scholarly journals Mechanical Thrombectomy With and Without Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Using Nested Knowledge

2021 ◽  
Vol 12 ◽  
Author(s):  
Gautam Adusumilli ◽  
John M. Pederson ◽  
Nicole Hardy ◽  
Kevin M. Kallmes ◽  
Kristen Hutchison ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: Mechanical thrombectomy (MT) is now the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation and may be performed irrespective of intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure. This study aims to understand better if tPA leads to higher rates of reperfusion and improves functional outcomes in AIS patients after MT and to simultaneously evaluate the functionality and efficiency of a novel semi-automated systematic review platform.Methods: The Nested Knowledge AutoLit semi-automated systematic review platform was utilized to identify randomized control trials published between 2010 and 2021 reporting the use of mechanical thrombectomy and IV-tPA (MT+tPA) vs. MT alone for AIS treatment. The primary outcome was the rate of successful recanalization, defined as thrombolysis in cerebral infarction (TICI) scores ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS) 0–2, 90-day mortality, distal embolization to new territory, and symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure.Results: We subjectively found Nested Knowledge to be highly streamlined and effective at sourcing the correct literature. Four studies with 1,633 patients, 816 in the MT+tPA arm and 817 in the MT arm, were included in the meta-analysis. In each study, patient populations consisted of only tPA-eligible patients and all imaging and clinical outcomes were adjudicated by an independent and blinded core laboratory. Compared to MT alone, patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10; 1.63]). However, there were no statistically significant differences in the rates of 90-day mRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67; 1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI: 0.80; 1.72]).Conclusions: Administering tPA prior to MT may improve the rates of recanalization compared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in this review. Further studies looking at the role of tPA before mechanical thrombectomy in different cohorts of patients could better clarify the role of tPA in the treatment protocol for AIS.

scholarly journals Medicolegal Considerations with Intravenous Tissue Plasminogen Activator in Stroke: A Systematic Review

2013 ◽  
Vol 2013 ◽  
pp. 1-6 ◽  
Author(s):  
Archit Bhatt ◽  
Adnan Safdar ◽  
Dhara Chaudhari ◽  
Diane Clark ◽  
Amber Pollak ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Malpractice Litigation ◽  
Extensive Search ◽  
Intravenous Tissue Plasminogen Activator ◽  
Increased Risk ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background.Intravenous tPA (tissue plasminogen activator) therapy remains underutilized in patients with Acute Ischemic Stroke (AIS). Anecdotal data indicates that physicians are increasingly liable for administering and for failure to administer tPA.Methods.An extensive search of Medline, Embase, Westlaw, LexisNexis Legal, and Google Scholar databases was performed. Case studies that involved malpractice litigation in ischemic stroke and thrombolytic therapy were analyzed systematically.Results.We identified 789 ischemic stroke litigation cases, of which 46 cases were related to intravenous tPA and stroke litigation. Case descriptions of 40 cases were available. Data for verdicts were available for 38 patients. The most frequent plaintiff claim was related to failure to administer intravenous tPA (38, 95%). Only 2 (5.0%) claim involved complications of treatment with tPA. Hospitals were defendants in majority of the 36 cases. Physicians were involved in 33 cases. While ED physicians were involved in 25 (60.52%) cases, neurologists were involved in 8 (20.0%) cases. There were 26 (65%) defendant-favored and 12 (30%) plaintiff-favored verdicts.Conclusion.Physicians and hospitals are at an increased risk of litigation in patients with AIS when in IV-tPA is being considered for treatment. While majority of the cases litigated were cases where tPA was not administered, only about 1 in 20 cases was litigated when complications occurred.

scholarly journals Imaging Evidence for Cerebral Hyperperfusion Syndrome after Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

