Intravenous Thrombolysis For Acute Stroke Research Articles

Thrombolysis Beyond the Guidelines

We report the first case of 2 intravenous thrombolysis treatments within 90 hours in a patient with early recurrent stroke. A 50-year-old man had improved significantly after intravenous thrombolysis for acute stroke. On the fourth day, he deteriorated dramatically because of recurrent stroke. Evidence of vessel reocclusion and profound perfusion/diffusion mismatch constituted the rationale for a second thrombolysis treatment, which resulted in vessel recanalization and significant neurologic improvement. The pathophysiological information obtained by multimodal magnetic resonance imaging may suit as a brain clock when repeat thrombolysis treatment is considered for early recurrent stroke.

Conservative Medical Treatment and Intravenous Thrombolysis in Acute Stroke from Carotid T Occlusion

Background: We aimed to analyse the course of early recanalization and corresponding functional outcome in patients with an acute occlusion of the carotid T who were treated conservatively or underwent intravenous thrombolysis. Methods: Forty-two patients with an acute occlusion of the carotid T within 6 h were recruited from consecutive admissions to a neurological department participating in the Duplex Sonography in Acute Stroke study. All patients underwent a standardized admission and follow-up procedure. Colour-coded duplex sonography was performed on admission, 30 min after thrombolysis, and at 6 and 24 h after onset of symptoms. Recanalization of the carotid T was classified as complete, partial and absent. Functional outcome was rated with the modified Rankin scale (mRS) at 3 months as favourable (mRS 0–2) or poor (mRS 3–6). Results: Within 6 h, complete or partial recanalization occurred in 1 of 27 patients treated conservatively and in 6 of 15 thrombolysed patients. Intravenous thrombolysis predicted early recanalization also after adjustment for age, sex, cardioembolic stroke aetiology and time to treatment (adjusted odds ratio, OR, 39.7; 95% confidence interval, CI, 2.0–801.7; p = 0.016). An early recanalization was the only selected predictor of a favourable outcome (OR, 13.6; 95% CI, 1.0–179.0; p = 0.047) at regression analysis, and was achieved in 3 thrombolysed patients but in none with conservative medical treatment. Conclusions: In patients treated conservatively, functional outcome is poor and early recanalization rarely occurs. The latter can be achieved by intravenous thrombolysis with a rate comparable to that found at an intra-arterial approach without major intracranial bleeding complications. Early recanalization is associated with a better functional outcome.

Intravenous thrombolysis for acute stroke.

Intravenous t-PA is effective if given to appropriate patients within 3 hours of stroke onset, and its effectiveness increases even within the first 3 hours when given as soon as possible. t-PA is reasonably safe if used in a carefully defined manner that ensures close attention to blood pressure, careful patient monitoring, no use of heparin and aspirin during first 24 hours, and appropriate patient selection. It is still unclear whether a lower dose of t-PA given with 3 hours could be as effective as but safer than the currently approved intravenous dose of 0.9 mg/kg over 1 hour. The effectiveness and safety of intravenous t-PA when given beyond 3 hours after stroke onset has yet to be conclusively demonstrated. One attractive development is the potential use of imaging, such as diffusion/perfusion MRI to determine if salvageable brain remains and if t-PA should be given in patients who are beyond the 3-hour time window. The drawback to MRI is the additional time required before the start of recanalization therapy.

Eligibility for intravenous thrombolysis in acute stroke: A multicenter prospective study

P182 Objective: To elucidate the proportion of patients who would have been eligible for alteplase treatment following the ECASS II criteria in a prospective study conducted in 20 Spanish general or university hospitals. Methods: The first 100 consecutive patients with an acute stroke admitted between 9/98 and 4/99 in each participating hospital were evaluated. Data concerning exclusion criteria for tPA, demographic variables, distance to hospital (<5km,5–20km,>20km), time (0–6am,6–12,12–6pm,6–12pm) and place (home, work/street, hospital) of symptoms onset, subject detecting the event (victim, family member, bystander), dispatch system (own initiative, EMS, primary physician, community hospital), delay and type of transport (own transport, basic, or advanced life support ambulance), cardiovascular risk factors, stroke severity (Canadian scale) and type of stroke were recorded. Results: Out of 1599 screened patients, 166 (10.4%) fulfilled all criteria for tPA treatment. Multiple reasons for exclusion were time from onset >6h in 23%, or unknown in 23%, delay in neurological attention >6h in 39%, TC not available within 6h from onset in 34%, hemorrhage in 14%, early signs of infarction involving >33% MCA in 8%, TIA or rapidly improving symptoms in 24%, coma or hemiplegia plus forced eye deviation in 5%, hypertension >185/110 in 2%, coagulation abnormalities in 1%, and other reasons in 6%. Univariate analyses showed that high eligibility for tPA was associated with type of the first medical intervention (emergency medical system)(p=0.006), type of transport (basic or advanced life support ambulance)(p<0.0001), stroke severity (p<0.001), and type of stroke (cardioembolic) (p=0.0027). Age, distance to hospital, time and place of stroke onset, subject detecting the event, and risk factors were not significantly related to eligibility. Conclusions: Candidates for intravenous tPA treatment within 6 hours from stroke onset are 10% of patients admitted in general hospitals of an EU country. Delay in neurologic attention and CT examination were the main reasons for exclusion. Dispatch system, and type of transport were modifiable factors related to eligibility.

