scholarly journals Thrombolysis in Acute Stroke

2021 ◽  
Author(s):  
Mustafa Çetiner
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Clinical Findings ◽  
Stroke Patients ◽  
Acute Ischemic Stroke Patient ◽  
Patient Selection Criteria ◽  
Neuroimaging Techniques

The first step in stroke care is early detection of stroke patients and recanalization of the occluded vessel. Rapid and effective revascularization is the cornerstone of acute ischemic stroke management. Intravenous thrombolysis is the only approved pharmacological reperfusion therapy for patients with acute ischemic stroke. Patient selection criteria based on patient characteristics, time, clinical findings and advanced neuroimaging techniques have positively affected treatment outcomes. Recent studies show that the presence of salvageable brain tissue can extend the treatment window for intravenous thrombolysis and that these patients can be treated safely. Recent evidence provides stronger support for another thrombolytic agent, tenecteplase, as an alternative to alteplase. Endovascular thrombectomy is not a contraindication for intravenous thrombolysis. Evidence shows that the bridging approach provides better clinical outcomes. It is seen that intravenous thrombolysis is beneficial in stroke patients, whose symptom onset is not known, after the presence of penumbra tissue is revealed by advanced neuroimaging techniques. Reperfusion therapy with intravenous thrombolysis is beneficial in selected pregnant stroke patients. Pregnancy should not be an absolute contraindication for thrombolysis therapy. This chapter aims to review only the current evaluation of intravenous thrombolytic therapy, one of the reperfusion therapies applied in the acute phase of stroke.

scholarly journals Early NT-ProBNP (N-Terminal Probrain Natriuretic Peptide) Elevation Predicts Malignant Edema and Death After Reperfusion Therapy in Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Author(s):  
Xuting Zhang ◽  
Shenqiang Yan ◽  
Wansi Zhong ◽  
Yannan Yu ◽  
Min Lou
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Natriuretic Peptide ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
Median Serum ◽  
The Relationship

Background and Purpose: We aimed to investigate the relationship between early NT-proBNP (N-terminal probrain natriuretic peptide) and all-cause death in patients receiving reperfusion therapy, including intravenous thrombolysis and endovascular thrombectomy (EVT). Methods: This study included 1039 acute ischemic stroke patients with early NT-proBNP data at 2 hours after the beginning of alteplase infusion for those with intravenous thrombolysis only or immediately at the end of EVT for those with EVT. We performed natural log transformation for NT-proBNP (Ln(NT-proBNP)). Malignant brain edema was ascertained by using the SITS-MOST (Safe Implementation of Thrombolysis in Stroke-Monitoring Study) criteria. Results: Median serum NT-proBNP level was 349 pg/mL (interquartile range, 89–1250 pg/mL). One hundred twenty-one (11.6%) patients died. Malignant edema was observed in 78 (7.5%) patients. Ln(NT-proBNP) was independently associated with 3-month mortality in patients with intravenous thrombolysis only (odds ratio, 1.465 [95% CI, 1.169–1.836]; P =0.001) and in those receiving EVT (odds ratio, 1.563 [95% CI, 1.139–2.145]; P =0.006). The elevation of Ln(NT-proBNP) was also independently associated with malignant edema in patients with intravenous thrombolysis only (odds ratio, 1.334 [95% CI, 1.020–1.745]; P =0.036), and in those with EVT (odds ratio, 1.455 [95% CI, 1.057–2.003]; P =0.022). Conclusions: An early increase in NT-proBNP levels was related to malignant edema and stroke mortality after reperfusion therapy.

Abstract 122: Quality of Care for Patients With Acute Ischemic Stroke as a Function of Hospital Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator Capability: Insights From China National Stroke Registry II

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Zhenzhen Rao ◽  
Zixiao Li ◽  
Hongqiu Gu ◽  
Yilong Wang ◽  
Yongjun Wang
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Care ◽  
Care Quality ◽  
Composite Score ◽  
Stroke Patients ◽  
Stroke Registry

