scholarly journals Intravenous thrombolysis in acute ischemic stroke patients with negative CT perfusion: a case series

2014 ◽  
Vol 3 (7) ◽  
pp. 204798161454321
Author(s):  
Ratnesh Mehra ◽  
Chiu Yuen To ◽  
Omar Qahwash ◽  
Boyd Richards ◽  
Richard D Fessler
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Ct Perfusion ◽  
Case Series ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Tissue Type ◽  
Stroke Patients ◽  
Radiographic Findings ◽  
Type Plasminogen Activator

Background Computed tomography perfusion (CTP) is a commonly used modality of neurophysiologic imaging to aid the selection of acute ischemic stroke patients for neuroendovascular intervention by identifying the presence of penumbra versus infarcted brain tissue. However many patients present with evidence of cerebral ischemia with normal CTP, and in that case, should intravenous thrombolytics be given? Purpose To demonstrate if tissue-type plasminogen activator (tPA)-eligible stroke patients without perfusion defects demonstrated on CTP would benefit from administration of intravenous thrombolytics. Material and Methods We retrospectively identified patients presenting with acute ischemic symptoms who received intravenous tPA (IV-tPA) from January to June 2012 without a perfusion defect on CTP. Clinical and radiographic findings including the NIHSS at presentation, 24 h, and at discharge, symptomatic and asymptomatic hemorrhagic transformation, and the modified Rankin score at 30 days were collected. A reduction of NIHSS of greater than 4 points or resolution of symptoms was considered significant. Results Seventeen patients were identified with a mean NIHSS of 8.2 prior to administration of intravenous thrombolytics, 3.5 after 24 h, and 2.5 at discharge. Among them, 13 patients had significant improvement of NIHSS with a mean reduction of 6.15 points at 24 h. One patient initially improved but had delayed hemorrhagic transformation and died. Two patients had improvement in NIHSS but were not significant and two patients had increased in NIHSS at 24 h, although one eventually improved at discharge. There was no asymptomatic hemorrhagic transformation. Mean mRS at 3 months is 1.76. Conclusion The failure to identify a perfusion deficit by CTP should not be used as a contraindication for intravenous thrombolytics. Criteria for administration of intravenous thrombolytics should still be based on time from symptom onset as previously published by NINDS.

Abstract TMP20: Extraischemic Hematomas Following Intravenous rt-PA For Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Masato Osaki ◽  
Masatoshi Koga ◽  
Mayumi Fukuda ◽  
Yuya shigehatake ◽  
Kazuyuki Nagatsuka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hemorrhagic Transformation ◽  
Tissue Type ◽  
Stroke Patients ◽  
Related Factors ◽  
Subarachnoidal Space ◽  
Type Plasminogen Activator ◽  
The Brain

Background and purpose: Extraischemic hematoma (EIH) is defined as hemorrhage that appears in regions of the brain without visible ischemic damage. The frequency, clinical features, disease-related factors, and prognosis of patients with EIH after IV recombinant tissue-type plasminogen activator (rt-PA) are not well known. We aimed to elucidate EIH and associated factors after IV rt-PA for acute ischemic stroke. Methods: We studied consecutive stroke patients who received IV rt-PA from 2005 through 2011. EIH was defined as any extra-ischemic hemorrhages identified on the follow-up CT within the initial 36 h after rt-PA. Results: Of the total 266 patients (177 men, 73±13 years old) studied, EIH was identified in 11 (4%, 5 men, 77±7 yo, 1 multiple EIH); 8 patients in the parenchyma (5 subcortex, 1 thalamus, 1 corona radiate, 1 cerebellum), 2 in the intraventricule, 1 in the subdural space, and 1 in the subarachnoidal space. As compared with 47 patients with hemorrhagic transformation (HT) from the index infarct (30 men, 73±10 yo) and 208 with “no hemorrhage” (NH, 142 men, 73±14 yo), Fazekas grade of periventricular hyperintensity (PVH) was higher [median 2 in EIH, 1 in HT, 1 in NH; P<0.001), DWI-ASPECTS was lower [7, 7.5, 9; P<0.001), and reduced eGFR (<60 ml/min/1.73 m2) was more common in patients with EIH (82%, 32%, 38%; P=0.007). On multivariate analysis, higher grade of PVH (OR 5.06, 95%CI 1.92-16.09 per 1 point; P<0.001) and reduced eGFR (OR 6.94, 95%CI 1.40-54.69; P=0.02) were associated with EIH. Percentages of the mRS 5-6 at 3 months were 46% in EIH, 36% in HT, and 16% in NH (P=0.001). EIH was an independent predictor of the mRS 5-6 (OR 4.90, 95%CI 1.11-22.35; P=0.036), along with older age, lower DWI-ASPECTS, higher NIHSS score, and prior antithrombotic use. Of 132 patients undergoing T2*-WI before or within several days after thrombolysis, microbleeds were more common in patients with EIH (86%) than the others (19% in HT, 24% in NH, P<0.001). Conclusions: EIH developed in 4% of the stroke patients after IV rt-PA. Severe PVH and renal dysfunction were associated with the occurrence of EIH. Severe PVH might indicate prevalent existence of microbleeds. EIH was predictive of unfavorable outcome following IV rt-PA.

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.

