Intravenous Fibrinolytic Therapy Research Articles

Short-Term Outcome Assessment of Acute Ischemic Stroke After Intravenous Fibrinolytic Therapy: A Cross-sectional Study

Background: The disease burden of acute ischemic stroke (AIS) is an important health issue in today’s patient care. Urgent intravenous thrombolytic (UIT) therapy is one of the most popular treatments in these cases. Objectives: This study aimed to evaluate the 1-month outcome of patients with AIS who received urgent intravenous fibrinolytic therapy. Methods: In a prospective cross-sectional study, we evaluated the 1-month outcome of cases with a confirmed diagnosis of AIS who had received UIT therapy at the emergency department. Demographic data, mortality and morbidity, hospital length of stay, admission functional disability by Modified Rankin Scale (MRS), National Institutes of Health Stroke Scale (NIHSS), and final disposition of patients were all evaluated and recorded via their medical records or structured telephone inquiries. We compared all variables between the 2 groups (i.e., survived and expired groups). Results: Among 490 cases we assessed, age had a mean ± SD of 69.41 ± 12.25 years, and most cases were males (74.3%). The 1-month mortality rate in our sample was 4.08% (20 cases). The mean ± SD of hospital length of stay was 6.84 ± 7.32 days, with no significant difference between the 2 groups (P = 0.869). Demographic data showed no significant differences between the 2 groups. NIHSS and MRS scores were significantly higher in the expired group than in the survived group (P = 0.005 and P = 0.001, respectively). Conclusions: NIHSS and MRS scores were significantly higher in the expired cases. The 1-month mortality rate in this study was 4.08%.

РЕЗУЛЬТАТЫ ПРИМЕНЕНИЯ КТ-АНГИОГРАФИИ БРАХИОЦЕФАЛЬНЫХ АРТЕРИЙ У ПАЦИЕНТОВ С ОНМК ПО ИШЕМИЧЕСКОМУ ТИПУ И ИХ СВЯЗЬ С ТЯЖЕСТЬЮ НЕВРОЛОГИЧЕСКОЙ СИМПТОМАТИКИ ПО ШКАЛЕ NIHSS

To determine the detection of large intracranial artery thrombosis by CT angiography (CTA) in patients with acute ischemic stroke, depending on the severity of neurological symptoms at the international NIHSS score. Materials and methods. Study population are patients, hospitalized to the M.P. Konchalovsky City clinical hospital in Moscow during 2019 with ischemic stroke and underwent CTA scans of extra-and intracranial arteries: total 173 patients (94 women (54.3%), man 79 (45,7 %), average age – 70 years) with a diagnosis of acute ischemic stroke, who were in all cases, NIHSS scale was used to assess the severity of neurological symptoms. Intravenous fibrinolytic therapy (FT) or intra-arterial mechanical thrombectomy (TE) was performed in all cases. The Spearman rank correlation was used to measure the correlation. Results. In 63 of 173 patients (36%) NIHSS score was 6 points or less. Occlusions of large intracranial arteries were detected in 27.7% (n=46) of cases, of which only 61% (n=28) patients reached the stage of TE. FT was performed in 54% of cases (n=94). Of 46 cases with occlusion of large intracranial arteries only 2 patients (4%) had NIHSS score 6 or less. Of all patients, who underwent the CTA, only 2 (1.2%) had NIHSS score 6 or less. There was a significant positive correlation between NIHSS score and the detection of intracranial artery thrombosis. Spearman's rank correlation coefficient Rs is 0.55 (p<0.0001). For one patient brought to the TE stage, there were 6 CTA of extra-and intracranial arteries. Conclusion. There is a strong relationship between NIHSS score and the detection of intracranial artery thrombosis by CTA. With the low values of the NIHSS score (less than 6), the probability of detection of thrombosis is extremely small. It is advisable to prescribe CTA for patients with NIHSS score of 7 or more only.