Background: Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator (rt-PA) availability at Chinese hospitals varies and may affect care quality for acute ischemic stroke patients. Limited research has shown whether there were differences in quality of care at China National Stroke Registry (CNSR II) hospitals based on rt-PA capability. Methods: For acute ischemic stroke patients admitted to CNSR II hospitals between 2012 and 2013, care quality at hospitals with or without Intravenous rt-PA capability was examined by evaluating conformity with performance and quality measures. The primary outcome was guideline-concordant care, defined as compliance with 10 predefined individual guideline-recommended performance metrics and composite score. A composite score was defined as the total number of interventions actually performed among eligible patients divided by the total number of recommended interventions among eligible patients. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to compare the relationship between hospitals with rt-PA capability and hospitals without rt-PA on quality measures. Results: This study included 19604 acute ischemic stroke patients admitted to 219 CNSR II hospitals. Before matching, there were 7928 patients admitted to 86 (40.4%) hospitals with rt-PA capability and 11676 patients admitted to 133 (59.6%) hospitals without rt-PA capability. After matching, 7606 pairs of patients in rt-PA-capable hospitals and rt-PA-incapable hospitals were analyzed. Before matching, the composite score of guideline-concordant process of care was higher at hospitals with rt-PA capability than hospitals without rt-PA capability (74% versus 73%, P=0.0126). Hospitals with rt-PA capability were more likely to perform deep vein thrombosis prophylaxis within 48 hours of admission, dysphagia screening, assessment or receiving of rehabilitation, discharge antithrombotic, anticoagulation for atrial fibrillation and medications for lowering low-density lipoprotein (LDL) ≥100mg/dL. But hospitals with rt-PA capability were less likely to perform antithrombotic medication within 48 hours of admission and hypoglycemic therapy at discharge for patients with diabetes. After matching, differences of stroke care quality between hospitals with rt-PA capability and without rt-PA capability still exist after adjusting covariates. Conclusions: The CNSR II hospitals were associated with better performance in some of the hospitals but not all of them. The difference in conformity between rt-PA-capable hospitals and rt-PA-incapable hospitals was modest for performance measures of stroke care. However, more room for improvement still exists in key quality performance measures and further studies should be explored.

scholarly journals Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel

2020 ◽  
Vol 15 (5) ◽  
pp. 540-554 ◽  
Author(s):  
Adnan I Qureshi ◽  
Foad Abd-Allah ◽  
Fahmi Al-Senani ◽  
Emrah Aytac ◽  
Afshin Borhani-Haghighi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Current Knowledge ◽  
Intravenous Thrombolysis ◽  
Adult Patients ◽  
World Health ◽  
Stroke Patients ◽  
International Panel ◽  
Health Organization ◽  
Tract Infections

Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.

scholarly journals Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

2021 ◽  
Vol 14 ◽  
pp. 175628642110211
Author(s):  
Georgios Magoufis ◽  
Apostolos Safouris ◽  
Guy Raphaeli ◽  
Odysseas Kargiotis ◽  
Klearchos Psychogios ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Inclusion Criteria ◽  
Stroke Patients ◽  
Treatment Algorithms ◽  
Late Presenters

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

scholarly journals Incorporation of α2-Plasmin Inhibitor into Fibrin Clots and Its Association with the Clinical Outcome of Acute Ischemic Stroke Patients

Biomolecules ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. 347
Author(s):  
Zsuzsa Bagoly ◽  
Barbara Baráth ◽  
Rita Orbán-Kálmándi ◽  
István Szegedi ◽  
Réka Bogáti ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Intravenous Thrombolysis ◽  
Fibrin Clot ◽  
Clot Lysis ◽  
Stroke Patients ◽  
Plasmin Inhibitor ◽  
Fibrin Clots

Cross-linking of α2-plasmin inhibitor (α2-PI) to fibrin by activated factor XIII (FXIIIa) is essential for the inhibition of fibrinolysis. Little is known about the factors modifying α2-PI incorporation into the fibrin clot and whether the extent of incorporation has clinical consequences. Herein we calculated the extent of α2-PI incorporation by measuring α2-PI antigen levels from plasma and serum obtained after clotting the plasma by thrombin and Ca2+. The modifying effect of FXIII was studied by spiking of FXIII-A-deficient plasma with purified plasma FXIII. Fibrinogen, FXIII, α2-PI incorporation, in vitro clot-lysis, soluble fibroblast activation protein and α2-PI p.Arg6Trp polymorphism were measured from samples of 57 acute ischemic stroke patients obtained before thrombolysis and of 26 healthy controls. Increasing FXIII levels even at levels above the upper limit of normal increased α2-PI incorporation into the fibrin clot. α2-PI incorporation of controls and patients with good outcomes did not differ significantly (49.4 ± 4.6% vs. 47.4 ± 6.7%, p = 1.000), however it was significantly lower in patients suffering post-lysis intracranial hemorrhage (37.3 ± 14.0%, p = 0.004). In conclusion, increased FXIII levels resulted in elevated incorporation of α2-PI into fibrin clots. In stroke patients undergoing intravenous thrombolysis treatment, α2-PI incorporation shows an association with the outcome of therapy, particularly with thrombolysis-associated intracranial hemorrhage.

Is acute reperfusion therapy safe in acute ischemic stroke patients who harbor unruptured intracranial aneurysm?

2015 ◽  
Vol 10 (SA100) ◽  
pp. 113-118 ◽  
Author(s):  
Ashkan Mowla ◽  
Karanbir Singh ◽  
Sandhya Mehla ◽  
Mohammad K. Ahmed ◽  
Peyman Shirani ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Aneurysm ◽  
Acute Ischemic Stroke ◽  
Reperfusion Therapy ◽  
Stroke Patients ◽  
Unruptured Intracranial Aneurysm

Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam H De Havenon ◽  
Christopher Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

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