeshi Morimoto
Keyword(s):  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Vessel Occlusion ◽  
Ischemic Lesion ◽  
Historical Cohort ◽  
Good Marker ◽  
Fluid Attenuated Inversion Recovery ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: Diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch was well recognized as an early sign of acute ischemic stroke lesions. In the era of mechanical thrombectomy (MT), DWI-FLAIR mismatch could be a good marker for candidates of MT. We thus investigated the association between DWI-FLAIR mismatch and functional outcomes in patients who received MT for acute large vessel occlusion (LVO). Methods: We conducted historical cohort study in consecutive patients who were evaluated by MRI for suspected stroke at single stroke center. We enrolled patients with occlusion of the ICA or M1 or M2 segment of MCA who were underwent MT within 24 hours after the last known to be well. FLAIR negative was defined when a visible acute ischemic lesion was present on DWI without traceable parenchymal hyperintensity on FLAIR. We estimated the adjusted OR of FLAIR negative for moderate outcome defined as mRS 0-3 at 90 days after onset. We also estimated the adjusted OR for symptomatic intracranial hemorrhage within 72 hours and mortality at 90 days. Results: Among 380 patients who received MT for acute LVO, 202 patients were included in this study. Patients with FLAIR negative was 146 (72%), and the rest were FLAIR positive. Patients with FLAIR negative had significantly higher baseline NIHSS (median 16 vs 13, p=0.01), more transferred-in (78% vs 63%, p=0.02), more intravenous thrombolysis (IVT) (45% vs 18%, P=0.0003), more cardioembolism (69% vs 54%, p=0.03), and shorter times from the onset to hospital door (median 175 vs 371 minutes, p<0.0001). Patients with FLAIR negative had more moderate outcome than the counterparts (61% vs 52%, p=0.24). The adjusted OR of FLAIR negative compared to positive was 2.97 (95%CI, 1.33-6.60, p=0.008). Symptomatic intracranial hemorrhage within 72 hours was less frequent in the FLAIR negative group (10% vs 20%, p=0.06), with an adjusted OR of 0.34 (95%CI, 0.13-0.87, p=0.02). Conclusions: DWI-FLAIR mismatch was associated with better functional outcome in patients received MT for acute LVO at 90 days. DWI-FLAIR mismatch should be a good marker for the candidate of MT for acute LVO. Future randomized trial to evaluate the effectiveness of MRI-based MT using DWI-FLAIR mismatch should be considered.

Chronic kidney disease and intravenous thrombolysis in acute stroke: A systematic review and meta-analysis

2015 ◽  
Vol 358 (1-2) ◽  
pp. 345-350 ◽  
Author(s):  
Jin-Man Jung ◽  
Hyun Jung Kim ◽  
Hyeongsik Ahn ◽  
Il Min Ahn ◽  
Youngrok Do ◽  
...  
Keyword(s):  
Systematic Review ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Acute Stroke ◽  
Meta Analysis ◽  
Intravenous Thrombolysis

Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Georgios Tsivgoulis ◽  
Aristeidis H Katsanos ◽  
Jürgen Eggers ◽  
Vincent Larrue ◽  
Lars Thomassen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Safety And Efficacy

Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO. Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented. Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.

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