Efficacy Of Intravenous Thrombolysis Research Articles

Intravenous thrombolysis versus dual antiplatelet therapy for patients with acute minor ischaemic stroke: a systematic review and meta-analysis.

The efficacy of intravenous thrombolysis (IVT) in patients with acute minor ischaemic stroke (AMIS) remains unclear. We performed a meta-analysis to compare the efficacy and safety of IVT and dual antiplatelet therapy (DAPT) in patients with AMIS. The Embase, Cochrane Library, PubMed, and Web of Science databases were searched up to 10 October, 2023. Prospective and retrospective studies comparing the clinical outcomes of IVT and DAPT were included. Odds ratios (ORs) and 95% confidence intervals (CIs) for early neurological deterioration (END), excellent and favourable functional outcomes, recurrent ischaemic stroke at 3months, mortality at 3months, and symptomatic intracranial haemorrhage (ICH) were pooled using a random-effects model. Of the five included studies, 6,340 patients were included. In patients with AMIS, IVT was not significantly associated with excellent and favourable functional outcomes, recurrent ischaemic stroke, or all-cause mortality at 3months compared to early DAPT. However, a higher risk of symptomatic ICH (OR, 9.31; 95% CI, 3.39-25.57) and END (OR, 2.75; 95% CI, 1.76-4.30) were observed with IVT. This meta-analysis indicated that IVT was not superior to DAPT in patients with AMIS, especially in those with nondisabling AIS. However, these findings should be interpreted with caution and have some limitations. Further, well-designed randomised controlled trials are warranted.

Acute recanalization therapy for ischemic stroke during pregnancy and puerperium

BackgroundThe safety and efficacy of intravenous thrombolysis (IVT) and endovascular thrombectomy for an ischemic stroke (IS) during pregnancy and puerperium are poorly studied. We evaluated the complications and outcome of recanalization therapy in maternal ISs.MethodsA nationwide cohort of maternal ISs in Finland during 1987–2016 was collected by linking national healthcare registers: Medical Birth Register, Hospital Discharge Register, and Cause-Of-Death Register. The diagnoses were verified retrospectively from patient records. IVT-treated patients were compared to controls, who were young females with non-pregnancy-related IS from the Helsinki Stroke Thrombolysis Registry.ResultsTotally, 12 of 97 (12.4%) maternal ISs were treated with recanalization therapy. Compared to controls, IVT-treated maternal IS patients had more frequently early (age-adjusted odds ratio (aOR) = 7.63, 95% CI 1.49–39.04) and major (aOR = 8.59, 95% CI 2.09–35.31) neurological improvements, measured using the National Institute of Health Stroke Scale. Good functional outcomes (modified Rankin Scale 0–2) at three months were equally common in maternal ISs and controls. No other complications were observed in IVT-treated maternal ISs than 1 (9.1%) symptomatic nonfatal intracranial hemorrhage. Among maternal IS patients treated with recanalization or conventional therapy, good functional outcome at the end of the follow-up was less common in recanalization-treated patients (66.7% vs 89.4%, aOR = 0.22, 95% CI 0.052–0.90), but otherwise outcomes were similar.ConclusionsIn this small nationwide cohort of maternal ISs, the complications of recanalization therapy were rare, and the outcomes were similar in IVT-treated maternal IS patients and controls. Maternal ISs should not be excluded from recanalization therapy in otherwise eligible situations.

Intravenous Thrombolysis in Posterior versus Anterior Circulation Stroke: Clinical Outcome Differs Only in Patients with Large Vessel Occlusion.