Signo de la arteria cerebral posterior hiperdensa migratoria tras trombólisis intravenosa

Computed tomography (CT) scanning of the brain continues to be the basic imaging mode in the acute phase of stroke. The hyperdense posterior cerebral artery sign is an early and infrequent radiological finding with topographic and prognostic value that must be taken into account in the initial CT scans. We report the case of a 79-year-old woman who suddenly presented with severe left homonymous hemianopsia, mild lower left facial paresis, 3/5 left hemiparesis and severe left hypaesthesia. In the initial brain CT scan, calcium hyper-density of the P1 segment is observed in the right posterior cerebral artery. Intravenous fibrinolytic therapy is administered. The patient shows clinical improvement, and in the follow-up brain CT scan at 24 hours after fibrinolysis, hyperdensity of the P3 segment is observed in the right posterior cerebral artery. Evidence of posterior cerebral artery hyperdensity is a rare radiological finding associated with an increased volume of ischaemic stroke. A computed tomography scan of the head in the acute phase is essential to try to clarify its causation. Calcium emboli are an under-diagnosed cause of stroke and occur spontaneously in a large proportion of cases. If calcium embolism is suspected, a study must be conducted in search of a carotid, valvular or aortic arch pathology. Migration of the arterial hyperdensity towards distal is associated with a better prognosis. This case presented good progress in contrast to the poor prognosis described in the literature in cases of arterial hyperdensity as an early marker of stroke in the acute phase.

ADAPT with New Catalyst 5 Reperfusion Catheter for Distal M2 Ischemic Stroke: Preliminary Experience

We sought to assess preliminary technical and clinical outcomes of Catalyst 5 (CAT 5) as front-line aspiration treatment for M2-M3 occlusion in acute ischemic stroke. Patients with symptomatic stroke and distal M2 or M3 occlusions were enrolled retrospectively. A direct aspiration first-pass technique was used as the first treatment option for absolute contraindication to intravenous fibrinolytic therapy. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. A total of 11 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 69.3 years). Tandem occlusion was present in 2 cases. Intracranial preocclusive mean vessel diameter was 1.9 mm. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 72.7% of patients with mean time to recanalization of 36.4 minutes and a mean of 1.9 attempts. First-attempt recanalization with CAT 5 was obtained in 54% of patients with a mean time to recanalization of 29.2 minutes. A stent retriever with proximal aspiration was incorporated as a rescue device in 2 cases. Embolization of new territories was reported after CAT 5 aspiration in 1 patient. No intracranial hemorrhage was detected on follow-up computed tomography. The median National Institutes of Health Stroke Scale score at discharge was 3. At 90 days, a modified Rankin Scale score of 0-2 was achieved in 90.9% of patients. Preliminary experience using CAT 5 in distal occlusions demonstrates that it may be safe and effective in acute stroke treatment.

Single-center experience using the 3MAX or 4MAX reperfusion catheter for the treatment of acute ischemic stroke with distal arterial occlusions in patients not eligible for intravenous fibrinolysis.

In acute stroke, distal cerebrovascular occlusions can be linked to severe clinical symptoms, and treatment by mechanical thrombectomy may have an important clinical impact. When intravenous fibrinolytic therapy is firmly contraindicated, it remains the only treatment option. A total of 42 patients with isolated distal arterial occlusions and absolute contraindication for intravenous fibrinolytic therapy were retrospectively included. Mechanical thrombectomy was performed using Penumbra 4MAX or 3MAX aspiration catheters. When aspiration alone did not result in successful revascularization, a stent retriever was added. Direct thromboaspiration was the first treatment option in all patients. 16.7% of cases required the additional use of a stent retriever. A TICI score ≥ 2b reperfusion at the end of the procedure was obtained in 76.2% and a Rankin Score of 2 or less at 90days in 45.7%. Two hemorrhagic complications were observed. Direct thromboaspiration appears a safe technique in acute isolated distal arterial occlusions. In a cohort of patients with absolute contraindication for intravenous fibrinolytic therapy, a significant percentage achieved good revascularization.