Eligibility for intravenous thrombolysis in acute stroke: A multicenter prospective study

P182 Objective: To elucidate the proportion of patients who would have been eligible for alteplase treatment following the ECASS II criteria in a prospective study conducted in 20 Spanish general or university hospitals. Methods: The first 100 consecutive patients with an acute stroke admitted between 9/98 and 4/99 in each participating hospital were evaluated. Data concerning exclusion criteria for tPA, demographic variables, distance to hospital ( 20km), time (0–6am,6–12,12–6pm,6–12pm) and place (home, work/street, hospital) of symptoms onset, subject detecting the event (victim, family member, bystander), dispatch system (own initiative, EMS, primary physician, community hospital), delay and type of transport (own transport, basic, or advanced life support ambulance), cardiovascular risk factors, stroke severity (Canadian scale) and type of stroke were recorded. Results: Out of 1599 screened patients, 166 (10.4%) fulfilled all criteria for tPA treatment. Multiple reasons for exclusion were time from onset >6h in 23%, or unknown in 23%, delay in neurological attention >6h in 39%, TC not available within 6h from onset in 34%, hemorrhage in 14%, early signs of infarction involving >33% MCA in 8%, TIA or rapidly improving symptoms in 24%, coma or hemiplegia plus forced eye deviation in 5%, hypertension >185/110 in 2%, coagulation abnormalities in 1%, and other reasons in 6%. Univariate analyses showed that high eligibility for tPA was associated with type of the first medical intervention (emergency medical system)(p=0.006), type of transport (basic or advanced life support ambulance)(p Conclusions: Candidates for intravenous tPA treatment within 6 hours from stroke onset are 10% of patients admitted in general hospitals of an EU country. Delay in neurologic attention and CT examination were the main reasons for exclusion. Dispatch system, and type of transport were modifiable factors related to eligibility.

Intravenous thrombolysis for acute stroke.

Until recently there was no specific therapy for stroke, but the recent publication of the National Institute of Neurological Disorders and Stroke(NINDS) t-PA for Acute Stroke Trial presents the first effective, specific therapy for stroke.1 In considering whether to apply thrombolysis to any given patient, the physician must consider the factors unique to each patient and the scientific literature regarding the therapy. We now review the literature that preceded the publication of the NINDS study to put the positive results into perspective. We selected papers for inclusion in our review in two ways. First, we collected the pivotal works known to one or more of the authors. Second, we performed a Medline retrieval for the years 1966 to 1996 using the search terms cerebrovascular disorders and human thrombolytic therapy, excluding references with the terms myocardial infarction or coronary angiography. We also excluded papers not written primarily in English. This search yielded 178 references. We carefully examined the titles and subject words. We eliminated 32 that appeared to be letters or editorials, 46 that appeared to be review articles with no original data, 10 that were case reports of one or a few patients, 23 that addressed the use of intra-arterial thrombolysis, and 53 that were concerned with other uses of thrombolysis such as removing intracerebral hematomas or preventing vasospasm. We retrieved, critically reviewed, and categorized the 14 remaining papers using the criteria listed in table 1. View this table: Table 1 Criteria used for categorizing publications reviewed here Rationale for cerebral artery thrombolysis. It has been assumed from the earliest writings on stroke and confirmed in recent studies employing vascular imaging techniques that most ischemic strokes result from vascular occlusion caused by thrombus.2,3 In a small minority of cases, ischemia may be caused by other mechanisms such as vasospasm. The …

Simultaneous bilateral thalamic hemorrhages following the administration of intravenous tissue plasminogen activator

A patient suffered the onset of simultaneous bilateral thalamic hemorrhage several hours after the administration of intravenous tissue plasminogen activator. The patient exhibited features of the paramedian diencephalic syndrome, including executive dysfunction, anterograde amnesia, inattention, and disturbances of visual perception. During rehabilitation, she made significant gains in overlearned activities of daily living tasks, but her inability to retain new information left her severely disabled. The use of intravenous thrombolytic therapy is believed to account for this patient's unusual stroke syndrome. With recent evidence supporting the efficacy of intravenous thrombolysis in acute stroke, patients with multiple hemorrhagic strokes as a result of thrombolysis may become more common on rehabilitation services.