scholarly journals Patient Selection For Acute Stroke Intravenous Thrombolysis

2017 ◽  
pp. 50
Author(s):  
Mehdi Farhoudi
Keyword(s):  
Time Window ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Exclusion Criteria ◽  
Level Of Evidence ◽  
Analysis Of Results ◽  
Scientific Statement ◽  
Selection For ◽  
In The Beginning ◽  
Related Level

Stroke is a leading cause of mortality worldwide. Unfortunately its incidence is more and the age of occurrence is one decade earlier in our country, Iran. About 75-90 percent of stroke etiology is ischemic. The only approved drug treatment for eligible acute ischemic stroke (AIS) patients is thrombolytic therapy by recombinant tissue plasminogen activator (tPA). Related level of evidence is the highest (1a) and it has been approved by FDA following NINDS study since 1996. First golden time for use of tPA was less than 3 hours but later it has extended to 4.5 hours following re-analysis of the data since 2009. In the beginning, related exclusion criteria was strict considering many absolute items, however, some of them changed or removed as relative exclusion criteria by practicing and performing researches and analysis of results and it is going to be more simplified. For example, in 2013 there were 15 absolute and 10 relative exclusion criteria for intravenous thrombolysis in AIS in less than 4.5 hours period from onset of symptoms but in 2016 following publishing American heart and Stroke Association (AHA/ASA) scientific statement this criteria was more clarified and some of relative exclusion criteria removed. And finally new published researches extended this therapeutic time window to 6 hours by using mechanical thrombectomy in defined patients not responding to IV thrombolysis. In the ninth national Iranian Stroke Congress this updated criteria will be discussed.                

scholarly journals Comparative study of intravenous thrombolysis with rt-PA and urokinase for patients with acute cerebral infarction

2020 ◽  
Vol 48 (5) ◽  
pp. 030006051989535
Author(s):  
Fan Sun ◽  
Heng Liu ◽  
Hui-xiao Fu ◽  
Shuo Zhang ◽  
Xu-dong Qian ◽  
...  
Keyword(s):  
Cerebral Infarction ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Cerebral Haemorrhage ◽  
Recombinant Tissue Plasminogen Activator ◽  
Serum Levels ◽  
Acute Cerebral Infarction ◽  
Bleeding Complications ◽  
Therapeutic Effects ◽  
Clinical Trial Evidence

Objective Cerebral infarction has a poor prognosis and causes a serious burden on families and society. Recombinant tissue plasminogen activator (rt-PA) and urokinase (UK) are commonly used thrombolytic agents in the clinic. However, direct and powerful clinical trial evidence to determine the therapeutic effect of rt-PA and UK on intravenous thrombolysis is lacking. Methods In this study, 180 patients with acute cerebral infarction were treated with rt-PA or UK. The National Institutes of Health Stroke Scale (NIHSS) scores, Barthel index, bleeding complications, and biomarkers were evaluated. Results No significant differences in NIHSS or Barthel scores were found between the groups. However, UK increased the risk of intracranial haemorrhage compared with rt-PA. rt-PA had increased activity in reducing serum levels of MMP-9 than UK. Conclusion Intravenous thrombolysis with rt-PA and UK in the time window of acute cerebral infarction can achieve similar therapeutic effects, but rt-PA can further reduce the risk of cerebral haemorrhage and is relatively safer than UK.

scholarly journals Flexible Versus Rigid Methods Of Intravenous Thrombolysis In Iran

2017 ◽  
pp. 6
Author(s):  
Kavian Ghandehari
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Tertiary Care ◽  
Intravenous Thrombolysis ◽  
Recent Decade ◽  
Recombinant Tissue Plasminogen Activator ◽  
Limiting Factor ◽  
Standard Protocol ◽  
Exclusion Criteria ◽  
Symptomatic Intracerebral Hemorrhage

