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

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.

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

2011 ◽  
Vol 2011 ◽  
pp. 1-3 ◽  
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).

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.

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

2016 ◽  
Vol 9 (4) ◽  
pp. 352-356 ◽  
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.

scholarly journals Intravenous Thrombolytic Treatment in the Oldest Old

2012 ◽  
Vol 2012 ◽  
pp. 1-7 ◽  
Author(s):  
Juan García-Caldentey ◽  
María Alonso de Leciñana ◽  
Patricia Simal ◽  
Blanca Fuentes ◽  
Gemma Reig ◽  
...  
Keyword(s):  
Intracranial Haemorrhage ◽  
Primary Outcome ◽  
Oldest Old ◽  
Demographic Data ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Thrombolytic Treatment ◽  
Old Patients ◽  
Nihss Score ◽  
Tissue Plasminogen

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.

Catch Plus thrombectomy device in acute stroke: initial evaluation

2016 ◽  
Vol 9 (12) ◽  
pp. 1214-1218 ◽  
Author(s):  
Ahmet Peker ◽  
Ethem Murat Arsava ◽  
Mehmet Akif Topçuoğlu ◽  
Anıl Arat
Keyword(s):  
Mechanical Thrombectomy ◽  
National Institutes Of Health ◽  
Initial Experience ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Thrombectomy Device ◽  
Baseline Characteristics ◽  
Mean Time

ObjectiveTo report our initial experience with the Catch Plus thrombectomy device (CPD) in patients with acute ischemic stroke (AIS).Materials and methodsWe retrospectively evaluated the procedural variables as well as the clinical and angiographic outcomes of patients with acute occlusion of a major intracranial artery in the anterior circulation who were treated with CPD at our center. Baseline characteristics (gender, age, comorbidities, cardiovascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and vessel occlusion sites) of these patients were recorded. Thrombolysis in Cerebral Infarction (TICI) score, incidence of symptomatic and asymptomatic bleeding, and 90 day modified Rankin Scale (mRS) scores were evaluated as indicators of outcome.Results38 patients with a mean age of 67.5 years were treated with CPD. Mean time from symptom onset to procedure initiation was 226.7 min. Recanalization (TICI 2b–3) was achieved in 27 patients (71.1%). The median NIHSS score on admission was 20. Rates of symptomatic and asymptomatic intracerebral hemorrhage were 7.9% and 13.2%, respectively. The 90 day clinical follow-up data were available for 37 patients. The 90 day mortality rate was 18.9%, and the 90 day clinically acceptable functional outcome (mRS score ≤2) rate was 43.2% (mRS score 0–3, 54.1%). Very distal thrombectomy involving the cortical arteries was performed on four patients without complications.ConclusionsOur initial experience suggests that mechanical thrombectomy with the CPD improves 90 day outcomes of patients with AIS by facilitating effective recanalization.

Management of tandem occlusion stroke with endovascular therapy

2012 ◽  
Vol 32 (5) ◽  
pp. E16 ◽  
Author(s):  
Haitham Dababneh ◽  
Waldo R. Guerrero ◽  
Anna Khanna ◽  
Brian L. Hoh ◽  
J Mocco
Keyword(s):  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
National Institutes Of Health ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Point Reduction ◽  
Mca Occlusion ◽  
Tandem Occlusion ◽  
Multimodality Approach ◽  
Extracranial Ica

Object Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant internal carotid artery (ICA) occlusion, and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. The authors report their experience with acute ischemic stroke patients who suffered tandem ICA/MCA (TIM) occlusions and underwent intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy. Methods In a retrospective analysis of their stroke database (2008–2011), the authors identified 2 patients with TIM occlusion treated with intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy. They examined early neurological improvement defined by a greater than 10-point reduction of National Institutes of Health Stroke Scale (NIHSS) score and an improved modified Rankin Scale (mRS) score at 60 days. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2 or 3 was also evaluated. Results In both patients a TICI score of 2b or 3 was achieved, signifying successful recanalization. In addition, both patients had a reduction in the NIHSS score by greater than 10 points and an mRS score of 0 at 60 days. Conclusions Tandem occlusions of the cervical ICA and MCA may be successfully treated using the multimodality approach of intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy.

scholarly journals Impact of the COVID-19 pandemic on emergency admission for patients with stroke: a time series study in Japan

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Takuaki Tani ◽  
Shinobu Imai ◽  
Kiyohide Fushimi
Keyword(s):  
Time Series ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Infection Prevalence ◽  
State Of Emergency ◽  
Hospitalised Patients ◽  
Number Of Patients ◽  
Significant Difference ◽  
Baseline Characteristics ◽  
The Impact

