Alteplase Infusion Research Articles

Efficacy and safety of reduced-dose and slow-infusion intravenous alteplase regimen in patients with acute pulmonary embolism at intermediate-high-risk

Abstract Background In patients with intermediate-high-risk (IHR) pulmonary embolism (PE), full-dose systemic thrombolytic treatment (STT) has been documented to lower the risk of hemodynamic decompensation and mortality, at the expense of an elevated risk of life-threatening bleeding. In this study, we aimed to evaluate the safety of reduced-dose STT regimen while maintaining effective reperfusion. Methods This single-center study comprised 124 retrospectively evaluated patients (female 58.9 % and mean age 55.4+15.8 years) diagnosed with acute PE at IHR status in accordance with European Society of Cardiology (ESC) 2019 acute PE guidelines in whom intravenous (i.v.) alteplase treatments were utilized. Patients fulfilling at least one of the following criteria have been included in the study: systolic blood pressure ≤ 110 mm Hg, heart rate > 100 bpm, SaO2 < 90 % on room air, respiratory rate > 20 breaths per minute, or serum lactate > 2 mmol/L. Exclusion criteria were any contraindication for STT and symptom onset > 14 days. Standard protocol for initial STT was i.v. infusion of alteplase of 25 mg over 4-6 hours. After completion of the infusion, a second STT in the same manner if one of the following criteria were present; heart rate > 100 bpm, SaO2 < 90 % or signs of organ hypoperfusion. Results Syncope and concomitant deep vein thrombosis were documented in 27.4 % and 49.2 % of patients, respectively. Baseline vital measures were as follows; heart rate: 112 +16.6 bpm, systolic blood pressure: 123+14.9 mm Hg, SaO2: 89 % (85-93), serum lactate 2.35 (1.6-2.9) mmol/L. Median alteplase dose and infusion duration were 50 (25-50) mg and 6 (4-10) hours, respectively. There were significant improvements in clinical parameters, pulmonary thrombus burden, pressure strain and right ventricular size and function as assessed by computed tomography and echocardiography (p< 0.001 for all). Minor and major bleeding events occurred in 3.2 % and 4.8 % of patients, respectively. One major bleed was due to cerebellar hemorrhage, but did not require surgery and patient was discharged without sequela. There were 6 (4.8 %) in-hospital deaths in which 2 were attributed to major hemorrhages and 4 due to hemodynamic decompensation. Conclusion In patients with acute IHR PE, reduced-dose and slow-infusion i.v. alteplase regimen seems to be a clinically relevant and safe reperfusion alternative to full-dose STT protocols associated with well-known major bleeding risks.

Clinical case of successful thrombolysis in a newborn with thrombosis of the left renal vein

Thrombosis occurring in the neonatal period is a nosology with a large number of complications, often leading to disability and death. This article highlights the successful treatment of a newborn child with renal vein thrombosis using systemic thrombolysis. A clinical case of successful systemic thrombolysis in a full-term boy in the early neonatal period with thrombosis of the left renal vein and transition of the floating part of the thrombus to the inferior vena cava is presented. A child aged 3 days was admitted to the neonatal intensive care unit from a maternity hospital, where thrombosis was suspected. Gross hematuria was observed. Laboratory data revealed thrombocytopenia and increased levels of fibrinogen and D-dimer. Ultrasound showed a sharp increase in the volume of the left kidney, a diffuse change in its parenchyma, a sharp depletion of blood flow, and accumulation of fluid in the perinephric tissue on the left, and a thrombus was observed in the lumen of the left renal vein with the presence of a floating part extending into the inferior vena cava. Thrombolytic therapy with the drug alteplase was started in combination with an infusion of unfractionated heparin. Doses were selected based on coagulogram parameters. On day 2 of therapy, hematuria resolved. On day 4 of therapy, the alteplase infusion was completed, and heparin therapy was continued. On day 13, the child was switched to a low-molecular-weight-heparin therapy. Dynamic ultrasound revealed size reduction, recanalization and further thrombus lysis, and normalization of intrarenal blood flow and kidney size. No renal dysfunction was recorded during observation. The child was transferred to the further care unit at aged 14 days and was discharged home at the age of 25 days in satisfactory condition on ongoing anticoagulant therapy under outpatient supervision of a hematologist. During follow-up observation at aged 1.5 months of life, no clinical, laboratory, and ultrasound indicators of renal function disorders were noted. Currently, there are no approved recommendations and protocols for individual thrombosis in newborns, although this particular age group is due to the vulnerability of hemostasis to the development of a thrombotic process.