Assessment of neurologists\u2019 knowledge regarding intravenous fibrinolytic therapy for acute stroke in Shanxi province in China

BackgroundLimitations in physicians’ knowledge regarding fibrinolytic therapy for acute ischemic stroke may contribute to low rate of fibrinolytic therapy in China. Here physicians’ knowledge was surveyed on intravenous fibrinolytic therapy for acute ischemic stroke.MethodsNeurologists (n = 175) from 27 major general hospitals in Shanxi province, P. R. China, were invited to complete questionnaires regarding their basic knowledge of intravenous fibrinolytic therapy for acute ischemic stroke. The questionnaire contained 12 multiple-choice questions. One point was assigned for a correct answer and zero point for a false or unanswered question.ResultsOne hundred and thirty-one neurologists (74.9%) responded to the questionnaires. The mean accuracy rate of 12 questions was 54.9 ± 25.01% (range 0.8–96.2%). The mean total score for respondents was 6.59 ± 2.03 (range 2–11). More years of experience and higher academic degrees were independent factors related to the total scores (P = 0.000 and P = 0.004, respectively).ConclusionsThe neurologists in this study were knowledge deficient in the area of intravenous fibrinolytic therapy for acute ischemic stroke. This partially accounts for the low rate of fibrinolytic therapy in China.

Intracranial stents in the endovascular treatment of acute ischemic stroke

ObjectiveTo evaluate the efficacy and safety of intracranial stenting as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. Material and methodsWe retrospectively studied 42 patients treated with intracranial stenting after failed mechanical thrombectomy between December 2008 and January 2016. We compared outcomes before and after the incorporation of stentrievers. We assessed the degree of recanalization in the carotid and basilar territories (modified TIMI score), prognostic factors, and outcome (modified Rankin scale at 3 months). Safety was evaluated in function of the appearance of symptomatic intracranial hemorrhage (SICH). ResultsMedian NIHSS was 17 in patients with carotid territory strokes and 26 in those with vertebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225min in carotid territory strokes and 390min in vertebrobasilar territory strokes. A total of 10 patients underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients developed SICH; both had undergone intravenous fibrinolytic therapy (p=0.0523). Recanalization was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of stentrievers (p=0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier group and in 14 (50%) patients in the later group (p=0.042). We found significant associations between recanalization and outcome (p=0.0415) and between shorter time to treatment and outcome (p=0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p=0.078). ConclusionsIntracranial stenting is the rescue treatment when the usual treatment fails. Stentrievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet treatment did not seem to increase the risk of SICH except in patients with prior intravenous fibrinolytic therapy.

Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus

ObjectiveTo evaluate the efficacy and safety of intracranial stenting as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. Material and methodsWe retrospectively studied 42 patients treated with intracranial stenting after failed mechanical thrombectomy between December 2008 and January 2016. We compared outcomes before and after the incorporation of stentrievers. We assessed the degree of recanalization in the carotid and basilar territories (modified TIMI score), prognostic factors, and outcome (modified Rankin Score at 3 months). Safety was evaluated in function of the appearance of symptomatic intracranial hemorrhage (SICH). ResultsMedian NIHSS was 17 in patients with carotid territory strokes and 26 in those with vertebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225minutes in carotid territory strokes and 390minutes in vertebrobasilar territory strokes. A total of 10 patients underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients developed SICH; both had undergone intravenous fibrinolytic therapy (p=0.0523). Recanalization was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of stentrievers (p=0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier group and in 14 (50%) patients in the later group (p=0.042). We found significant associations between recanalization and outcome (p=0.0415) and between shorter time to treatment and outcome (p=0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p=0.078). ConclusionsIntracranial stenting is the rescue treatment when the usual treatment fails. Stentrievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet treatment did not seem to increase the risk of SICH except in patients with prior intravenous fibrinolytic treatment.

