Safety and efficacy of low-dose alteplase in the treatment of acute ischemic stroke in Egyptian patients

Background: Neurointerventional procedures in acute ischemic stroke often require immediate antiplatelet therapy in the cases of acute stenting and occasionally re-occluding vessels. Intravenous cangrelor is a P2Y12 receptor antagonist with short onset and quick offset. The study objective was to evaluate the safety and efficacy of intravenous cangrelor in patients with acute ischemic stroke requiring urgent antiplatelet effect.Methods: Patients who received intravenous cangrelor intra-procedurally during acute ischemic stroke treatment were identified from a prospectively collected database. Cangrelor was administered as a bolus of 15 mcg/kg, followed by an infusion rate of 2 mcg/kg/min. A historical control group consisting of anterior circulation tandem occlusions was used to compare to patients with similar lesions who received intravenous cangrelor. Outcomes of interest included in-stent thrombosis, thromboembolic complications, intracranial hemorrhage, and functional outcomes at 90 days.Results: Twelve patients received intravenous cangrelor for acute ischemic stroke between October 2018 and April 2020 at a comprehensive stroke center. Eleven patients had intra or extracranial stenting performed, which included two posterior circulation lesions. No cases of symptomatic intracranial hemorrhage were reported. At 90 day follow-up, two patients had died and 10 had a good functional outcome. Patients with anterior circulation tandem occlusions who received cangrelor and those who received dual antiplatelets orally had similar radiographic and clinical outcomes.Conclusion: Low dose intravenous cangrelor is similar in safety and efficacy to oral antiplatelets in acute ischemic stroke in a small case series. Larger prospective studies on the efficacy, safety, and effect on procedure times of intravenous cangrelor in neurointervention are warranted.

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Pre-treatment of Single and Double Antiplatelet and Anticoagulant With Intravenous Thrombolysis for Older Adults With Acute Ischemic Stroke: The TTT-AIS Experience

Frontiers in Neurology ◽

10.3389/fneur.2021.628077 ◽

2021 ◽

Vol 12 ◽

Author(s):

Sheng-Feng Lin ◽

Han-Hwa Hu ◽

Bo-Lin Ho ◽

Chih-Hung Chen ◽

Lung Chan ◽

...

Keyword(s):

Older Adults ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Low Dose ◽

Standard Dose ◽

Intravenous Thrombolysis ◽

Safety And Efficacy ◽

Logistic Regression Models ◽

Symptomatic Intracranial Hemorrhage ◽

Pre Treatment

Background: This study aimed to investigate the safety and efficacy of single antiplatelet, anticoagulant and Dual Antiplatelet pre-treatment (DAPP) in older, moderate to high severity acute ischemic stroke patients treated with intravenous thrombolysis (IVT).Methods: A prospective cohort study was conducted to monitor the development of symptomatic intracranial hemorrhage (SICH) and functional outcomes at 90 days. Two different dosages of alteplase were used for IVT. Logistic regression models were used for analysis of the safety and efficacy outcomes.Results: A total of 1,156 patients were enrolled and categorized into six groups based on their pre-treatment medications: (1) aspirin (n = 213), (2) clopidogrel (n = 37), (3) DAPP of aspirin + clopidogrel (n= 27), (4) warfarin (n = 44), (5) any of the above pre-medications (n = 331), and (6) none of these medications as controls (n = 825). The DAPP group showed significantly increased SICH by the NINDS (adjusted OR: 4.90, 95% CI 1.28–18.69) and the ECASS II (adjusted OR: 5.09, 95% CI: 1.01–25.68) standards. The aspirin group was found to significantly improve the favorable functional outcome of the modified Rankin Scale (mRS) of 0–1 (adjusted OR: 1.91, 95% CI, 1.31.2.78), but no significance for mRS of 0–2 (adjusted OR: 1.39, 95% CI, 0.97–1.99). The DAPP group also significantly increased mortality (adjusted OR: 4.75, 95% CI: 1.77–12.72). A significant interaction between different dosages for IVT and the functional status was noted. Compared to standard dose, the DAPP group showed higher proportions of disability and mortality with low dose of IVT.Conclusion: For older adults with higher baseline severity of acute ischemic stroke, DAPP may increase the risk of SICH and mortality post IVT. However, DAPP is still not an indication to withdraw IVT and to prescribe low-dose IVT for older adults.

