EPILEPTIC MANIFESTATIONS IN STROKE PATIENTS TREATED WITH INTRAVENOUS ALTEPLASE

Introduction: Stroke thrombectomy devices and the experience of neurointerventionists have improved significantly over the last few years making targeting distal occlusions such as of the M2 segment of the middle cerebral artery more feasible. We aimed to study the trend in the successful first pass (SFP) of M2 occlusions over time using the data from a contemporary multicenter registry. Methods: We reviewed the data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which included data from 11 thrombectomy-capable stroke centers to identify stroke patients who underwent mechanical thrombectomy of M2 segment occlusion. SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single thrombectomy device pass. We analyzed the linear trendline of the rate of SFP over time. Then, we used a logistic regression model to assess predictors of SFP of M2 segment occlusion. Results: We included 401 patients who underwent stroke thrombectomy of M2 occlusion; median age was 71 (IQR 60-80), 212 (52.9%) were females, 174 (43.4%) were white, National Institute of Health stroke scale (NIHSS) was 14 (IQR 8-19), Alberta Stroke Program Early CT (ASPECT) score on presentation was 9 (IQR 7-10) and onset wot groin time was 287 (IQR 181-454). SFP was achieved in 118 (29.4%) patients (linear trendline over time is in Figure 1). Presenting after 2014 was an independent predictor of SFP (OR 1.9, 95% CI 1.1-3.2, P=0.019) after controlling for age, sex, NIHSS on presentation, intravenous alteplase (IV-tPA), and onset to groin time. Conclusion: SFP rate of M2 segment occlusion has increased after 2014 likely secondary the improvement in stroke thrombectomy devices and neurointerventionists experience.

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Safety and efficacy of intravenous thrombolysis in stroke patients on prior antiplatelet therapy in the WAKE-UP trial

Neurological Research and Practice ◽

10.1186/s42466-020-00087-9 ◽

2020 ◽

Vol 2 (1) ◽

Author(s):

Benedikt M. Frey ◽

◽

Florent Boutitie ◽

Bastian Cheng ◽

Tae-Hee Cho ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Intravenous Thrombolysis ◽

Hemorrhagic Transformation ◽

Favorable Outcome ◽

Stroke Patients ◽

Antiplatelet Treatment ◽

Safety And Efficacy ◽

History Of ◽

Intravenous Alteplase

Abstract Background One quarter to one third of patients eligible for systemic thrombolysis are on antiplatelet therapy at presentation. In this study, we aimed to assess the safety and efficacy of intravenous thrombolysis in stroke patients on prescribed antiplatelet therapy in the WAKE-UP trial. Methods WAKE-UP was a multicenter, randomized, double-blind, placebo-controlled clinical trial to study the efficacy and safety of MRI-guided intravenous thrombolysis with alteplase in patients with an acute stroke of unknown onset time. The medication history of all patients randomized in the WAKE-UP trial was documented. The primary safety outcome was any sign of hemorrhagic transformation on follow-up MRI. The primary efficacy outcome was favorable functional outcome defined by a score of 0–1 on the modified Rankin scale at 90 days after stroke, adjusted for age and baseline stroke severity. Logistic regression models were fitted to study the association of prior antiplatelet treatment with outcome and treatment effect of intravenous alteplase. Results Of 503 randomized patients, 164 (32.6%) were on antiplatelet treatment. Patients on antiplatelet treatment were older (70.3 vs. 62.8 years, p < 0.001), and more frequently had a history of hypertension, atrial fibrillation, diabetes, hypercholesterolemia, and previous stroke or transient ischaemic attack. Rates of symptomatic intracranial hemorrhage and hemorrhagic transformation on follow-up imaging did not differ between patients with and without antiplatelet treatment. Patients on prior antiplatelet treatment were less likely to achieve a favorable outcome (37.3% vs. 52.6%, p = 0.014), but there was no interaction of prior antiplatelet treatment with intravenous alteplase concerning favorable outcome (p = 0.355). Intravenous alteplase was associated with higher rates of favorable outcome in patients on prior antiplatelet treatment with an adjusted odds ratio of 2.106 (95% CI 1.047–4.236). Conclusions Treatment benefit of intravenous alteplase and rates of post-treatment hemorrhagic transformation were not modified by prior antiplatelet intake among MRI-selected patients with unknown onset stroke. Worse functional outcome in patients on antiplatelets may result from a higher load of cardiovascular co-morbidities in these patients.

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Epileptic manifestations in stroke patients treated with intravenous alteplase

European Journal of Neurology ◽

10.1111/ene.13292 ◽

2017 ◽

Vol 24 (6) ◽

pp. 755-761 ◽

Cited By ~ 20

Author(s):

C. Bentes ◽

H. Martins ◽

A. R. Peralta ◽

C. Morgado ◽

C. Casimiro ◽

...