The safety and efficacy of intravenous thrombolysis (IVT) are well established in anterior circulation stroke (ACS) but are much less clear for posterior circulation stroke (PCS). The aim of this study was to evaluate the occurrence of parenchymal hematoma (PH) and 3-month clinical outcomes after IVT in PCS and ACS. In an observational, cohort multicenter study, we analyzed data from ischemic stroke patients treated with IVT prospectively collected in the SITS (Safe Implementation of Treatments in Stroke) registry in the Czech Republic between 2004 and 2018. Out of 10,211 patients, 1166 (11.4%) had PCS, and 9045 (88.6%) ACS. PH was less frequent in PCS versus ACS patients: 3.6 vs. 5.9%, odds ratio (OR) = 0.594 in the whole set, 4.4 vs. 7.8%, OR = 0.543 in those with large vessel occlusion (LVO), and 2.2 vs. 4.7%, OR = 0.463 in those without LVO. At 3 months, PCS patients compared with ACS patients achieved more frequently excellent clinical outcomes (modified Rankin scale [mRS] 0-1: 55.5 vs. 47.6%, OR = 1.371 in the whole set and 49.2 vs. 37.6%, OR = 1.307 in those with LVO), good clinical outcomes (mRS 0-2: 69.9 vs. 62.8%, OR = 1.377 in the whole set and 64.5 vs. 50.5%, OR = 1.279 in those with LVO), and had lower mortality (12.4 vs. 16.6%, OR = 0.716 in the whole set and 18.4 vs. 25.5%, OR = 0.723 in those with LVO) (p < 0.05 in all cases). In PCS versus ACS patients, an extensive analysis showed a lower risk of PH both in patients with and without LVO, more frequent excellent and good clinical outcomes, and lower mortality 3 months after IVT in patients with LVO.

Intravenous thrombolysis in acute ischemic stroke patients with pre-stroke disability: A systematic review and meta-analysis.

Intravenous thrombolysis (IVT), which is safe and effective, is the first-line therapy for acute ischemic stroke (AIS). However, its benefit for AIS patients with pre-stroke disability (PSD) is controversial. We determined the association of PSD with the safety and efficacy of IVT among patients with AIS. We searched PubMed, Embase, and the Cochrane Library from inception to May 23, 2022. The articles focusing on outcomes of AIS patients with PSD receiving IVT were retrieved. We used the random-effects model to pool outcomes including mortality, 24h NIHSS improvement, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome (FFO), the favorable outcome, and mortality prevalence. Ten studies (including 245,773 participants) that reported the outcomes of AIS patients with PSD undergoing IVT were included. In unadjusted analyses, PSD was associated with mortality (10 studies; odds ratio [OR] 1.739, 95% confidence interval [CI], 1.336-2.407), FFO (7 studies; OR 1.057, 95% CI, 1.015-1.100), 24h NIHSS improvement (5 studies; OR .840, 95% CI, .819-.917, p=.000), and sICH (9 studies; OR .773, 95% CI, .481-1.243). In adjusted analyses, PSD was associated with mortality (seven studies; ORadj 1.789, 95% CI, 1.413-2.264), FFO (five studies; ORadj 1.087, 95% CI, 1.002-1.179), 24h NIHSS improvement (five studies; ORadj .837, 95% CI, .799-.876), and sICH (five studies; ORadj .857, 95% CI, .725-1.012). The prevalence of FFO and mortality in patients with pre-stroke modified Rankin Scale scores of 2-5 were 49% (0.42-0.56) and 37% (0.21-0.53), respectively. Patients with PSD undergoing IVT had a higher mortality rate than those without PSD. Meanwhile, PSD was associated with FFO, and there was no significant difference in sICH and 24h NIHSS improvement. High-quality data are needed to clarify the benefits of administering IVT in these patients.

Abstract 25: Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis

Introduction: Intravenous thrombolysis (IVT) is efficacious treatment of acute ischemic stroke (AIS). However, certain circumstances associated with increased bleeding risk, such as recent direct oral anticoagulation (DOAC) intake limits its use. Nonetheless, emerging evidence has shown promising results in this patient group. We investigated the safety and efficacy of IVT in patients with AIS and recent DOAC use. Methods: We conducted systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use. Outcomes of interest were symptomatic intracranial hemorrhage (sICH), any ICH, serious systemic bleeding (SSB), and 90-day functional independence (mRS 0-2). Moreover, we calculated pooled odds ratios (OR) for each outcome using a random effect meta-analysis to compare the rates between the patients with DOAC and non-DOAC upon IVT. Ultimately, we completed a sensitivity analysis for idarucizumab, NIHSS, and the timing of DOAC administration. Results: Our meta-analysis included 14 studies with 247079 patients (3610 in DOAC and 243469 in non-DOAC). In the DOAC group, the rate of sICH was 3% (95%CI 3 - 4%), any ICH was 12% (95%CI 7 - 19%), SSB 0.7% (95%CI 0 - 1%), and 90-day mRS 0-2 was 57% (95%CI 43 - 70%). No difference in the rates of sICH (3.4vs.3.5%; OR=0.95; 95%CI 0.67 - 1.36), any ICH (17.7vs.17.3%; OR=1.23; 95%CI 0.61 - 2.48), SSB (0.7vs.0.6%; OR=1.27; 95%CI 0.79 - 2.02), and 90-day mRS 0-2 (46.4vs.56.8%; OR=1.21; 95%CI 0.400 - 3.67) was found between DOAC and non-DOAC groups. Subgroup analysis revealed no significant difference in the sICH rate between idaricuzumab and no idaricizumab administration prior to IVT [Figure 1]. Conclusions: Our analysis demonstrated no significant difference in functional independence and hemorrhagic complication rates in AIS patients treated with IVT with recent DOAC compared to the no-DOAC group. Further prospective randomized clinical trials are needed to shed more light on this topic.