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Alteplase in Acute Ischemic Stroke: A Time to Pass the Torch

Alteplase, a biosynthetic form of human tissue‐type plasminogen activator, is Food and Drug Administration‐approved for the treatment of acute ischemic stroke and currently the standard of care for thrombolytic therapy. Tenecteplase, a modified form of alteplase using recombinant technology, has several pharmacological advantages over alteplase, including longer half‐life, higher fibrin specificity, and greater resistance to plasminogen activator inhibitor‐1. Additionally, tenecteplase is given as a single bolus administration compared to the bolus plus 1‐hour continuous infusion of alteplase. Given these pharmacologic and logistical differences along with studies demonstrating noninferiority compared with alteplase, tenecteplase has become an alternative thrombolytic for the management of acute ischemic stroke. There is a growing body of evidence that suggests tenecteplase is a safe and effective alternative to alteplase. This systematic review evaluates the available literature for the use of tenecteplase in acute ischemic stroke and provides relevant discussion regarding role in therapy, therapeutic strategies, and areas requiring further research.

Intravenous thrombolysis for bioprosthetic valve thrombosis.

A 77-year-old woman experienced new-onset dyspnoea on exertion 1 year after alcohol septal ablation and transcatheter aortic valve implantation (TAVI) with a balloon-expandable valve for symptomatic severe aortic stenosis and basal septal hypertrophy. Transthoracic echocardiographic assessment (TTE) revealed an incremental transvalvular peak velocity from 2.9 m/s 3 days after TAVI to 4.3 m/s. Multislice computed tomography (MSCT) demonstrated hypoattenuated leaflet thickening (HALT) of all leaflets and reduced leaflet motion (RLM) of one leaflet (Panel A). Her antithrombotic regimen was changed from apixaban 5 mg bi-daily to acenocoumarol with a target international normalized ratio (INR) of 2.5–3.5. Six weeks later, symptoms persisted and the transvalvular peak velocity was 3.9 m/s (Panel B). A decision was made to attempt to resolve the thrombus with repeated intravenous infusions of alteplase.1,2 Four sequential infusions of 25 mg alteplase/25 h resulted in an uneventful but stepwise decrease of the transvalvular peak velocity to 2.8 m/s (Panel C–F). Multislice computed tomography confirmed normalization of leaflet motion with some residual remaining leaflet thickening (Panel F). MSCT cine images before and after alteplase infusion are available in the Supplementary data online (Videos S1 and S2).

Thrombectomy alone vs thrombectomy with over 2/3-dose intravenous thrombolysis pretreatment in the DIRECT-MT trial

BackgroundThe DIRECT-MT trial showed that endovascular thrombectomy (EVT) alone was noninferior to EVT preceded by intravenous alteplase. However, the infusion of intravenous alteplase was uncompleted before the initiation of EVT in most cases of this trial. Therefore, the additional benefit and risk of over 2/3-dose intravenous alteplase pretreatment remain to be assessed. MethodsWe assessed patients with acute anterior circulation ischemic stroke who received EVT alone or with over 2/3-dose intravenous alteplase pretreatment from the DIRECT-MT trial. Patients were assigned to the thrombectomy-alone group and the alteplase pretreatment group. The primary outcome was the distribution of modified Rankin Scale (mRS) at 90 days. The interaction of treatment allocation and collateral capacity was assessed. ResultsA total of 393 patients (thrombectomy alone: 315; alteplase pretreatment: 78) were identified. The thrombectomy alone was comparable with alteplase pretreatment prior to the thrombectomy on the distribution of mRS at 90 days without significant effect modification by collateral capacity (adjusted common odds ratio (acOR), 1.12; 95% CI, 0.72–1.74; adjusted P for interaction = 0.83). Successful reperfusion before thrombectomy and the number of passes in the thrombectomy alone group differed significantly from the alteplase pretreatment group (2.6% vs. 11.5%; corrected P = 0.02 and 2 vs. 1; corrected P = 0.003). There was no interaction between treatment allocation and collateral capacity on all outcomes. ConclusionsEVT alone and EVT preceded by over 2/3-dose intravenous alteplase might have equal efficacy and safety for patients with acute anterior circulation large vessel occlusion, except for successful perfusion before thrombectomy and the number of passes.