Retroperitoneal Bleed with Ticagrelor Administration Following Fibrinolytic Therapy in Acute ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction, in anticipation of primary percutaneous coronary intervention, clopidogrel, prasugrel or ticagrelor are given with Aspirin on presentation. The Authors report a case of acute ST elevation anterior wall myocardial infarction administered ticagrelor with Asprin with intent to treat by primary percutaneous coronary intervention, but patient subsequently opted for intravenous fibrinolytic therapy instead of primary percutaneous coronary intervention . Although fibrinolytic therapy was successful in achieving reperfusion, patient developed significant retroperitoneal bleed requiring multiple blood transfusions. Only clopidogrel is recommended in the setting of fibrinolytic therapy in the guidelines and no data are presently available with ticagrelor. Key words: ST elevation myocardial infarction, Ticagrelor, Fibrinolysis, Primary percutaneous coronary intervention (PCI).

Intravenous Fibrinolytic Therapy in Central Retinal Artery Occlusion: A Patient-Level Meta-analysis.

Central retinal artery occlusion (CRAO) is an ophthalmologic emergency that can result in blindness. At present, no proven therapy for CRAO exists. Treatment with fibrinolytic agents has shown promise but remains of unproven benefit. To assess the efficacy of systemic fibrinolytic therapy for patients with CRAO and to define a time window of efficacy. We systematically queried PubMed, Web of Science, and Scopus using the following index terms: "retinal artery occlusion" OR "retinal ischemia" AND "thrombolysis" OR "fibrinolysis" OR "tissue plasminogen activator" OR "streptokinase" OR "urokinase." Search was not limited by year of publication or language and was conducted in August 2014. In addition, we evaluated the references from relevant review articles. We assembled observational studies reporting on visual acuity outcomes after CRAO. Inclusion criteria were complete reporting of visual outcomes after CRAO (with or without fibrinolytic therapy) and a series of more than 5 patients for fibrinolysis treatment or more than 20 cases when untreated or treated with conservative modalities. Patient-level data were sought for studies reporting outcomes of treatment with fibrinolysis. Summary statistics were obtained for conservative treatment and natural history studies. The studies were weighted by the inverse of variance and merged in a random-effects model. Rate of visual recovery (defined as improvement of visual acuity from 20/200 or worse at presentation to 20/100 or better) was calculated for patients treated with fibrinolytic and conservative therapies and those who received no treatment. We obtained summary statistics from 7 studies that included 396 patients who received no treatment after CRAO and from 8 studies that included 419 patients treated with ocular massage, anterior chamber paracentesis, and/or hemodilution (conservative treatment). Patient-level data were obtained for 147 patients treated with systemic fibrinolysis. We found that fibrinolysis was beneficial at 4.5 hours or earlier after symptom onset compared with the natural history group (17 of 34 [50.0%] vs 70 of 396 [17.7%]; odds ratio, 4.7 [95% CI, 2.3-9.6]; P < .001). Absolute risk reduction was 32.3%, with a number needed to treat of 4.0 (95% CI, 2.6-6.6). We also found that conservative treatment significantly worsened visual acuity outcomes and recovery rates after CRAO compared with the natural history group (31 of 419 [7.4%; 95% CI, 3.7%-11.1%] vs 70 of 396 [17.7%; 95% CI, 13.9%-21.4%]; P < .001; number needed to harm, 10.0 [95% CI, 6.8-17.4]). Our analysis suggests that a clinical trial of early systemic fibrinolytic therapy for CRAO is warranted and that conservative treatments are futile and may be harmful.