Effects of intravenous rtPA in patients with minor stroke

Background Whether minor ischemic stroke (MIS) patients can benefit from intravenous thrombolysis (IVT) remains controversial. The association between the efficacy of IVT and baseline National Institute of Health Stroke Scale (NIHSS) score is unclear in MIS, while the association in moderate and severe stroke is known. This study aimed to explore the effect of IVT in patients with MIS and analyze its efficacy in patients with different baseline NIHSS scores. Methods Patients with a NIHSS score ≤5 within 4.5 h of stroke onset were screened in 32 centers. Patients with and without IVT were matched to a ratio of 1:1 with propensity scores. An excellent outcome was defined as a modified Rankin Scale (mRS) score ≤1 at three months after stroke onset. Safety outcomes included mortality and symptomatic intracranial hemorrhage (sICH). Multivariate analysis was used to compute the adjusted odds ratio (OR) for excellent outcomes. The effect of IVT was further analyzed in subgroups according to the baseline NIHSS score. Results Of the 23,853 screened, 3336 patients with MIS who arrived at the hospital within 4.5 h of onset were included. The 1163 patients treated with IVT were matched with 1163 patients without IVT. IVT in minor strokes generated an adjusted OR of 1.38 (95% CI: 1.09–1.75, p = 0.009) for excellent outcomes. There were no significant differences in mortality (0.17% vs. 0.09%, p = 1.000) and sICH (0.69% vs. 0.86%, p = 0.813) between patients with and without IVT. Subgroup analysis showed that there was no significant effect of IVT in the baseline NIHSS 0-1 or 2-3 subgroups, with adjusted OR of 0.816 (95% CI 0.437–1.53, p = 0.525) and1.22 (95% CI 0.845–1.77, p = 0.287), respectively. In patients with NIHSS score of 4–5, IVT was significantly effective, with an adjusted OR of 1.53 (95% CI 1.02–2.30, p = 0.038). Conclusion IVT can improve MIS outcomes. The risks of sICH and mortality did not increase, especially in patients with NIHSS scores 4 to 5, who could benefit from IVT significantly.

Effect of multidisciplinary refined time management combined with organized stroke management on the efficacy of intravenous thrombolysis in patients with acute ischemic stroke

This study aims to investigate the effects of multidisciplinary refined time management combined with organized stroke management in intravenous thrombolysis on patients with acute ischemic stroke. 226 acute ischemic stroke patients treated with intravenous thrombolysiswere selected for retrospective analysis. A Control group participants underwent organized stroke management, whereas study group participants underwent multidisciplinary refined time management based on the control group. The study group responded to intravenous thrombolysis for 24 hours at an overall rate of 92.92%, significantly higher than 79.65% in the control group (p &lt; 0.05). The time from onset to emergency, time for National Institute of Health Stroke Scale (NIHSS) scoring by emergency doctors, consultation time for neurologists, judgement time for head computed tomography (CT), interpretation time for examination results, communication time with family members to sign the consent form, and time from admission to medication in the study group were significantly shorter than that in control group (p &lt; 0.05). The incidence of hemorrhagic transformation, six-month mortality and six-month rehospitalization rate in the study group were significantly lower than those in the control group (p &lt; 0.05). Before thrombolysis, cerebrovascular reserve function and neurological function indexes in both groups were improved, and there was significant difference before and after thrombolysis in this group (p &gt; 0.05); After thrombolysis, mean blood flow velocity (MFV) and breath-holding index (BHI) in the study group were significantly higher than those in the control group (p &lt; 0.05); pulsatility index (PI) was lower than that in the control group, showing a significant difference (p &lt; 0.05); Serum nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) were significantly higher than those in the control group (p &lt; 0.05). Multidisciplinary refined time management combined with organized stroke management can improve the effect of intravenous thrombolysis in acute ischemic stroke.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis.

Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Abstract 236: Effects of intravenous thrombolysis on thrombectomy outcomes: a systematic review and meta‐analysis

Introduction Efficacy and safety of intravenous thrombolysis (IVT) in patients undergoing mechanical thrombectomy (MT) is still debatable. However, IVT's efficacy on stent retriever (SR) and aspiration thrombectomy (ASP) outcomes specifically remain unclear. In our meta‐analysis, we aimed to explore the effects of IVT on SR and ASP thrombectomy outcomes. Methods A systematic literature review was steered using Medline, Embase, Scopus, Web of Science, and Cochrane Center of Clinical Trials databases, according to PRISMA guidelines. Outcomes of interest included successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b), functional independence (modified Rankin Scale (mRS) ≤2), modified first pass efficacy (mFPE), symptomatic intracranial hemorrhage (sICH), and embolization to new territories (ENT). Results We included four randomized controlled trials with 1176 patients. SR and ASP had similar mTICI ≥2b, mFPE, and mRS 0‐2 rates whether they received IVT or not. SR without IVT was associated with a lower rate of mFPE compared with the SR+IVT (RR 0.85, 95% CI 0.74 to 0.97). Additionally, ASP without IVT resulted in a lower rate of mRS 0‐2 than the ASP+IVT (RR 0.78, 95% CI 0.60 to 1.01). Finally, bridging therapy did not increase sICH and ENT rates after ASP or SR thrombectomy. Conclusion Our analysis suggests that SR and ASP thrombectomy have equivalent efficacy and safety outcomes regardless of prior IVT administration. Moreover, our results indicate that administration of IVT before MT may improve certain outcomes based on the used first‐line MT technique.

Efficacy and Safety of Thrombolytic Therapy in Mongolian Young Adults with Acute Ischemic Stroke

Objectives: The study aimed to assess the safety and efficacy of intravenous thrombolysis (IVT) in Mongolian young patients with acute ischemic stroke (AIS).Methods: Data of 30 AIS patients aged &lt;50 years who were treated with IVT between 2013 and 2023 at the Stroke Department of Third Central Hospital were retrospectively analyzed. For outcome comparison, 60 controls with AIS not treated with IVT and 60 older controls (&gt;50 years) treated with IVT matched age, gender and baseline NIHSS score were selected. Functional outcome at three (3) months defined as “Favorable” and “Unfavorable” (modified Rankin Scale score 0-1 vs 2-6). Symptomatic intracerebral hemorrhage (sICH) was defined according to the SITS-MOSTStudy.Results: “Favorable” outcome at 3 months was significantly higher in young IVT-treated patients (53.3% vs 30.0%, p &lt; 0.05) compared with their matched young and older controls treated with IVT (53.3% vs 26.7%, p = 0.019). The sICHoccurred in 3% of young IVT-treated patients and in 5% of older controls but this difference was nonsignificant. Mortality rate was 21.7% (p = 0.245) among older controls, whereas in young IVT-treated and matched young controls 10% during the 3months follow-up.Conclusions: IVT is safe and beneficial for Mongolian young adults with AIS.

Predictive role of pre-thrombolytic hs-CRP on the safety and efficacy of intravenous thrombolysis in acute ischemic stroke