2016 ◽  
Vol 2016 ◽  
pp. 1-5
Author(s):  
Yi Zhang ◽  
Abhay Kumar ◽  
John B. Tezel ◽  
Yihua Zhou
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Cerebral Hyperperfusion Syndrome ◽  
Hyperperfusion Syndrome ◽  
Cerebral Hyperperfusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background. Cerebral hyperperfusion syndrome (CHS), a rare complication after cerebral revascularization, is a well-described phenomenon after carotid endarterectomy or carotid artery stenting. However, the imaging evidence of CHS after intravenous tissue plasminogen activator (iv tPA) for acute ischemic stroke (AIS) has not been reported.Case Report. Four patients were determined to have manifestations of CHS with clinical deterioration after treatment with iv tPA, including one patient who developed seizure, one patient who had a deviation of the eyes toward lesion with worsened mental status, and two patients who developed worsened hemiparesis. In all four patients, postthrombolysis head CT examinations were negative for hemorrhage; CT angiogram showed patent cervical and intracranial arterial vasculature; CT perfusion imaging revealed hyperperfusion with increased relative cerebral blood flow and relative cerebral blood volume and decreased mean transit time along with decreased time to peak in the clinically related artery territory. Vascular dilation was also noted in three of these four cases.Conclusions. CHS should be considered in patients with clinical deterioration after iv tPA and imaging negative for hemorrhage. Cerebral angiogram and perfusion studies can be useful in diagnosing CHS thereby helping with further management.

Abstract T P14: Multi-modality Treatment of Acute Ischemic Strokes Improves Patient Outcome at Discharge vs Intravenous Tissue Plasminogen Activator

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Haitham Dababneh ◽  
Asif Bashir ◽  
Mohammed Hussain ◽  
Sara Misthal ◽  
Mohammad Moussavi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Group Analysis ◽  
Treatment Modalities ◽  
Poor Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background and Purpose: Since the introduction of Intravenous Tissue Plasminogen Activator (IV tPA) and mechanical thrombectomy, the management of acute ischemic stroke has advanced. The objective of this analysis is to compare treatment modalities and the outcome among stroke patients. Methods: This is a retrospective analysis of all patients (n=142) that presented to our hospital with ischemic stroke and received treatment between January 2009 and July 2012. We divided the patients into two groups based on the treatment they received: A) patients received only IV tPA B) patients received both IV tPA and mechanical thrombectomy. Analysis of variance was used to compare the difference of the means between the two groups. Uni- and multivariate logistic regression models were used to compare the association of different treatment modalities with the modified rankin scale (mRS) at discharge. Discharge status was dichotomized based on an mRS greater than 2 as a poor outcome. Multivariate models were created adjusting for age, gender, NIHSS, hypertension (HTN), diabetes mellitus (DM), and hyperlipidemia (HLD). All measurements were done using the SAS software version 9.2. Results: Group analysis including n, gender, mean age, mean NIHSS and mortality at discharge was as follows: A) 104, 50% female, 73±14, 12±7, 6.73% B) 38, 50% female, 71±14, 18±7, 7.89%. When controlling for age, gender, DM, HTN, and HLD, patients in group B had a better outcome than group A (OR 0.3, 95% CI, 0.09-0.96) despite presenting with a worse NIHSS. There was no difference in mortality between the two groups. There was a significant association between NIHSS at admission and mRS at discharge (OR 1.2, 95% CI, 1.13-1.29). There was also a significant association between having DM and a poor outcome (OR 3.94, 95% CI, 1.37-11.37). Conclusion: In our patient subset, multi-modality treatment of acute stroke is safe and associated with a better clinical outcome than IV tPA alone at discharge. Further prospective studies are needed to corroborate our findings.