VIsion Salvage Using Intra-Ophthalmic Arterial Alteplase Combine with Nimodipine in Central Retinal Artery Occlusion (VISION).

To investigate the efficacy and safety of selective intra-ophthalmic arterial combined nimodipine and alteplase infusion in patients with central retinal artery occlusion (CRAO). Non-randomized, prospective interventional study. All patients with CRAO who presented at our institute within 24 hours from CRAO onset from August 2020 to July 2022 were included. Intra-arterial nimodipine and alteplase were given selectively into the ophthalmic artery. Visual acuity was recorded during and after the procedure. Change in best corrected visual acuity (BCVA) 1 month post-treatment, relative to baseline, was set as the primary outcome measure. Significant improvement in vision and adverse events are reported as secondary outcomes. Nine patients with non-arteritic CRAO were enrolled. A total of nine patients with CRAO underwent selective intra-ophthalmic arterial nimodipine and alteplase injection. Overall, BCVA had statistically significantly improved by 0.78 logarithm of the minimum angle of resolution (logMAR) at 1 month compared with baseline (95% confidence interval: (-1.24, -0.31), p-value = 0.001). Seven (77.8%) patients had significant visual improvement (≥0.3 logMAR) at 1-month post-treatment. There were minor adverse events during administration of the nimodipine, including chemosis and headache, which resolved after the discontinuation of nimodipine. There were also asymptomatic thromboembolic events in 2 patients (22.2%) after the intervention procedure, without any morbidity or mortality. The use of selective intra-ophthalmic arterial combined nimodipine and alteplase was efficacious in improving BCVA at 1 month for patients with non-arteritic CRAO presenting between 24 hours from onset, with minor adverse events but no serious adverse events.

Abstract Number ‐ 259: Recanalization Before Completion of Alteplase Infusion Leads to Improved Outcomes: A Retrospective Analysis

Introduction The recently published CHOICE trial found that intra‐arterial infusion of alteplase improved clinical outcomes in patients undergoing EVT for LVO AIS, an effect that was possibly due to a reduction in reperfusion‐related injury. Here, we examine whether intravenous alteplase, administered after successful endovascular reperfusion, results in improved clinical outcomes. Methods From our prospectively collected multicenter institutional registry drawn from four comprehensive stroke centers in the greater Houston area, we identified cases who underwent EVT with substantial reperfusion (TICI 2b/3) prior to termination of the intravenous alteplase continuous drip. Control patients were then identified as patients who underwent EVT with TICI 2b/3 after completion of intravenous alteplase, matching on age, baseline Modified Rankin Scale (mRS), initial NIH Stroke Scale (NIHSS), and comorbidities. The primary outcome was 90 day disability and was determined by mRS shift analysis, comparing the case and control populations. Results Among 21 cases and 24 matched controls, there were no significant difference between the mean age, gender, race, initial NIHSS, baseline mRS, or ASPECT score. Time from last known well to recanalization was longer in controls (48 min vs 151 min, p< 0.01). Patients who achieved reperfusion prior to termination of the alteplase continuous drip had better 90 day clinical outcomes relative to their presentation mRS when compared to patients who achieved reperfusion after termination of the alteplase. A change in mRS of 1 or less was seen in 71% vs 33% in the continued infusion group vs controls respectively. Conclusions Patients undergoing EVT who continued to be treated with intravenous alteplase following reperfusion had better 90d clinical outcomes relative to those with reperfusion after infusion termination. These findings further support the possible efficacy of thrombolytics following endovascular reperfusion.