PurposeTo investigate the predictive role of pre-thrombolytic high sensitivity C-reactive protein (hs-CRP) on the safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke (AIS).MethodsPatients with AIS who underwent intravenous thrombolysis with recombinant plasminogen activator (rtPA) or urokinase without endovascular therapy from June 2019 to June 2022 were retrospectively analysed. All patients were grouped into two groups (high or low hs-CRP group) according to the median value of hs-CRP before intravenous thrombolysis. The baseline NIHSS, NIHSS changes before and after thrombolysis (ΔNIHSS), the rate of good thrombolysis response (NIHSS decreased ≥ 2 points from baseline), the rate of any intracranial hemorrhage, age, sex, hypertension, diabetes, uric acid and platelet count were compared between the two groups. Logistic regression analysis was performed to identify possible prognostic factors for a good thrombolysis response.ResultsA total of 212 patients were included in the analysis, with a mean age of 66.3 ± 12.5 years. In total, 145 patients received rtPA, and 67 patients received urokinase. Patients were divided into a high hs-CRP group (> 1.60 mg/L) and a low hs-CRP group (≤ 1.60 mg/L) according to the median hs-CRP level (1.60 mg/L). The ΔNIHSS of the high hs-CRP group was significantly smaller than that of the low hs-CRP group (0 [-1 ~ 0] vs. -1 [-2 ~ 0], P < 0.05). The good rate of thrombolysis response in the high hs-CRP group was significantly lower than that in the low hs-CRP group (21.9% vs. 36.5%, P < 0.05). Similar results were shown in the rtPA subgroup between the high and low hs-CRP groups but not in the urokinase subgroup. Logistic regression analysis showed that hs-CRP > 1.60 mg/L was negatively correlated with a good thrombolysis response rate (OR = 0.496, 95% CI = 0.266–0.927, P = 0.028).Conclusionhs-CRP > 1.6 mg/L may serve as a poor prognosis predictive factor for patients with AIS receiving intravenous thrombolysis. However, due to the small sample size of this study, further studies are needed to verify our results.

Systemic thrombolysis in patients with acute stroke and active cancer: a systematic review and meta-analysis.

Cancer patients frequently have concomitant cerebrovascular diseases, which significantly worsen their prognosis. Prospective studies validating intravenous thrombolysis (IVT) safety profile in patients with acute ischemic stroke and active cancer are still lacking. Therefore, we aimed to evaluate IVT's efficacy and safety profile in acute ischemic stroke patients with comorbid active cancer. We included in a meta-analysis all relevant published studies, including patients with acute ischemic stroke with or without active cancer and receiving IVT, according to recommendations for IVT treatment for acute ischemic stroke. The primary outcomes were: any intracerebral hemorrhage, all-cause mortality, and good functional outcome reported as modified Rankin Scale (mRS) ≤ 2 at the end of the scheduled follow-up period. We included 11 studies in the meta-analysis. IVT was not associated with a significant increase in the incidence of intracerebral hemorrhage (OR 1.35; 95% CI 0.85-2.14; I2 76%), nor with a significant increase in death for any cause (OR 1.26; 95% CI 0.91-1.75; I2 71%); furthermore, IVT did not influence mRS between cancer and non-active cancer stroke patients (OR 0.72; 95% CI 0.35-1.49; I2 59%). IVT seems safe and effective in patients with ischemic stroke and concomitant cancer. Due to the low overall quality of the evidence, high-quality randomized controlled trials with adequate sample sizes are needed.

Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis.

To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.

Safety and Efficacy of Intravenous Thrombolysis in the 3- to 4.5-hour Window in Acute Ischemic Stroke Patients Who Have Both Diabetes Mellitus and History of Prior Stroke

Background: For acute ischemic stroke (AIS) patients with history of prior stroke (PS) and diabetes mellitus (DM), intravenous recombinant tissue plasminogen activator (IV-tPA) therapy in the 3- to 4.5-hour window is off-label in Korea. This study aimed to assess the safety and efficacy of IV-tPA in these patients.Methods: Using data from a prospective multicenter stroke registry between January 2009 and March 2021, we identified AIS patients who received IV-tPA in the 3- to 4.5-hour window, and compared the outcomes of symptomatic intracranial hemorrhage (SICH), 3-month mortality, 3-month modified Rankin Scale (mRS) score 0-1 and 3-month mRS distribution between patients with both PS and DM (PS/DM, n=56) versus those with neither PS nor DM, or with only one (non-PS/DM, n=927).Results: The PS/DM group versus the non-PS/DM group was more likely to have a prior disability, hypertension, hyperlipidemia, coronary heart disease and less likely to have atrial fibrillation. The PS/DM and the non-PS/DM groups had comparable rates of SICH (0% vs. 1.7%; &lt;i&gt;p&lt;/i&gt;&gt;0.999) and 3-month mortality (10.7% vs. 10.2%; &lt;i&gt;p&lt;/i&gt;=0.9112). The rate of 3-month mRS 0-1 was non-significantly lower in the PS/DM group than in the non-PS/DM group (30.4% vs. 40.7%; adjusted odds ratio [95% confidence interval], 0.81 [0.41-1.59]).Conclusions: In the 3- to 4.5-hour window, AIS patients with PS/DM, as compared to those with non-PS/DM, might benefit less from IV-tPA. However, given the similar risks of SICH and mortality, IV-tPA in the late time window could be considered in patients with both PS and DM.