Thrombolysis with administration of intravenous (IV) recombinant tissue plasminogen activator (rtPA) has been performed in some tertiary care hospitals in Iran in recent decade. Mininstery of Health and Medical Education of Iran approved a new management strategy which covers the cost of Alteplase since 2015. This is a great advance in increasing chance for Iranian stroke patients to get the treatment. Delay in performing triage and CT and laboratory tests is another limiting factor which can be decreased by defining special team members for thrombolysis. Most of the Iranian neurologists are not expert for performing the management. This limitation can be managed by continous thrombolysis work shops. However many of the Neurologists may not be interested to do the thrombolysis due to its risks and lack of financial benefits for responsible doctor.  Most of the contraindications for thrombolysis with tPA originated as exclusion criteria in famous clinical trials. These were derived from expert consensus for the National Institute of Neurological Disorders and Stroke (NINDS) trial. Despite the fact that the safety and efficacy of IV rtPA has been repeatedly confirmed in large international observational studies over the past 20 years, most patients with acute ischemic stroke  still do not receive thrombolytic treatment. Some of the original exclusion criteria have proven to be unnecessarily restrictive in real-world clinical practice. It has been suggested that application of relaxed exclusion criteria might increase the IV thrombolysis rate up to 20% with comparable outcomes to thrombolysis with more conventional criteria. We review the absolute and relative contraindications to IV rtPA for acute ischemic stroke, discussing the underlying rationale and evidence supporting these exclusion criteria. There are two therapeutic strategies for selecting the contraindications and exclusion criteria. Flexible method is ignoring some absolute or partial exclusion critera as illustrated above. This method will increase the probability of symptomatic intracerebral hemorrhage and death and may increase  numbers of legal condemnations for treating physician. Rigid method is prohibition of violations from standard protocols of thrombolysis which decreases both numbers of managed patients and thrombolysis contraindications. Physicians who prefer the first therapeutic strategy refer to data of published articles and guidelines of American and European stroke societies. There are two points of view; first, the Iranian neurologists do not have thrombolysis experience as well as western neurologusts. For instance very limited number of Iranian neurologists have enough experience for detection of ASPECT score. Second, due to some social factors number of legal condemnations  due to medical malpractice has been hugely increased in recent two decades in Iran. Based on these points second strategy is more wise for Iranian neurologists. The speaker has made a standard protocol of thrombolysis based on international gudelines and his experience. This standard protocol which is designed according to the rigid method is available by search in Google engine and is provided in Persian language.  

Abstract TMP21: Intravenous Thrombolysis with Alteplase for Acute Ischemic Stroke in Patients with Thrombocytopenia

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ashkan Mowla ◽  
Haris Kamal ◽  
Navdeep Lail ◽  
Rick Magun ◽  
Sandhya Mehla ◽  
...  
Keyword(s):  
Platelet Count ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Case Series ◽  
Intravenous Thrombolysis ◽  
P Value ◽  
Class Iii ◽  
Exclusion Criteria ◽  
Level Of Evidence ◽  
Significant Difference

Objective: To evaluate the rate of symptomatic intracranial hemorrhage (sICH) in patients who received Intravenous tPA(IVT) for acute ischemic stroke(AIS) and were later found to have platelets less than 100,000 /mm 3 . Background: With increasing use of IVT for AIS and more studies on its risk and benefits, many of the initial exclusion criteria which were part of the pivotal NINDS trial have been challenged with well-designed case series and reports. Based on the latest scientific statement from the AHA/ASA on the exclusion and inclusion criteria for IVT in AIS published in February 2016, the safety and efficacy of IVT in AIS is unknown for the patients with platelet count <100,000(Class III, Level of evidence C). The platelet threshold of 100,000 /mm 3 was derived from expert consensus in the NINDS trial and since many of the exclusion criteria have been challenged, this value also comes into question. Methods: We retrospectively reviewed the charts of all patients who received IVT for AIS from the beginning of 2006 till the end of August 2015 at our large volume comprehensive stroke center (SUNY Buffalo). Those with platelets <100,000/mm 3 were identified. Head CT done in 24 to 36 hours Post-thrombolysis was reviewed to evaluate the rate of sICH. sICH was defined as ICH with an increase in National Institute of Health Stroke Scale of at least 4 points. Results: A total of 835 patients received IV rtPA for AIS in our center during a 9·6-year period. Fifty one patients (6.1 %) were found to have sICH. A total of 5 patients (0.6 %) were identified to have platelet count <100,000 /mm 3 . One of them (20%) developed sICH post IV tPA administration .The mean platelet count of those 5 patients was 63,000 ± 19,000 /mm 3 (Range: 38,000 - 85,000 /mm 3 ) . To the best of our knowledge, only 21 thrombocytopenic patients have been reported to receive IV rtPA for AIS in the medical literature. Combining our 5 cases with 21 patients previously reported, we have 26 AIS patients who had platelet count <100,000 /mm 3 and received IV rtPA, with 2 of them developed sICH (7.7 %). Comparing the rate of sICH among this group with the patients with normal platelet count in our cohort, there was no statistically significant difference (7.7% versus 6.04%, p-value = 0.73). Conclusion: Although our extremely low number of cases precludes any solid conclusion, IV rtPA for AIS might be safe in patients with platelet count <100,000/ mm 3 and it is reasonable not to delay IV rtPA administration while waiting for the platelet count result, unless there is strong suspicion for abnormal platelet count.