Endovascular treatment of Stroke: Historical Perspective

Page e4 Effective acute ischemic stroke therapy hinges on rapid restoration of blood flow to the ischemic tissue. Since the National Institute of Neurological Diseases and Stroke r-tPA study,1 intravenous fibrinolytic therapy in appropriately selected patients has been the primary method used to open the vessels and improve neurological outcome from stroke. The intravenous administration allowed for widespread dissemination of the technique, since therapy could be started very rapidly after the diagnosis is made. However, successful treatment with r-tPA requires careful patient selection and adherence to strict inclusion and exclusion criteria. As a result, there is a significant number of patients who could not receive the therapy. Even though significantly better than placebo for most stroke patients, some still suffered a poor outcome in spite of therapy. This raised the question whether there could be a way to directly apply the fibrinolytic agent to the occlusive thrombus with catheter-based techniques in an effort to more effectively treat large vessel occlusions. Intra-arterial thrombolysis was reported helpful in restoring flow in relatively small series of patients, especially situations like basilar thrombosis, with a dire natural history.2 However, only one study, the PROACT study showed a positive impact on neurological outcome compared to placebo.3 Results of this study were often used to justify endovascular treatment of patients ineligible or unresponsive to intravenous r-tPA but intra-arterial administration of the fibrinolytic was often unsuccessful restoring flow in the occluded vessel, and not infrequently was associated with hemorrhagic transformation of the stroke. The endovascular armamentarium increased in the early years of the 21st century with the development of the MERCI device (Stryker, Fremont, CA, USA), a cork-screw-like device designed to mechanically retrieve thrombus.4,5 This resulted in a higher success rate in opening occluded vessels compared to pharmacological methods and could be used in patients in whom r-tPA is contraindicated. In the years that followed, additional mechanical thrombectomy devices were introduced including stent-like retrievers like the Solitaire (ev3-Medtronic, Irvine, CA, USA), and the Trevo (Stryker, Fremont, CA, USA), and the Penumbra aspiration system (Penumbra, San Leandro, CA, USA) which all appeared to be far more effective than Merci in opening occluded vessels. The IMS III study sought to provide evidence of the effectiveness of endovascular techniques plus intravenous r-tPA versus intravenous r-tPA alone, but it enrolled patients when these newer devices were just becoming available. Most endovascular patients were only treated with intra-arterial r-tPA and, not surprisingly, the study showed no benefit in outcome.6 This prompted some to predict the death of endovascular stroke therapy. A short time later, results of well-designed studies beginning with the MR CLEAN study7 appeared in rapid succession showing significantly improved outcome with endovascular treatment of large vessel occlusions using the modern stent-like retrievers.8-11 Within a short period of time, endovascular therapy went from being on the verge of extinction to being an integral part of comprehensive stroke care. The future will no doubt see investigations refining patient selection criteria, evaluating the role of advanced imaging techniques, evolving and improving the devices and techniques and improving infrastructure to allow all appropriate patients have access to these devices and the trained physicians that can use them safely and effectively.

Coronary Aneurysm Closure With Pericardial Covered Stent Evaluated With Optical Coherence Tomography

A 62-year-old man with personal history of arterial hypertension and smoking was admitted to our hospital with ST elevation myocardial infarction. Intravenous fibrinolytic therapy was given by emergency services during hospital transfer, which was effective. Routine coronary angiography showed moderate lesion on the proximal left anterior descending, proximal coronary aneurysm (Figure 1A, asterisk) and significant lesions at mid segment of circumflex (white arrow) and proximal segment of the second marginal (arrowhead). The case was discussed with the heart team and the decision was made to perform percutaneous coronary intervention. Balloon predilation was performed and drug-eluting stent was implanted in second marginal followed by direct drug-eluting stent implantation at mid segment of circumflex, fitting the proximal stent to distal origin of aneurysm. A 3.5 18 mm, pericardial, covered stent (Aneugraft, ITGI Medical Ltd., Israel) was implanted at circumflex aneurysm, overlapped to the distal drug-eluting stent with good final result (Figure 1B). Several optical coherence tomography pullbacks were conducted in order to confirm correct implantation of pericardial covered stent (Figure 2A, asterisk) and correct overlapping with distal drug-eluting stent (Figure 2B, white arrow). Patient was discharged on dual antiplatelet therapy with aspirin and clopidogrel for 1 year. Although initially designed for vein graft angioplasty, pericardial covered stents have been used to treat other problems in interventional cardiology, such as coronary aneurysm, with limited experience. We present here what is, to the best of our knowledge, the first case to use optical coherence tomography to evaluate the final result of pericardial covered stenting in coronary aneurysm. Figure 1. Figure 2.