Systemic Inflammation Indices in Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator: Clinical Yield and Utility

Angiology ◽  
2020 ◽  
pp. 000331972096999
Author(s):  
Mehmet Akif Topcuoglu ◽  
Mehmet Yasir Pektezel ◽  
Ezgi Yilmaz ◽  
Ethem Murat Arsava
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Clinical Utility ◽  
Lymphocyte Ratio ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Immune Inflammation ◽  
Iv Tpa

Inflammation indices derived from complete blood counts (CBCs) have been proposed to estimate benefit and risk of intravenous (IV) tissue plasminogen activator (tPA) in acute ischemic stroke. In 165 acute ischemic patients, the neutrophil-to-lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio, and systemic immune-inflammation index (SII) were calculated before and 24 hours after IV tPA. The area under receiver operating characteristic (AUC-ROC) curves, and positive and negative likelihood ratios (+LR,−LR) were produced to measure their diagnostic accuracy and clinical utility for tPA effectiveness, hemorrhage risk and third-month prognosis. None of the indices obtained “before” IV-tPA was found to be useful in determining acute and long-term functional efficacy and bleeding risk. Lymphocyte decrease, neutrophil increase, and parallel NLR and SII increase at the 24th-hour were associated with poor functional outcome. However, their clinical utility was not sufficient due to absence of effective thresholds. NLR threshold >5.65 provided ROC-AUC 0.86, sensitivity 71.3%, specificity 65.7%, −LR 0, +LR 3.76, and SII threshold >1781 had ROC-AUC 0.802, sensitivity 58.7%, specificity 72.7%, −LR 0.11, +LR 4.52, corresponding to an acceptable clinical yield. Systemic immune-inflammation index and NLR, but not other CBC-derived inflammatory parameters, have moderate utility as marker of tPA-related symptomatic hemorrhage occurrence.

Abstract WP242: A Drill Down Analysis of Door-to-Needle Time of Acute Ischemic Stroke Patients Treated with Intravenous Tissue Plasminogen Activator

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Marija Lum ◽  
Jon Schrock
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Symptom Onset ◽  
Demographic Data ◽  
Head Ct ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: Target stroke guidelines recommend a door-to-needle time (DNT) ≤60 minutes for acute ischemic stroke (AIS) patients treated with tissue plasminogen activator (tPA). Research has shown that <30% of patients achieve this goal. It is unclear how the timing of chest radiography (CXR) and electrocardiography (EKG) affect DNT. We studied all steps involved in the evaluation and treatment of AIS with IV tPA to look for causes of delay. Methods: A retrospective review of all AIS patients treated in the ED with IV tPA over a four year period was performed. Transferred patients were excluded. Times comparing intervals from door to head CT, CT result, EKG, CXR, and IV tPA treatment, were evaluated. Demographic data and length of symptom onset were recorded. Non-modifiable delays in treatment were recorded. Data are presented in minutes (min) as medians with interquartile range and χ 2 testing was used as appropriate. Results: A total of 79 AIS patients met inclusion criteria, with 22 (28%) receiving IV tPA ≤60 minutes. Treatment with tPA in ≤60 minutes was significantly greater if symptom onset was >90 minutes (p<0.05) and if the EKG was done after the head CT (p<0.05). There was a change in median CT times with those who received EKG before CT and those who did not, 23 min (15-36 min) and 17 min (10-24min), respectively. Patients who received a CXR before CT had a median CT time of 32 min (21-38min) compared to 19 min (13-27min) for patients who did not. Unavoidable delays related to trauma, intubation, or delayed familial consent occurred in 7 (9%) patients. Post-tPA hemorrhage occurred in 13 (16%) patients. Eight (10%) patients expired. Conclusion: Non-critical studies performed prior to head CT increase DNT. An EKG performed before the head CT is completed increased CT time by 6 minutes and a CXR obtained before the head CT increased CT time by 13 minutes. Physician urgency is also a critical factor in DNT and is diminished in patients who arrive soon after symptom onset. DNT ≤60 minutes for AIS patients are affected by the level of urgency and order of diagnostic studies. Current primary stroke center recommendations of an EKG and CXR within 45 minutes may result in delayed treatment if these studies are performed before the head CT.

scholarly journals Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Hubert Lee ◽  
Ayman M. Qureshi ◽  
Nils H. Mueller-Kronast ◽  
Osama O. Zaidat ◽  
Michael T. Froehler ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Systematic Evaluation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature.Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol.Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75–6.63], p &lt; 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09–1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26–0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0–2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51–7.34%, I2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]).Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.

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