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Low dose concomitant treatment with chlorpromazine and promethazine is safe in acute ischemic stroke

Journal of Neurosurgical Sciences ◽

10.23736/s0390-5616.19.04665-4 ◽

2019 ◽

Vol 63 (3) ◽

Author(s):

Haomeng Zhu ◽

Ankush Chandra ◽

Xiaokun Geng ◽

Zhe Cheng ◽

Yanna Tong ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Low Dose ◽

Concomitant Treatment

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Faculty Opinions recommendation of Low-Dose versus Standard-Dose Intravenous Alteplase in Acute Ischemic Stroke.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.726345307.793530194 ◽

2017 ◽

Author(s):

Shyam Prabhakaran

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Low Dose ◽

Standard Dose ◽

Intravenous Alteplase

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Association between MEG3 polymorphisms (rs941576 and rs7158663) and risk of acute ischemic stroke in Egyptian patients

Gene Reports ◽

10.1016/j.genrep.2021.101286 ◽

2021 ◽

pp. 101286

Author(s):

Olfat Shaker ◽

Wafaa Sroor ◽

Ola Ali ◽

Hanan Soliman ◽

Marwa Abdeen

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Egyptian Patients

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Comparative Analysis on Low- and Standard-Dose Regimes of Alteplase Thrombolytic Therapy for Acute Ischemic Stroke: Efficacy and Safety

European Neurology ◽

10.1159/000485460 ◽

2017 ◽

Vol 79 (1-2) ◽

pp. 68-73 ◽

Cited By ~ 2

Author(s):

Guangjian Zhao ◽

Tingfen Huang ◽

Mei Zheng ◽

Yansen Cui ◽

Yunyong Liu ◽

...

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Dose Group ◽

Low Dose ◽

Standard Dose ◽

Efficacy And Safety ◽

Significant Difference ◽

Symptomatic Intracranial Hemorrhage ◽

Intravenous Alteplase

Objective: This study analyzed the efficacy and safety of low-dose and standard-dose alteplase intravenous thrombolytic therapy for acute ischemic stroke (AIS). Methods: Patients with AIS who underwent intravenous alteplase thrombolysis from July 2012 to December 2016 were retrospectively analyzed and correspondingly divided into low-dose (0.6–0.89 mg/kg) group and standard-dose group (0.9 mg/kg) according to alteplase dosage. The clinical outcome was evaluated by modified Rankin Scale (mRS) at 90 days after onset. The safety index was the mortality at 90 days after onset and the incidence of symptomatic intracranial hemorrhage (SICH) within 7 days. Results: A total of 1,486 patients were included (1,115 cases in low-dose group and 371 cases in standard-dose group). There were no significant differences in baseline data between the 2 groups. As mRS, good outcome rate as well as mortality rate in both groups had no significant difference (36.1 vs. 37.6%; χ2 = 10.882, p = 0.890; 5.5 vs. 7.3%; χ2 = 2.163, p = 0.076), but the incidence of SICH in low-dose group was significantly lower than that of the standard-dose group (2.2 vs. 5.9%; χ2 = 3.157, p = 0.001). Conclusion: The efficacy of low-dose alteplase intravenous thrombolytic therapy for AIS was equivalent to the standard-dose regimen but with higher safety.

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Abstract T P48: Intravenous Thrombolysis Using Low-Dose Alteplase for Nonagenarians with Acute Ischemic Stroke: The SAMURAI rtPA Registry

Stroke ◽

10.1161/str.45.suppl_1.tp48 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mikito Hayakawa ◽

Masatoshi Koga ◽

Shoichiro Sato ◽

Shoji Arihiro ◽

Yoshiaki Shiokawa ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Low Dose ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Efficacy And Safety ◽