Spatial Distribution of Perfusion Abnormality in Acute MCA Occlusion is Associated with Likelihood of Later Recanalization

The aim of this study is to investigate whether different spatial perfusion-deficit patterns, which indicate differing compensatory mechanisms, can be recognized and used to predict recanalization success of intravenous fibrinolytic therapy in acute stroke patients. Twenty-seven acute stroke data sets acquired within 6 hours from symptom onset including diffusion- (DWI) and perfusion-weighted magnetic resonance (MR) imaging (PWI) were analyzed and dichotomized regarding recanalization outcome using time-of-flight follow-up data sets. The DWI data sets were used for calculation of apparent diffusion coefficient (ADC) maps and subsequent infarct core segmentation. A patient-individual three-dimensional (3D) shell model was generated based on the segmentation and used for spatial analysis of the ADC as well as cerebral blood volume (CBV), cerebral blood flow, time to peak (TTP), and mean transit time (MTT) parameters derived from PWI. Skewness, kurtosis, area under the curve, and slope were calculated for each parameter curve and used for classification (recanalized/nonrecanalized) using a LogitBoost Alternating Decision Tree (LAD Tree). The LAD tree optimization revealed that only ADC skewness, CBV kurtosis, and MTT kurtosis are required for best possible prediction of recanalization success with a precision of 85%. Our results suggest that the propensity for macrovascular recanalization after intravenous fibrinolytic therapy depends not only on clot properties but also on distal microvascular bed perfusion. The 3D approach for characterization of perfusion parameters seems promising for further research.

Implementation of clinical practice guidelines for acute ischaemic stroke in specialist care centres

IntroductionCerebrovascular disease is associated with high morbidity and mortality. In 2008, the Spanish Ministry of Health published its Clinical Practice Guidelines for stroke prevention, but implementation of that document has not yet been assessed. Our study aims to investigate compliance with the Guidelines by analysing control over vascular risk factors, antithrombotic treatment and lipid lowering treatment in patients who had suffered an acute ischaemic stroke and who were under the care of neurologists or internists. MethodsCross-sectional study based on data from clinical reports (vascular risk factors, diagnosis and treatment), blood pressure readings and laboratory tests pertaining to 203 patients diagnosed with acute ischaemic stroke and admitted to a medium-to-long stay hospital for rehabilitation and care. ResultsThe mean patient age was 75±10 years; 56% were women. The most common risk factors were hypertension (68%) and diabetes mellitus (40%). Intravenous fibrinolytic therapy had been administered to 8.9% of the patients. Of the patients with thrombotic cerebral infarction, 91.7% received antiplatelet agents; 59.4% of patients with embolic infarction received anticoagulants. Statins were prescribed to 65% of patients with thrombotic infarction. Laboratory tests upon admission showed that 23% of patients had total cholesterol levels above 175mg/dl and 26.6% had plasma glucose levels above 126mg/dl. Of the patient total, 70% received antihypertensive therapy, but 47.5% had blood pressure levels above 130/80mm Hg. ConclusionsIn our opinion, secondary prevention of acute cerebrovascular disease could be improved, mainly by increasing the percentage of patients treated with antiplatelet or anticoagulant drugs (depending on aetiology), increasing prescription of statins, and improving blood pressure control.

Implementación de las guías de práctica clínica sobre ictus isquémico agudo en atención especializada