Abstract Background Appropriate treatment of stroke immediately after its onset contributes to the improved chances, while delay in hospitalisation affects stroke severity and fatality. This study aimed to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on emergency hospitalisation of patients with stroke in Japan. Methods This was an observational study that used nationwide administrative data of hospitalised patients diagnosed with stroke. We cross-sectionally observed patients’ background factors during April and May 2020, when the COVID-19 pandemic-related state of emergency was declared; we also observed these factors in the same period in 2019. We also modelled monthly trends in emergency stroke admissions, stroke admissions at each level of the Japan Coma Scale (JCS), fatalities within 24 h, stroke care unit use, intravenous thrombolysis administration, and mechanical thrombectomy implementation using interrupted time series (ITS) regression. Results There was no difference in patients’ pre-hospital baseline characteristics between the pre-pandemic and pandemic periods. However, ITS regression revealed a significant change in the number of emergency stroke admissions after the beginning of the pandemic (slope: risk ratio [RR] = 0.97, 95% confidence interval [CI]: 0.95–0.99, P = 0.027). There was a significant difference in the JCS score for impaired consciousness in emergency stroke, which was more severe during the pandemic than the pre-pandemic (JCS3 in level: RR = 1.75, 95% CI: 1.29–2.33, P < 0.001). There was no change in the total number of fatalities with COVID-19, compared with those without COVID-19, but there were significantly more fatalities within 24 h of admission (fatalities within 24 h: RR = 1.75, 95% CI: 1.29–2.33, P < 0.001). Conclusions The infection prevalence of COVID-19 increased the number of fatalities within 24 h as well as the severity of illness in Japan. However, there was no difference in baseline characteristics, intravenous thrombolysis administration, and mechanical thrombectomy implementation during the COVID-19 pandemic. A decrease in the number of patients and fatalities was observed from the time the state of emergency was declared until August, the period of this study.

scholarly journals Spinal epidural hematoma: an important stroke mimic

2013 ◽  
Vol 12 (1) ◽  
pp. 30-33
Author(s):  
James W. Schmidley ◽  
◽  
Sidney Mallenbaum ◽  
Kevin Broyles ◽  
◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Epidural Hematoma ◽  
Spinal Epidural Hematoma ◽  
Cervical Lesions ◽  
Stroke Patients ◽  
Acute Cerebral Ischemia ◽  
Tissue Plasminogen ◽  
Stroke Mimic ◽  
Acute Brain Ischemia ◽  
Spinal Epidural

Tissue plasminogen activator (tPA) is, on occasion, given to patients who do not suffer from acute cerebral ischemia. As the underlying conditions often mistaken for acute ischemic stroke tend to produce transient dysfunction, and are generally seen in individuals younger than stroke patients, the outcome of such mistaken treatment is generally benign. We will describe two elderly patients with acute hemiparesis caused by spinal epidural hematomas (SEDH), both of whom were initially considered candidates for tPA. The literature review and discussion will emphasize features allowing the distinction between these unusual hemiparetic presentations of SEDH and acute brain ischemia, and briefly review other cervical lesions that may rarely present with hemiparesis.

scholarly journals Enrollment bias: frequency and impact on patient selection in endovascular stroke trials

2015 ◽  
Vol 8 (4) ◽  
pp. 353-359 ◽  
Author(s):  
Sunil A Sheth ◽  
Jeffrey L Saver ◽  
Sidney Starkman ◽  
Ileana D Grunberg ◽  
Judy Guzy ◽  
...  
Keyword(s):  
First Generation ◽  
National Institutes Of Health ◽  
Stroke Therapy ◽  
Tertiary Referral Center ◽  
Prognostic Features ◽  
Intravenous Tissue Plasminogen Activator ◽  
Acute Cerebral Ischemia ◽  
Tissue Plasminogen ◽  
Scale Scores ◽  
Angiographic Data

BackgroundSelection bias may have affected enrollment in first generation endovascular stroke trials. We investigate, evaluate, and quantify such bias for these trials at our institution.MethodsDemographic, clinical, imaging, and angiographic data were prospectively collected on a consecutive cohort of patients with acute ischemic stroke who were enrolled in formal trials of endovascular stroke therapy (EST) or received EST in clinical practice outside of a randomized trial for acute cerebral ischemia at a single tertiary referral center from September 2004 to December 2012.ResultsAmong patients considered appropriate for EST in practice, 47% were eligible for trials, with rates for individual trials ranging from 17% to 70%. Compared with trial ineligible patients treated with EST, trial eligible patients were younger (67 vs 74 years; p<0.05), more often treated with intravenous tissue plasminogen activator (53% vs 34%; p<0.01), and had shorter last known well to puncture times (328 vs 367 min; p<0.05). Focusing on the largest trial with a non-interventional control arm, compared with trial eligible patients treated with EST outside the trial, enrolled patients presented later (274 vs 163 min; p<0.001), had higher National Institutes of Health Stroke Scale scores (20 vs 17; p<0.05), and larger strokes (diffusion weighted imaging volumes 49 vs 18; p<0.001).ConclusionsThe majority of patients felt suitable for EST at our institution were excluded from recent trials. Formal entry criteria succeeded in selecting patients with better prognostic features, although many of these patients were treated outside of trials. Acknowledging and mitigating these biases will be crucial to ongoing investigations.

scholarly journals Intravenous Thrombolysis for a Stroke Mimic Patient

2021 ◽  
pp. 704-709
Author(s):  
Lilly Nguyen ◽  
Joyce Hoonsuh Lee ◽  
Latha Ganti ◽  
Mark Rivera-Morales ◽  
Larissa Dub
Keyword(s):  
Cerebrovascular Disease ◽  
Acute Stroke ◽  
Plasminogen Activator ◽  
Young Woman ◽  
Intravenous Thrombolysis ◽  
Herbal Supplements ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Stroke Mimic

The authors present the case of a young woman on phentermine and herbal supplements who presented as an acute stroke alert with right-sided facial droop and numbness. She was treated acutely with intravenous tissue plasminogen activator (tPA). However, the workup did not reveal any evidence of cerebrovascular disease or cerebral infarct. The authors discuss plausible stroke mimics and the safety of administering tPA to such patients.

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