Keyword(s):

Stroke Patients ◽

Intravenous Alteplase

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Orolingual angioedema following intravenous alteplase therapy for stroke patients treated with angiotensin converting enzyme (ACE) inhibitor: Case report

Nosotchu ◽

10.3995/jstroke.10373 ◽

2016 ◽

Vol 38 (3) ◽

pp. 173-175

Author(s):

Masakazu Sano ◽

Shinya Yamashita ◽

Toyotaka Aiba

Keyword(s):

Case Report ◽

Angiotensin Converting Enzyme ◽

Ace Inhibitor ◽

Converting Enzyme ◽

Stroke Patients ◽

Intravenous Alteplase

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Influence of recent direct-to-EVT trials on practical decision-making for the treatment of acute ischemic stroke patients

Interventional Neuroradiology ◽

10.1177/15910199211057984 ◽

2021 ◽

pp. 159101992110579

Author(s):

Rosalie McDonough ◽

Johanna Ospel ◽

Nima Kashani ◽

Manon Kappelhof ◽

Jianmin Liu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Treatment Strategies ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Randomized Controlled ◽

Intravenous Alteplase ◽

Short Time ◽

Current Guidelines

Background Current guidelines recommend that eligible acute ischemic stroke (AIS) patients receive intravenous alteplase (IVT) prior to endovascular treatment (EVT). Six randomized controlled trials recently sought to determine the risks of administering IVT prior to EVT, five of which have been published/presented. It is unclear whether and how the results of these trials will change guidelines. With the DEBATE survey, we assessed the influence of the recent trials on physicians’ IVT treatment strategies in the setting of EVT for large vessel occlusion (LVO) stroke. Methods Participants were provided with 15 direct-to-mothership case-scenarios of LVO stroke patients and asked whether they would treat with IVT + EVT or EVT alone, a) before publication/presentation of the direct-to-EVT trials, and b) now (knowing the trial results). Logistic regression clustered by respondent was performed to assess factors influencing the decision to adopt an EVT-alone paradigm after publication/presentation of the trial results. Results 289 participants from 37 countries provided 4335 responses, of which 13.5% (584/4335) changed from an IVT + EVT strategy to EVT alone after knowing the trial results. Very few switched from EVT alone to IVT + EVT (8/4335, 0.18%). Scenarios involving a long thrombus (RR 1.88, 95%CI:1.56–2.26), cerebral micro-hemorrhages (RR 1.78, 95%CI:1.43–2.23), and an expected short time to recanalization (RR 1.46 95%CI:1.19–1.78) had the highest chance of participants switching to an EVT-only strategy. Conclusion In light of the recent direct-to-EVT trials, a sizeable proportion of stroke physicians appears to be rethinking IVT treatment strategies of EVT-eligible mothership patients with AIS due to LVO in specific situations.

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Abstract MP6: Thrombolysis for Acute Wake-Up And Unclear Onset Strokes With Alteplase at 0.6mg /kg in Clinical Practice: THAWS2 Study

Stroke ◽

10.1161/str.52.suppl_1.mp6 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Sohei Yoshimura ◽

Masatoshi Koga ◽

Takashi Okada ◽

Manabu Inoue ◽

Kaori Miwa ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Mechanical Thrombectomy ◽

Randomized Control Trials ◽

Stroke Patients ◽

Vessel Occlusion ◽

Acute Hospitalization ◽

Multicenter Observational Study ◽

Intravenous Alteplase ◽

Randomized Control

Background and Purpose: IV alteplase at 0.6 mg/kg for acute wake-up and unclear onset strokes was recommended in Japanese stroke guidelines in March 2019. We determined the safety and effectiveness of this newly recommended thrombolysis in clinical practice. Methods: This is a multicenter observational study, enrolling acute ischemic stroke patients with a time last-known-well >4.5 h who have a mismatch between DWI and FLAIR treated with intravenous alteplase. The safety outcomes are intracranial hemorrhage (ICH) with neurological deterioration within 36 h after thrombolysis, all cause deaths within 90 days, and adverse events. The efficacy outcomes are functionally independence defined as a mRS score of 0-1 at 90 days, and NIHSS change at 24h from baseline. Results: Between 2019 March and 2020 March, 63 patients (33 females; age, 74±11y; premorbid functionally independence, 50 (82%); median NIHSS on admission, 11) were enrolled at 14 hospitals. Of them, 40 patients (63%) recognized stroke symptoms at wake-up time, and median time between last-known-well and admission was 6.5 h. Baseline MRA showed any vessel occlusion in 52 patients (88%). IV alteplase was disrupted in one patient. Two patients (3%) had symptomatic ICH (≥4 increase in NIHSS) within 36 h. NIHSS change was -5.1±8.1. Twenty-one patients (36%) had functionally independence at discharge and there was no death during acute hospitalization. Of the overall 63 patients, 22 also underwent mechanical thrombectomy (36%, 72±9y, median NIHSS 16), showing no symptomatic ICH, mean NIHSS change of -8.9±7.5, and 8 patients (42%) had functionally independence at discharge. Conclusions: In clinical practice, IV alteplase for wake-up and unclear onset stroke patients with DWI-FLAIR mismatch seemed to be safe and effective compared with previous randomized control trials. Mechanical thrombectomy could be combined with alteplase safely and effectively.

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Telemedicine for Evaluation of Stroke Patients

Acute Stroke Management in the First 24 Hours ◽

10.1093/med/9780190856519.003.0007 ◽

2018 ◽

pp. 118-127

Author(s):

Kaustubh Limaye ◽

Lawrence R. Wechsler

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Video Communication ◽

Legal Issues ◽

Comprehensive Care ◽

Stroke Patients ◽

Endovascular Thrombectomy ◽

Intravenous Alteplase

Telemedicine uses video communication to evaluate patients at an originating site by a distant physician. Telestroke was developed to apply telemedicine for the delivery of stroke expertise to hospitals with limited or no available stroke capability. This chapter reviews the most commonly used models of telestroke networks. It discusses the evidence for telestroke, including its value in managing patients with ischemic stroke who are candidates for intravenous alteplase and endovascular thrombectomy, as well as patients with intracerebral hemorrhage. Economic, legislative, and legal issues of treating patients within a telestroke network are also reviewed. Future advances in telemedicine will continue to deliver expert care in a way that brings comprehensive care to patient’s doorstep.

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