IntroductionCerebrovascular disease is associated with high morbidity and mortality. In 2008, the Spanish Ministry of Health published its Clinical Practice Guidelines for stroke prevention, but implementation of that document has not yet been assessed. Our study aims to investigate compliance with the Guidelines by analysing control over vascular risk factors, antithrombotic treatment and lipid lowering treatment in patients who had suffered an acute ischaemic stroke and who were under the care of neurologists or internists. MethodsCross-sectional study based on data from clinical reports (vascular risk factors, diagnosis and treatment), blood pressure readings and laboratory tests pertaining to 203 patients diagnosed with acute ischaemic stroke and admitted to a medium-to-long stay hospital for rehabilitation and care. ResultsThe mean patient age was 75±10 years; 56% were women. The most common risk factors were hypertension (68%) and diabetes mellitus (40%). Intravenous fibrinolytic therapy had been administered to 8.9% of the patients. Of the patients with thrombotic cerebral infarction, 91.7% received antiplatelet agents; 59.4% of patients with embolic infarction received anticoagulants. Statins were prescribed to 65% of patients with thrombotic infarction. Laboratory tests upon admission showed that 23% of patients had total cholesterol levels above 175mg/dl and 26.6% had plasma glucose levels above 126mg/dl. Of the patient total, 70% received antihypertensive therapy, but 47.5% had blood pressure levels above 130/80mm Hg. ConclusionsIn our opinion, secondary prevention of acute cerebrovascular disease could be improved, mainly by increasing the percentage of patients treated with antiplatelet or anticoagulant drugs (depending on aetiology), increasing prescription of statins, and improving blood pressure control

Assessment and Improvement of Figures to Visually Convey Benefit and Risk of Stroke Thrombolysis

Deciding whether to use intravenous fibrinolytic therapy for acute cerebral ischemia within 3 hours of onset is challenging for patients, family members, and health care providers. Visual displays can permit individuals to rapidly understand response patterns to therapy. This study sought to evaluate, refine, and improve existing visual aids for stroke fibrinolytic decision-making. Existing visual aids were identified by Medline search and querying of national guideline organizations, pharmaceutical manufacturers, and stroke specialists, and were rated on a formal 8-point quality rating scale (0, lowest; 8, highest). Based on available instruments, new visual displays were developed to improve informed decision-making in routine practice. Two existing visual aids were identified, one from an emergency medicine society and one from a pharmaceutical company. Both were comparison visual displays of outcomes with and without treatment; no decision matrix visual aid was found. Both scored 4.0 on the quality scale, showing defects of effect size distortion, privileging less salient outcomes, dissimilar representation by treatment group, and limited stakeholder participation in generation. Revised versions of these graphics were developed with higher quality scores (6.75 and 7.75). In addition, a new decision matrix display with quality score 8.0 was developed that complements the numeric text of a national patient education tool developed jointly by US neurology, emergency medicine, and stroke patient organizations. Existing visual aids for stroke fibrinolysis decision-making have deficiencies. New visual displays are now available to convey the health benefits and risks of fibrinolytic stroke therapy efficiently and informatively to patients and family members.

Antithrombotic and fibrinolytic drugs for retinal vein occlusion: A systematic review and a call for action

Optimal management of retinal vein occlusion (RVO) is still a matter of debate. Antithrombotic and fibrinolytic drugs have been investigated after demonstration of a role of thrombosis in the complex pathogenesis of the disease. Aim of our study was to systematically summarise best available evidence on the acute treatment and on the secondary prevention of RVO with antithrombotic and fibrinolytic drugs. A computer-assisted search of the MEDLINE and EMBASE electronic databases up to January 2009 was performed. Two review authors selected all published randomised controlled trials (RCTs) from the search, assessed study quality and extracted data. Based on Jadad's score, RCTs were stratified into three quality categories. A total of six RCTs were included. Only one RCT of high quality was identified. A total of 384 patients were investigated, 234 with central retinal vein occlusion and 150 with branch retinal vein occlusion. No study enrolled more than 100 patients. Three studies compared therapeutic doses of low-molecular-weight heparin (LMWH) with low-dose aspirin, one study compared ticlopidine with placebo and two studies compared intravenous fibrinolytic therapy followed by warfarin or aspirin with either haemodilution or no treatment. A partial improvement of visual acuity was reported in every study, independently of the study drug. No long-term secondary prevention study was published. The present systematic review suggests that antithrombotic therapy, in particular LMWH, may be part of the therapeutic armamentarium for patients with recent onset RVO. No firm recommendation can be provided given the limited available evidence.