Abstract W P63: Intravenous Thrombolysis for Acute Ischemic Stroke in Nonagenarians

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Raul Guisado ◽  
Reza Malek ◽  
Ursula Kelly-Tolley ◽  
Arash Padidar ◽  
Harmeet Sachdev
Keyword(s):  
Ischemic Stroke ◽  
Mortality Rate ◽  
Acute Ischemic Stroke ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Early Improvement ◽  
Hospital Patients ◽  
Contrast Ct ◽  
Overall Mortality

The safety and effectiveness of intravenous thrombolysis for acute ischemic stroke (AIS) has been established for populations older than 80 years of age . However, management of AIS in nonagenerians is not clear. Previous reports suggest that the rate of ICH after i.v. alteplase is not increased and the rate of early improvement is similar in nonagenerians compared to younger groups, but there is concern with overall mortality and functional outcomes. We report on 20 consecutive patients with AIS treated with i.v. alteplase within 3 hours of onset in two Comprehensive Stroke Centers in San Jose, CA. Methods: Patients were immediately evaluated by members of the Stroke Team of each hospital. . Patients were eligible if they had disabling neurological symptoms, no contraindications for i.v.alteplase and were independent in ADLs prior to the index event. Non-contrast CT brain scan, CT perfusion and CT angiography of head and neck were used to determine the presence of potentially salvageable brain. Results (Table): Mean age was 91 years (range 90 - 98 years). The initial NIHSS was 15.7 ± 6.8. The median NIHSS at hospital discharge was 7.4 ± 8.4 (p <0.001). The median door to needle time was 50.5 minutes (range 36 - 74 minutes). There was no hemorrhagic transformation and no in-hospital mortality. The overall mortality rate at 90 days was 30% (6 of 20 patients) and the rate of good outcome in survivors, defined as mRS ≤ 3 at 90 days was 35.7% (5 of 14 patients). Comment: Intravenous thrombolysis for ischemic stroke in nonagenerians is safe and effective, with good rates of immediate improvement. However, the l90 days mortality rate is high and the long term functional outcome is poor. This data can be useful in helping families make treatment decisions in the most elderly patients with acute ischemic stroke.

Abstract TMP19: Intravenous Recombinant Tissue-type Plasminogen Activator Use in Young Adults With Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jodi A Dodds ◽  
Ying Xian ◽  
Shubin Sheng ◽  
Gregg Fonarow ◽  
Ronald A Matsouaka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Older Patients ◽  
Young Patients ◽  
Tissue Type ◽  
Stroke Patients ◽  
Younger Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator

Background: Intravenous recombinant tissue-type plasminogen activator (rt-PA) administration improves outcomes in acute ischemic stroke. However, young patients (<40 years old) presenting with stroke symptoms may experience delays in treatment due to misdiagnosis or a reluctance to treat since they do not fit the profile of a typical stroke patient. Methods: We analyzed data from the large national Get With The Guidelines–Stroke registry for acute ischemic stroke patients hospitalized between January 2009 and September 2015. Multivariable models with generalized estimating equations (GEE) were used to test for differences between younger (age 18-40) and older (age > 40) acute ischemic stroke patients, controlling for patient and hospital characteristics including stroke severity. Results: Of 1,320,965 AIS patients admitted to participating hospitals, 2.3% (30,448) were aged 18-40. Among these patients, 12.5% received rt-PA versus 8.8% of those aged >40 (p<0.001). Of patients arriving within 3.5 hours of symptom onset without contraindications, 68.7% of younger patients received IV rt-PA versus 63.3% of older patients (adjusted OR [aOR] 1.30, 95% CI 1.21 to 1.40), without evidence that age-related differences varied by sex (interaction p-value 0.25). Odds ratios of achieving target door-to-CT times and door-to-needle (DTN) times, and outcomes of rtPA-treated patients, are shown in the Table. Conclusions: Young acute ischemic stroke patients did not receive rt-PA treatment at lower rates than older patients. Outcomes were better and the rate of symptomatic intracranial hemorrhage was lower in the young patients. However, younger patients had significantly longer door-to-CT and DTN times, providing an opportunity to improve the care of these patients.

scholarly journals Intravenous Tissue-Type Plasminogen Activator in Acute Ischemic Stroke Patients With History of Stroke Plus Diabetes Mellitus

Stroke ◽  
2019 ◽  
Vol 50 (6) ◽  
pp. 1497-1503 ◽  
Author(s):  
Matthew E. Ehrlich ◽  
Li Liang ◽  
Haolin Xu ◽  
Andrzej S. Kosinski ◽  
Adrian F. Hernandez ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
Stroke Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator ◽  
History Of

DWI Lesion Characteristics As A Predictor For Outcome In Acute Stroke Patients Treated By IV-tPA

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
H Aref ◽  
S Farag ◽  
S Helmy ◽  
H Mahmoud
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
P Value ◽  
Stroke Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator ◽  
Iv Tpa

Abstract Background Thrombolysis with tissue-type plasminogen activator (IV-tPA) is a well-proved, widely used treatment in acute ischemic stroke patients, many predictors of functional outcome have been proposed as Age, vascular risk factors, initial clinical evaluation on admission using National institute of health stroke scale(NIHSS), functional state of patient(b.L) baseline before stroke and 3 months (3m) after stroke using modified Rankin stroke scale (MRS)and the most controversial Diffusion weighted image characteristics (volume, heterogeneity) Objective To evaluate DWI MRI characteristics (volume, heterogeneity) as a predictor for outcome in Acute stroke patients treated by IV-tPA Patients and Methods This study will be done on a sample of 100 acute ischemic stroke Egyptian patients receiving intra-venous tissue -type plasminogen activator presenting to Ain-Shams university hospitals Results Highly statistically significant (p-value &lt; 0.001) Positive correlation (r = 0.394) between volume (DWI) and MRS (3m) post discharge in studied patients, No statistically significant (pvalue &gt; 0.05) relation between heterogeneity and other studied parameters (MRS, NIHSS D & ADC values) in studied patients Conclusion DWI infarct volume is a predictor for outcome in acute ischemic stroke patients treated by tPA

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