Point-of-care diagnosis and monitoring of fibrinolysis resistance in the critically ill: results from a feasibility study

BackgroundFibrinolysisis is essential for vascular blood flow maintenance and is triggered by endothelial and platelet release of tissue plasminogen activator (t-PA). In certain critical conditions, e.g. sepsis, acute respiratory failure (ARF) and trauma, the fibrinolytic response is reduced and may lead to widespread thrombosis and multi-organ failure. The mechanisms underpinning fibrinolysis resistance include reduced t-PA expression and/or release, reduced t-PA and/or plasmin effect due to elevated inhibitor levels, increased consumption and/or clearance. This study in critically ill patients with fibrinolysis resistance aimed to evaluate the ability of t-PA and plasminogen supplementation to restore fibrinolysis with assessment using point-of-care ClotPro viscoelastic testing (VET).MethodsIn prospective, observational studies, whole-blood ClotPro VET evaluation was carried out in 105 critically ill patients. In 32 of 58 patients identified as fibrinolysis-resistant (clot lysis time > 300 s on the TPA-test: tissue factor activated coagulation with t-PA accelerated fibrinolysis), consecutive experimental whole-blood VET was carried out with repeat TPA-tests spiked with additional t-PA and/or plasminogen and the effect on lysis time determined. In an interventional study in a patient with ARF and fibrinolysis resistance, the impact of a 24 h intravenous low-dose alteplase infusion on coagulation and fibrinolysis was prospectively monitored using standard ClotPro VET.ResultsDistinct response groups emerged in the ex vivo experimental VET, with increased fibrinolysis observed following supplementation with (i) t-PA only or (ii) plasminogen and t-PA. A baseline TPA-test lysis time of > 1000 s was associated with the latter group. In the interventional study, a gradual reduction (25%) in serial TPA-test lysis times was observed during the 24 h low-dose alteplase infusion.ConclusionsClotPro viscoelastic testing, the associated TPA-test and the novel experimental assays may be utilised to (i) investigate the potential mechanisms of fibrinolysis resistance, (ii) guide corrective treatment and (iii) monitor in real-time the treatment effect. Such a precision medicine and personalised treatment approach to the management of fibrinolysis resistance has the potential to increase treatment benefit, while minimising adverse events in critically ill patients.Trial registration: VETtiPAT-ARF, a clinical trial evaluating ClotPro-guided t-PA (alteplase) administration in fibrinolysis-resistant patients with ARF, is ongoing (ClinicalTrials.gov NCT05540834; retrospectively registered September 15th 2022).

Does Adjunctive Prophylactic Intracoronary Infusion of Low Dose Alteplase Prevent No-Reflow Phenomenon During Primary Percutaneous Coronary Intervention?

Primary percutaneous coronary intervention (PPCI) is the gold standard approach to restore blood flow in ST-segment elevation myocardial infarction (STEMI); however, the no-reflow phenomenon as a potential complication of PPCI can worsen the outcomes. It has been hypothesized that adjunctive prophylactic intracoronary infusion of low-dose fibrinolytic might improve the PPCI outcomes; however, this theory is a matter of debate. The current study aims to investigate the value of adjunctive prophylactic intracoronary low-dose alteplase to prevent the no-reflow phenomenon in patients with STEMI. This case-control study was conducted on 80 STEMI patients who underwent PPCI. The patients were assigned into the case group who were intervened by 10 mg adjunctive intracoronary alteplase immediately at the end of the balloon angioplasty (n=40) and controls (n=40) who underwent conventional PPCI only. The angioplasty-associated outcomes including final TIMI score, need for no-reflow treatment, ST-segment resolution, post-PPCI complications, and death were compared between the groups. Alteplase use was accompanied by significantly improved final TIMI flow scores (P-value<0.001) and fewer requirements for no-reflow treatments (P-value<0.001); however, it did not improve the ST-segment resolution (P-value=0.491). The mortality rate and post-angioplasty complications did not differ between the groups (P-value>0.05). Based on the findings of this study, adjunctive infusion of low-dose intracoronary alteplase during PPCI could not efficiently prevent the no-reflow phenomenon. Although the final TIMI flow and need for post-stenting no-reflow treatment improved, ST-segment resolution did not occur dramatically. Given that, this approach requires further investigations and should be considered cautiously.