An early invasive strategy versus ischemia-guided management after fibrinolytic therapy for ST-segment elevation myocardial infarction: A meta-analysis of contemporary randomized controlled trials

Although the use of an early invasive strategy among patients with ST-segment elevation myocardial infarctions (STEMI) who are treated initially with fibrinolytic therapy is common, the safety and efficacy of this approach remains uncertain. We performed a meta-analysis to best estimate the benefits and harms of an early invasive strategy in STEMI patients treated initially with full-dose intravenous fibrinolytic therapy, as compared to a traditional strategy of ischemia-guided management. We included contemporary randomized controlled trials, defined a priori as those with >50% stent use during percutaneous coronary intervention (PCI). Outcomes extracted from the published results of eligible trials included all-cause mortality, reinfarction, stroke, and in-hospital major bleeding. We identified 5 contemporary trials enrolling 1,235 patients who met our inclusion criteria. Of the patients randomized to an early invasive strategy, 86% underwent PCI with 87% receiving stents. Follow-up duration ranged from 30 days to 1 year. An early invasive strategy was associated with significant reductions in mortality (odds ratio [OR] 0.55, 95% CI 0.34-0.90) and reinfarction (OR 0.53, 95% CI 0.33-0.86) compared with ischemia-guided management. There were no significant differences in the risk of stroke (OR 1.31, 95% CI 0.42-4.10) or major bleeding (OR 1.41, 95% CI 0.74-2.69). An early invasive strategy after fibrinolytic therapy is associated with significant reductions in mortality and reinfarction. Our results suggest a potentially important role for this strategy in the management of STEMI patients but should be confirmed by large randomized trials.

Variations in the use of emergency PCI for the treatment of re-infarction following intravenous fibrinolytic therapy: impact on outcomes in HERO-2

Patients who suffer re-infarction during initial hospitalization for ST-elevation myocardial infarction (STEMI) have decreased survival compared to patients without re-infarction, so treatment of re-infarction may influence survival. To determine whether the utilization of reperfusion therapies varied within 12 h of re-infarction and was associated with 30-day mortality, we studied 552 patients with re-infarction of 17,073 patients with STEMI enrolled in HERO-2 in five regions (Russia, Eastern Europe, Western Countries, Asia, and Latin America). Patients presenting within 6 h of symptom-onset were randomized to receive either bivalirudin or unfractionated heparin intravenously just prior to streptokinase. Re-infarction occurred in 2.8 and 3.6% of bivalirudin and heparin treated patients, respectively (P = 0.004), but treatment assignment did not influence mortality after re-infarction. Patients with re-infarction had a higher 30-day mortality than those without re-infarction (24 vs. 10%; P < 0.001 by Cox model). Within 12 h of re-infarction, fibrinolytic therapy was administered to 12.0 and 8.2% underwent percutaneous coronary intervention (PCI); these two treatments were more frequently utilized in patients from Western countries (n = 112), compared to patients from other countries (n = 440) (34.8 and 16.1% compared to 6.1 and 6.1%, respectively, P < 0.001). Mortality was 15% in patients receiving reperfusion therapy for re-infarction and 27% for those with conservative management, hazard ratio (HR) 0.53 (95% CI 0.32-0.88), P = 0.01. In multiple Cox regression analysis which included adjustment for clinical variables and randomized treatment assignment, 30-day mortality after re-infarction varied by region (highest Latin America 29%, lowest Western countries 15%; P = 0.01). Other independent prognostic factors included age, time from randomization to re-infarction, and Killip class at randomization. The HR for PCI treatment of re-infarction was 0.18 [(95% CI 0.04-0.76), P = 0.02] in analyses which excluded deaths within 12 h. Treatment of re-infarction with reperfusion therapies was markedly under-utilized, especially in non-western countries. PCI for re-infarction, in particular, was associated with a lower 30-day mortality, which may reflect both patient selection and effects of treatment.

PCI Faster During Business Hours

“Time is muscle” applies to intravenous fibrinolytic therapy and percutaneous coronary intervention (PCI). To assess whether times to these treatments