Abstract 3174: Intravenous Thrombolysis in 3-4.5 hours: Utilization and outcomes Analysis of the Minnesota Stroke Registry

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Wondwossen G Tekle ◽  
Saqib I Chaudry ◽  
Ameer Hassan ◽  
James Peacock ◽  
Kamakshi Lakshiminarayan ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Symptom Onset ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Unfavorable Outcome ◽  
Initial Examination ◽  
Stroke Registry ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Assisting Device

Background: The results of the third European Cooperative Acute Stroke Study (ECASS 3) demonstrated that intravenous (IV) thrombolysis for acute ischemic stroke (AIS) improved patient outcomes when administered within 3-4.5 hours (hrs) after symptom onset. We analyzed data from the Minnesota Stroke Registry to assess the rates of IV thrombolytic utilization in this expanded window and examine outcomes of patients treated within the 3-4.5 hrs window. Methods: We identified patients who had received IV recombinant tissue plasminogen activator (rt-PA) at any of the 19 participating hospitals from Jan 1, 2008 till Dec 31, 2010. Treatment groups were those actually treated by IV rt-PA in 0-3 hrs and those treated by IV rt-PA in 3-4.5 hrs. We compared the rates of unfavorable outcome (inability to ambulate independently with or without assisting device at discharge) and in-hospital mortality among patients treated with IV rt-PA within 3-4.5 hrs to those who received IV rt-PA within the conventional 0-3 hrs window. Results: Out of the total 519 patients who received IV rt-PA for AIS, 433 (83%) were treated within 0-3 hrs and 86 (17%) within 3-4.5 hrs. Adjusting for age, sex, and “adverse initial examination findings” (reduced level of consciousness, aphasia, and weakness), there was a trend towards higher rates of unfavorable outcome at discharge among those treated within 3-4.5 hrs compared to those treated within 0-3 hrs time window (Odds ratio [OR], 1.76; 95% confidence interval [CI], 0.95 to 3.26). In hospital mortality did not differ between the 3-4.5 hrs groups and 0-3 hrs groups (OR, 1.05; 95% CI, 0.38 to 2.96). Incidence of symptomatic intracerebral hemorrhage was non-significantly lower in the 3-4.5 hrs group compared to the 0-3 hrs group (2.3% vs.4.6%, p=0.34). Conclusion: Patients who received IV rt-PA within the 3-4.5 hrs window comprised 17% of all IV rt-PA cases treated in the MSR hospitals after guidelines recommended time window expansion. Outcomes of these patients were comparable to those treated within 3 hours of symptom onset.

scholarly journals Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol

2017 ◽  
Vol 12 (6) ◽  
pp. 671-678 ◽  
Author(s):  
Salwa El-Tawil ◽  
Joanna Wardlaw ◽  
Ian Ford ◽  
Grant Mair ◽  
Tom Robinson ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Patient Selection ◽  
Multimodal Imaging ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Computed Tomography Perfusion ◽  
Tissue Plasminogen ◽  
Selection For

Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.

scholarly journals Intravenous Thrombolysis After Reversal of Dabigatran With Idarucizumab in Acute Ischemic Stroke: A Case Report

2021 ◽  
Vol 13 ◽  
Author(s):  
Dan Xie ◽  
Xuefan Wang ◽  
Yao Li ◽  
Ruiling Chen ◽  
Yingying Zhao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Case Report ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Case Reports ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Limb Weakness ◽  
Left Limb

Background: As there is a growing concern about the cerebral embolism events secondary to non-valvular atrial fibrillation (NVAF), novel oral anticoagulant (NOAC) has been more and more widely used as an anticoagulation treatment for the prevention of stroke. However, in the face of life-threatening bleeding or emergency surgery/treatment, NOAC-related antagonists such as idarucizumab need to be urgently used to reverse the NOAC. Using recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis for acute ischemic stroke requires a time window of 4.5 h. This case reports rt-PA intravenous thrombolysis after reversal of dabigatran anticoagulation with idarucizumab in patients with acute ischemic stroke.Case Presentation: We report the case of 62-year-old Chinese female with NVAF treated with dabigatran 110 mg twice daily, and missed a dose on the eve of the stroke. The patient presented with acute ischemic stroke causing the angle of mouth deviated to right side and left limb weakness in the early morning of the next day. However, the last dosing time of dabigatran was between 24 and 48 h, the patients were given rt-PA intravenous thrombolysis after reversal of dabigatran anticoagulation with idarucizumab, while any potential relative contraindication had been excluded by means of laboratory test and CT scan in the hospitalization services. National Institute of Health stroke scale (NIHSS) score was reduced from 4 to 1, and the patient was discharged after 2 weeks.Conclusion: Our case report adds to the evidence that idarucizumab administration is safe and effective in the setting of patients with atrial fibrillation treated with dabigatran who develop acute ischemic stroke requiring rt-PA intravenous thrombolysis.

Association of admission leukocyte count with clinical outcomes in acute ischemic stroke patients undergoing intravenous thrombolysis with recombinant tissue plasminogen activator

2020 ◽  
Vol 17 ◽  
Author(s):  
Jie Chen ◽  
Fu-Liang Zhang ◽  
Shan Lv ◽  
Hang Jin ◽  
Yun Luo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Leukocyte Count ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Functional Independence ◽  
Tissue Plasminogen ◽  
Poor Outcomes

Objective:: Increased leukocyte count are positively associated with poor outcomes and all-cause mortality in coronary heart disease, cancer, and ischemic stroke. The role of leukocyte count in acute ischemic stroke (AIS) remains important. We aimed to investigate the association between admission leukocyte count before thrombolysis with recombinant tissue plasminogen activator (rt-PA) and 3-month outcomes in AIS patients. Methods:: This retrospective study included consecutive AIS patients who received intravenous (IV) rt-PA within 4.5 h of symptom onset between January 2016 and December 2018. We assessed outcomes including short-term hemorrhagic transformation (HT), 3-month mortality, and functional independence (modified Rankin Scale [mRS] score of 0–2 or 0–1). Results:: Among 579 patients who received IV rt-PA, 77 (13.3%) exhibited HT at 24 h, 43 (7.4%) died within 3 months, and 211 (36.4%) exhibited functional independence (mRS score: 0–2). Multivariable logistic regression revealed admission leukocyte count as an independent predictor of good and excellent outcomes at 3 months. Each 1-point increase in admission leukocyte count increased the odds of poor outcomes at 3 months by 7.6% (mRS score: 3–6, odds ratio (OR): 1.076, 95% confidence interval (CI): 1.003–1.154, p=0.041) and 7.8% (mRS score: 2–6, OR: 1.078, 95% CI: 1.006–1.154, p=0.033). Multivariable regression analysis revealed no association between HT and 3-month mortality. Admission neutrophil and lymphocyte count were not associated with 3-month functional outcomes or 3-month mortality. Conclusion:: Lower admission leukocyte count independently predicts good and excellent outcomes at 3 months in AIS patients undergoing rt-PA treatment.

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