Intravenous thrombolysis + endovascular thrombectomy versus thrombolysis alone in large vessel occlusion mild stroke: a propensity score matched analysis.

The best reperfusion treatment for patients with mild acute ischaemic stroke harbouring proximal anterior circulation large vessel occlusion (LVO) is unknown. The aim was to compare the safety and efficacy of intravenous thrombolysis (IVT) plus endovascular thrombectomy (EVT) versus IVT alone in LVO patients with mild symptoms. From the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis and Thrombectomy Register (SITS-ISTR), were included: (i) consecutive acute ischaemic stroke patients, (ii) treated within 4.5h from symptoms onset, (iii) baseline National Institutes of Health Stroke Scale (NIHSS) score ≤5 and (iv) intracranial internal carotid artery [ICA], M1 or T occlusion [defined as occlusion of ICA terminal bifurcation]. After propensity score matching, 3-month functional outcomes (modified Rankin Scale [mRS] 0-1 and 0-2) and safety outcomes (symptomatic intracerebral haemorrhage and death) were compared (via univariable and multivariable logistic [and ordinal] regression analyses) in patients treated with IVT + EVT versus IVT alone. In all, 1037 patients were included. After propensity score matching (n= 312 per group), IVT + EVT was independently associated with poor functional outcomes (adjusted odds ratio [aOR] 0.46 for mRS 0-1, 95% confidence interval [CI] 0.30-0.72, p= 0.001; aOR 0.52 for mRS 0-2, 95% CI 0.32-0.84, p= 0.007; aOR 1.61 for 1-point shift in mRS score, 95% CI 1.12-2.32, p= 0.011), with no significant differences in safety outcomes compared to IVT alone, despite numerically higher rates of symptomatic intracerebral haemorrhage (3.3% vs. 1.1%; p= 0.082), a higher rate of any haemorrhagic transformation (17.6% vs. 7.3%; p< 0.001) and subarachnoid haemorrhage (7.9% vs. 1.5%; p= 0.002) in the IVT + EVT group. In anterior circulation LVO patients presenting with NIHSS score ≤5, IVT + EVT (vs. IVT alone) was associated with poorer 3-month functional outcome. Randomized controlled trials are needed to elucidate the best treatments in mild LVO patients.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with End-Stage Renal Disease on Hemodialysis: A Narrative Review.

Acute ischemic stroke (AIS) is a significant and devastating complication in patients with end-stage renal disease on hemodialysis (ESRD/HD). Since one-third of AIS in ESRD/HD patients occurs during or soon after dialysis, patients are more likely to present within the time window when intravenous thrombolysis (IVT) can be performed. IVT may improve prognosis in ESRD/HD patients with AIS. However, ESRD/HD patients have been excluded from large trials and may have been withheld from IVT due to concerns about bleeding complications. To date, there is no clear evidence and firm guidance on the safety and efficacy of IVT in ESRD/HD patients with AIS. This narrative review aimed to evaluate critical scientific data on the benefits and risks of IVT use in patients with ESRD/HD and AIS. We searched the electronic database of PubMed for studies evaluating the relationship between AIS, ESRD/HD, and IVT. Reference sections and additional publications were also searched manually. Studies on AIS in patients with ESRD/HD requiring maintenance dialysis that referred to IVT were included. In total, 560 studies were found in the PubMed electronic database during the period covered, of which 10 met the selection criteria. IVT for AIS in ESRD/HD patients could improve neurological outcomes and be safely performed even with the possibility of hemorrhagic complications associated with hypertension. Despite the high complication and mortality rates in ESRD/HD patients with AIS after IVT, the association with IVT was unclear. IVT for AIS in ESRD/HD patients may improve outcomes and should not be withheld based solely on ESRD/HD status.

Effect of bleeding risk prediction on decision making of intravenous thrombolysis before thrombectomy: a subgroup analysis of DIRECT-MT

BackgroundThe major concern for bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is the potentially increased risk of symptomatic intracerebral hemorrhage (sICH). Thus we conducted this study to clarify whether...