Low dose ultra-slow infusion thrombolytic therapy (LDUSITT) as an alternative option in a COVID-19 patient with free-floating right atrial thrombus: a case report and review of literature

The hyper-coagulopathy nature of COVID-19 is a prevalent consequence among patients. Free-floating right atrial thrombi are a relatively rare finding and the optimal therapy is a therapeutic dilemma.We present a 37-year-old woman with acute dyspnea and fatigue. Several ground glass opacities were shown on computed tomography of chest that further proved to be associated with severe COVID-19 disease. A transthoracic echocardiography revealed a mobile right atrial mass with bilateral pulmonary embolism. She was considered high risk for surgical therapy by cardiovascular surgeons. She was then started on anticoagulation therapy for 5 days however the size regression of the thrombus remained unchanged. A regimen of low dose (24 mg) ultra-slow (24 h) intravenous infusion of alteplase, without bolus was initiated. Following the third day of thrombolytic therapy, the control echocardiography demonstrated complete resolution of the thrombus.Prolonged infusion of low dose fibrinolytics can be an alternative treatment to surgery for right heart thrombi.

530: EVALUATION OF ALTEPLASE INFUSION DELAY FOLLOWING BOLUS AND IMPACT ON OUTCOMES IN ISCHEMIC STROKE​

Introduction: Alteplase is most beneficial when given early in acute ischemic stroke (AIS) and therefore a door-to-needle time (DTN) of less than 30 minutes is recommended by the AHA. Institutions may administer the alteplase bolus immediately following results of the non-contrast CT scan, however the start of alteplase infusion may be delayed for various reasons. Delays between the alteplase bolus and infusion can result in reduced drug concentration due to a short half-life (5 minutes), but it is unknown how a prolonged delay between bolus and infusion impacts outcomes. We performed a single health-system retrospective assessment determine if a delay of more than 5 minutes between alteplase bolus and infusion impacts outcomes in patients with AIS. Methods: Adult patients who received alteplase for the treatment of AIS between March 2015 through October 2021 were included. Patients were excluded if they received alteplase at an outside hospital; underwent a mechanical thrombectomy; lacked documentation of admission or discharge NIHSS; or if pregnant. The primary outcome evaluated the change in the NIHSS from admission to discharge in patients with less than or equal to a five-minute difference compared to patients with greater than a five-minute difference from alteplase bolus to infusion. Secondary outcomes evaluated admission NIHSS compared to 90-day mRS, discharge location, in-hospital mortality, and 90-day mortality. Results: 1229 patients were included. 280 patients had a bolus to infusion delay of > 5 minutes and 949 patients had a delay of ≤ 5 minutes. There was no difference in the change in NIHSS from admission to discharge (decrease of 3 points). There was also no difference in the secondary outcomes except for 90-day mortality which was statistically higher in the group of patients with a bolus to infusion delay (6.8% vs 3.3% p-value: 0.009). The difference in 90-day mRS (n=470) was not statistically significant but did show a trend towards worse outcomes in patients with an initial NIHSS of 5-14. Conclusions: Delay in alteplase infusion following bolus did not consistently show worse patient outcomes but did show an increase in 90-day mortality and mRS. Interpretation of these study results should be taken with caution due to the retrospective nature and missing data points for 90-day mRS.

A pilot randomised trial of catheter-directed thrombolysis or standard anticoagulation for patients with intermediate-high risk acute pulmonary embolism.