Multivariate Adjustment ◽

Potential Efficacy ◽

Symptomatic Intracranial Hemorrhage ◽

Baseline Characteristics

Objective: Although intravenous thrombolysis (IVT) using alteplase for octogenarians with acute ischemic stroke becomes relatively familiar, it is unclear whether IVT for nonagenarians is a futile intervention. The purpose of this study is to clarify the efficacy and safety of IVT using low-dose alteplase (0.6 mg/kg) for nonagenarians compared with octogenarians. Methods: Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI) rtPA registry retrospectively collected 600 consecutive acute stroke patients receiving IVT from 10 Japanese stroke centers between October 2005 and July 2008. We extracted all octogenarians (O group) and nonagenarians (N group) from the registry. We compared baseline characteristics, symptomatic intracranial hemorrhage (SICH), and 3-month outcomes between the groups. 3-month outcomes include; functional independence (FI) defined as a mRS score 0-2, good outcome (GO) as a mRS score 0-2 or same as the premorbid mRS, poor outcome (PO) defined as a mRS score 5-6, and death. Results: Twenty-five nonagenarians (mean age, 93 years) and 124 octogenarians (mean age, 84 years) were included. N group was more female-predominant (76% versus 56%, p=0.06) and premorbidly dependent (44% versus 14%, p<0.001) than O group. There were no significant differences of median baseline NIHSS score (16 versus 14, p=0.95) and Alberta Stroke Program Early CT Score (9 versus 9, p=0.36) between the groups. The rate of FI tended to be lower in N group than O group (16% versus 36%, p=0.06), otherwise, the differences of the rates of GO (28% versus 37%, p=0.39), PO (40% versus 36%, p=0.73), death (20% versus 11%, p=0.23) and SICH (0% versus 2.4%, p=1.00) were not significant between the groups. In comparison with O group, N group was not associated with 3-month clinical outcomes (FI; OR 0.61; 95% CI, 0.15-2.42, GO; 0.98; 0.31-3.07, PO; 0.63; 0.15-2.70, death; 3.18; 0.62-16.3) and SICH (0.68; 0.17-2.69) after multivariate adjustment. Conclusions: IVT using low-dose alteplase for N group resulted in less frequent achievement of FI mainly because of more premorbid dependency than O group, however, showed at least a similar safety and a potential efficacy.

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Safety and efficacy of mechanical thrombectomy in acute ischemic stroke of anticoagulated patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013714 ◽

2018 ◽

Vol 10 (12) ◽

pp. e29-e29 ◽

Cited By ~ 10

Author(s):

Vincent L’Allinec ◽

Marielle Ernst ◽

Mathieu Sevin-Allouet ◽

Nathalie Testard ◽

Béatrice Delasalle-Guyomarch ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Mechanical Thrombectomy ◽

Univariate Analysis ◽

Recombinant Tissue Plasminogen Activator ◽

Reperfusion Therapy ◽

Safety And Efficacy ◽

Risk Of Death ◽

Anticoagulated Patients

BackgroundAnticoagulated patients (APs) are currently excluded from acute ischemic stroke reperfusion therapy with intravenous recombinant tissue plasminogen activator (IV-rtPA); however, these patients could benefit from mechanical thrombectomy (MT). Evidence for MT in this condition remains scarce. The aim of this study was to analyze the safety and efficacy of MT in APs.MethodsWe analyzed three patient groups from two prospective registries: APs with MT (AP-MT group), non-anticoagulated patients treated with MT (NAP-MT group), and non-anticoagulated patients treated with IV-rtPA and MT (NAP-IVTMT group). Univariate and multivariate logistic regression were used to evaluate treatment efficacy with modified Rankin Scale (mRS) ≤2 and safety (radiologic intracranial hemorrhage (rICH), symptomatic intracranial hemorrhage (sICH) and death rate at 3 months) between groups.Results333 patients were included in the study, with 44 (12%) in the AP-MT group, 105 (31%) in the NAP-MT group, and 188 (57%) in the NAP-IVTMT group. Univariate analysis showed that the AP-MT group was older (P<0.001), more often had atrial fibrillation (P<0001), and had a higher ASPECTS (P<0.006 and P<0.002) compared with the NAP-MT group and NAP-IVTMT groups, respectively. Multivariate analysis showed that the AP-MT group had a lower risk of rICH (OR 2.77, 95% CI 1.01 to 7.61, P=0.05) but a higher risk of death at 3 months (OR 0.26, 95% CI 0.09 to 0.76, P=0.01) compared with the NAP-IVTMT group. No difference was found between the AP-MT and NAP-MT groups.ConclusionsWith regard to intracranial bleeding and functional outcome at 3 months, MT in APs seems as safe and efficient as in NAPs. However, there is a higher risk of death at 3 months in the AP-MT group compared with the NAP-IVTMT group.

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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 ◽

10.1161/str.48.suppl_1.tmp25 ◽

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.

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