Intravenous Thrombolysis Improves the Prognosis of Patients with Acute Ischemic Stroke and Chronic Kidney Disease

BackgroundChronic kidney disease (CKD) is associated with a higher mortality rate and a poor prognosis among patients with acute ischemic stroke (AIS) who receive intravenous thrombolysis (IVT); however, it is still unclear whether IVT improves the prognosis of patients with AIS and CKD. ObjectiveWe conducted this study to evaluate the impact of IVT in patients with AIS and CKD. MethodsWe analyzed patients with AIS and CKD in 3 stroke centers who met the indications for IVT between January 2015 and January 2020. The patients were grouped into an IVT group and a non-IVT group according to whether patients received IVT. After propensity score matching at a 1:1 ratio, symptomatic intracranial hemorrhage (sICH) and the modified Rankin Scale (mRS) score at 3 months were compared to assess the safety and efficacy of IVT in patients with AIS with CKD. ResultsA total of 888 patients were enrolled: 763 in the IVT group and 125 in the non-IVT group. After matching, 250 patients were analyzed, and no significant differences were found in sICH between the 2 groups. However, the IVT group had a better 90-day mRS (0–2) score (70.4% vs. 57.6; p = 0.048) than the non-IVT group. ConclusionsIVT improved the 3-month prognosis and did not increase the occurrence of sICH among patients with AIS with CKD.

Safety and efficacy of intravenous thrombolysis in acute ischemic stroke patients with a history of intracranial hemorrhage: A systematic review and meta-analysis

Acute ischemic stroke (AIS) is a fatal and debilitating condition killing 2.7 million people each year worldwide. The most commonly used treatment modality for AIS is intravenous thrombolysis (IVT) with alteplase which is indicated for those presenting within 4.5 h of onset. Due to a lack of reliable evidence on harm or benefit, the 2019 American Heart Association/American Stroke Association (AHA/ASA) guidelines consider a history of previous intracranial hemorrhage (ICH) as potentially harmful and no longer an absolute contraindication for IVT in patients with AIS, and the U.S. Food and Drug Administration (FDA) removed chronic ICH as a specific contraindication for IVT from the label in 2015. Despite a shift in guidelines, physicians frequently face the dilemmatic choice whether to administer IVT in this subset of patients due to the risk of symptomatic intracranial hemorrhage (SICH). The benefit of IVT in such patients has not been thoroughly investigated, and there are only a few studies on the subject in the literature to date. We conducted the present meta-analysis in an aim to provide solid evidence on the efficacy and safety of IVT for treating AIS in patients with a history of remote ICH. Our meta-analysis found that IVT improves functional outcomes in AIS patients with prior remote ICH without increasing SICH or all-cause mortality. These findings may contribute to the decision-making process for IVT administration in AIS patients.

Clinical outcomes following reperfusion therapy in acute ischemic stroke patients with infective endocarditis: a systematic review.

BackgroundAcute ischemic stroke (AIS) is a common and fatal complication of infective endocarditis (IE); however, there is a lack of understanding regarding treatment efficacy. This systematic review aimed to evaluate the safety and efficacy of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) in IE patients experiencing AIS.ObjectivesThe aim of this study was to perform a systematic review investigating the outcomes of AIS in IE patients receiving IVT and/or EVT as a treatment method and to evaluate the safety and efficacy of these methods of reperfusion therapy.DesignA systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was conducted.Data Sources and MethodsThe EMBASE, Cochrane, and PubMed databases were searched for literature published between 2005 and 2021 investigating outcomes of reperfusion therapy post-AIS in IE and non-IE patients. Descriptive statistics were used to describe the overall frequency of clinical outcomes, and groupwise comparisons were performed using Fisher’s exact test to assess the significance of groupwise differences.ResultsThree studies were finally included in the systematic review. A total of 13.5% of IE patients compared to 37% of non-IE patients achieved a good functional outcome (modified Rankin Scale score≤ 2) (P < .001). Furthermore, a larger percentage of the IE cohort achieved good functional outcomes after EVT (22.0%) compared to IVT (10.4%) (P = .013). The IE cohort also had a higher 3-month postreperfusion mortality rate (48.8%) compared to the non-IE cohort (24.9%) (P < .001). The rate of intracranial hemorrhage (ICH) postreperfusion was also significantly higher in the IE cohort (23.5%) than in the non-IE cohort (6.5%) (P < .001).ConclusionAIS patients with IE, treated with IVT, EVT, or a combination of the two, experience worse clinical and safety outcomes than non-IE patients. EVT yielded better functional outcomes, albeit with higher postreperfusion ICH rates, than IVT.