Intermediate-high risk acute pulmonary embolism (PE) remains associated with substantial mortality despite anticoagulation therapy. The aim of this randomised pilot study was to compare catheter-directed thrombolysis to standard anticoagulation therapy. Intermediate-high risk acute PE patients were admitted to a tertiary care centre (November 2019 to April 2021) and randomised in a 1:1 ratio to catheter-directed thrombolysis (CDT) or standard anticoagulation. Two catheters were used for the infusion of alteplase (1 mg/hr/catheter; total dose 20 mg) in the CDT group. The primary efficacy endpoint targeted improvement of right ventricular (RV) function, a decrease in pulmonary pressure, and a reduction of thrombus burden. Twenty-three patients were included (12 in the CDT group and 11 in the standard care group). The primary efficacy endpoint was achieved more frequently in the CDT group than in the standard care group (7 of 12 patients vs 1 of 11 patients, p=0.0004). An RV/left ventricular ratio reduction ≥25% (evident on computed tomography angiography) was achieved in 7 of 12 patients in the CDT group vs 2 of 11 patients in the standard care group (p=0.03). A systolic pulmonary artery pressure decrease of ≥30% or normotension at 24 hrs after randomisation was present in 10 of 12 patients in the CDT group vs 2 of 11 patients in the standard care group (p=0.001). There was no intracranial or life-threatening bleeding (type 5 or 3c bleeding, according to the Bleeding Academic Research Consortium classification). CDT for intermediate-high risk acute PE appears to be safe and effective. Further research is warranted to assess clinical endpoints.

Minimally Invasive Drainage of Intracerebral Hemorrhage. A South American Experience with the MISTIE Procedure

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke but is associated with greater rates of disability or mortality. One of the factors of a poor prognosis is large hematoma volume. The MISTIE III trial with the aim of decreasing clot size showed that the greater the ICH reduction, the higher likelihood of lower mortality without a net increase in the proportion of patients with severe disability. Our aim is to describe our experience with treating selective patients with ICH per the MISTIE trial protocol in a university hospital in Argentina during 4 years. A retrospective analysis was performed of consecutive patients with ICH treated at a single university tertiary-care center from 2017 to 2021 with the MISTIE protocol. We deployed this procedure in 7 patients with a median age of 61 years, median National Institutes of Health Stroke Scale score of 14, an ICH volume of 35 mL and median ICH score of 2. Five of 7 patients achieved the target goal of hematoma reduction; 4 of the patients had a total independence level and 1 needed minimal help at 12 months after discharge. Five patients had a good functional outcome (modified Rankin Scale score 0-3 and extended Glasgow Outcome Scale score 4-8) and 2 patients had died but neither because of consequences of thrombolysis of the intracerebral hemorrhage. We did not find bleeding complications during catheter placement, alteplase infusion, or after catheter removal. The procedure can be carried out safely in Latin American centers that have experience in managing neurocritical patients.

Effectiveness and safety of intravenous alteplase in patients with acute ischemic stroke: Results of a single centre study

: To evaluate effectiveness and safety of intravenous alteplase (tPA) for the treatment of acute ischemic stroke. In this prospective observational study, adult patients with ischemic stroke were treated with intravenous alteplase. We recorded baseline demographics and NIHS score was calculated at baseline, 2 hours, 24 hours and 7 days. Improvement was assessed by evaluating total NIH stroke score at different time points. Based on the neurological assessment, patients were categorised into three categories: unchanged (U), improving (I) and deteriorating (D). Blood pressure was closely monitored until 24 hours after infusion of alteplase. Both neurological assessment and blood pressure was monitored every 15 minutes for the first 2 hours after start of infusion, then every 30 minutes for next 6 hours, and hourly from the post infusion hour until 24 hours after infusion. Twenty-six patients [male 16 (61.50%); female 10 (38.50%)] between 34 to 86 years of age were enrolled in this study. Total NIHS score reduced from 10.77 (+5.01) at pre-treatment to 4.04 (+4.00) at 7 days. The improvement in NIHS score at two hours versus pre-treatment (p&amp;#60;0.001), at 24 hours versus 2 hours (p=0.002) and 7 days versus 24 hours (p&amp;#60;0.001) was statistically significant. Clinically no significant change was observed in the blood pressure of the patients till 24 hours after thrombolysis. At the end of 24 hours, 40% patients showed improved status and in 60% patients, status was unchanged. Intravenous alteplase is effective and safe treatment approach for treatment of acute ischemic stroke. No major complications were observed in this study.

Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism.

Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism.

Effectiveness of alteplase infusion for the management of prosthetic mitral valve thrombosis in paediatric age group and proposed algorithm.

The incidence of prosthetic valve implantation is increasing in the paediatric population. Prosthetic valve thrombosis leading to obstruction could potentially be a life-threatening complication. There is a debate regarding optimal management of this complication, and there is limited use of thrombolytic therapy in childhood in the setting of valve thrombosis. We aim to share our experience of successfully using fibrinolytic therapy in terms of alteplase for paediatric prosthetic mitral valve thrombosis and to propose a management algorithm. This retrospective analysis of the database was conducted at our hospital including patients who underwent thrombolysis (alteplase) for prosthetic mitral valve thrombosis from June, 2011 to June, 2021. A total of 10 patients with 20 attempts of alteplase infusion were found in our record. Alteplase was successful in 19 attempts to relieve valve thrombosis. The safe and effective dose of alteplase was between 0.1 and 0.3 mg/kg/hour. There were no associated major bleeding complications and alteplase was administered either by central or peripheral line. Thrombolysis by alteplase infusion was found to be successful in relief of prosthetic mitral valve thrombosis in paediatric population without major bleeding complications.

Abstract WMP28: The Safety And Feasibility Of Early Mobility In Acute Ischemic Stroke Patients After IV Alteplase

Background and Purpose: Acute stroke patients who receive intravenous (IV) alteplase have historically remained on bedrest for the first 24 hours after infusion completion. We sought to determine the safety and feasibility of mobilizing patients with low NIHSS between 6 and 24 hours post-alteplase infusion. Methods: Patients with NIHSS ≤5 after IV alteplase infusion were included. We excluded patients also undergoing mechanical thrombectomy. Subjects were stratified into an early mobilization group and a standard care group based on nursing compliance with an early mobilization protocol. Safety endpoints included falls, neurological deterioration in NIHSS (increase of ≥ 2 points), and physiological events (defined by out-of-range vital signs). Each safety endpoint was quantified for both groups. Additionally, demographic characteristics and past medical history were compared between the groups to identify any statistically significant differences (p &lt; 0.05). Results: Between June 2020 and April 2021, 93 acute stroke patients received IV alteplase and had an NIHSS of ≤5 following thrombolytic therapy. Of the included subjects, 54 received early mobilization while 39 did not. There were no statistically significant differences in gender, race, or past medical history between the two groups. Among safety endpoints, there were no reported instances of falls, neurological deterioration in NIHSS, or significant physiological events in either group. Conclusions: Our study demonstrates that instituting early mobilization as soon as 6 hours after alteplase infusion completion is safe and feasible mild acute stroke patients. Future studies should explore efforts to increase the number of patients who receive early mobilization and investigate functional outcomes between patients receiving early mobilization compared to standard medical care.

Thrombosis of the right atrium in acute massive pulmonary embolism: a clinical case of effective thrombolysis by alteplase in a patient with unstable hemodynamics

The article presents a clinical case of treatment of a patient with acute massive pulmonary embolism. A 70-year-old patient was urgently admitted to the intensive care unit with complaints of sudden onset of chest pain for the first time, severe shortness of breath and two episodes of syncope in the last 4 hours. When the patient was admitted to the hospital, the heart rate was 131 beats / min, blood pressure was 80/50 mm Hg, SpO2 was 88 %, and PO2 was 76 mm Hg. Echocardiographically revealed dilated right atrium and right ventricle, hyperechogenic «floating» formation of the right atrium; moderate tricuspid regurgitation and pronounced pulmonary hypertension with systolic pressure in the pulmonary artery ~ 63 mm Hg were observed, and preserved systolic function of the left ventricle; inferior vena cava 20 mm, on the udder did not fall. It was urgently decided to carry out thrombolytic therapy to the patient in connection with unstable hemodynamics. The patient was started administration of alteplase according to the accelerated scheme: 10 mg of tissue plasminogen activator as an intravenous bolus for 1 minute of administration, then – intravenous infusion of alteplase 90 mg for the next 2 hours until the maximum total dose of 100 mg. Three hours after thrombolytic therapy – hemodynamic parameters of the patient had a positive dynamics: blood pressure – 125/80 mm Hg, pulse – 76/min, SaO2 – 98 %, PO2 – 90 mm Hg. On transthoracic echocardiography – no thrombus in the right atrium and right ventricle, as well as a small tricuspid regurgitation, with slight pulmonary hypertension (PsystRV – 36 mm Hg). This clinical case demonstrates thrombolysis with alteplase – «rescue therapy» and a fairly effective treatment option for patients with unstable hemodynamics, acute massive pulmonary embolism, complicated by thrombosis of the right atrium and/or right ventricle and existing hypertensive.

Advances in Stroke: Treatments-Interventional.

Advances in Stroke: Treatments-Interventional.

Abstract 1122‐000170: Stent Retrievers Utilization in Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Introduction : Patients with Cerebral Venous Sinus Thrombosis (CVT) are candidates for Endovascular Mechanical Thrombectomy (EMT) in cases of coma on presentation or clinical deterioration despite anticoagulation. We present two cases of CVT successfully treated with mechanical thrombectomy using Medtronic’s Solitaire Stent retriever. Methods : A retrospective review at a single center university hospital was performed for all cerebral venous sinus thrombosis case log from December 2018 to November 2020. Cases resistant to conventional medical therapy that underwent intrasinus stent retriever endovascular thrombectomy were noted. Results : Case 1: 26 year‐old male with a history of hypertension presented with 2 weeks of headaches, left sided numbness and blurriness of vision. Imaging revealed superior sagittal (SSS) and bilateral transverse sinus thrombosis. Patient was treated with heparin infusion and discharged home on oral apixaban. The following day he presented with new onset expressive aphasia. Imaging was unchanged. Due to worsening symptoms despite anticoagulation, Patient underwent mechanical thrombectomy using a stent retriever. Solitaire 6 × 40 mm stent was advanced and deployed through the microcatheter and retracted in the upper segment of posterior one third of SSS followed by alteplase infusion at 1 mg/hr (25 ml/hr) via Berenstein catheter for the next 36 hours. Intravenous heparin infusion was also started with aPTT goal 60–80. Cerebral angiogram was repeated two days later revealing successful recanalization of previously thrombosed SSS and bilateral transverse sinuses with significantly improved cerebral venous drainage. Patient was transitioned again to oral apixaban. Repeat CTA in 3 months showed significantly improved patency and recanalization. Case 2: A 42 year‐old male with history of ulcerative colitis presented with sudden onset right‐sided hemiparesis and hemisensory loss along with one month of headaches. Presenting NIHSS 14. Imaging revealed SSS thrombosis with thrombosis of the left transverse sinus complicated by left frontal intraparenchymal hemorrhage and subarachnoid hemorrhage. Patient underwent mechanical thrombectomy of SSS using Solitaire 6 × 40mm stent retriever with distal aspiration resulting in improved flow. Clinical course was complicated by seizures and acute respiratory distress syndrome requiring intubation followed by tracheostomy and G‐tube placement which were eventually removed during recovery. Patient was treated with high intensity heparin during his hospitalization and eventually transitioned to apixaban. Work up revealed protein S deficiency. Serial CT angiograms at 6 and 11 months revealed resolution of CVT. NIHSS improved to 1 with mRS of 2. Conclusions : These cases imply that intra‐cerebrovenous sinus mechanical thrombectomy with stent retrievers may be considered in patients with continuing worsening despite optimal medical management.