Intravenous Thrombolysis For Ischemic Stroke Research Articles

Safety and Efficacy of Intravenous Thrombolysis for Ischemic Stroke in Elderly Patient with Thrombocytopenia

Introduction: Stroke remains as one of the diseases with a high mortality and morbidity which could be prevented by a prompt and concise treatment. Intravenous thrombolysis (IV-rTPA) is the mainstay treatment for hyperacute ischemic stroke with onset less than 4.5 hours. However, there are several contraindications that should be monitored, one of them being thrombocytopenia. We would like to report the use of IV-rTPA in geriatric patient with thrombocytopenia to highlight the efficacy and safety profile of the drug. Case Report: A 85-year-old woman was admitted to the emergency ward with weakness on the left extremities, slurred speech, and right-upward gaze of the eyes one hour prior to the admission in ER. Her history was significant for hypertension and type II diabetes mellitus. Physical examination revealed a muscle strength of +5/+1, left 7th and 12th cranial nerves palsy, a NIHSS score of 15, and a RACE score of 7. The laboratory result was significant for thrombocytopenia (96.000/μl). IV-rTPA was administered and two hours later, we noticed an improvement of the patient’s NIHSS score to 11. During the IV-rTPA administration, we noted a minor gum bleed, which was considered insignificant. The patient was admitted to the ICU and observed for the next 72 hours. No signs of bleeding or clinical deterioration were observed during that period. Discussion: Numerous studies have confirmed the efficacy of IV-rTPA in acute ischemic stroke if administered before 4,5 hours of onset. Thrombocytopenia is known as a contraindication of IV-rTPA which may increase the risk of bleeding. In this case, IV-rTPA is administered due to hyperacute onset and no known history of bleeding, even though the platelet count was low. Therefore, IV-rTPA may be considered if the benefits outweigh the risks with a thorough monitoring of the patient’s condition.

Abstract WP100: Trends in the Utilization of Intravenous Thrombolysis for Ischemic Stroke in Korea From 2013 to 2022

Introduction: IV thrombolysis is a proven treatment for acute ischemic stroke (AIS), but it is still underutilized in real-world clinical practice. Using a nationwide multicenter stroke registry, we aimed to determine whether there are significant trends in the rate of IV thrombolysis in different patient populations. Methods: This study assessed patients with AIS or transient ischemic attack (TIA) registered prospectively in the Clinical Research Center for Stroke-Korea (CRCS-K) registry between 2013 and 2022. Trends in IV thrombolysis rate were respectively analyzed for all patients (cohort 1), patients who arrived at the hospital within 4.5 hours of onset (cohort 2), and patients potentially eligible for IV thrombolysis (cohort 3), using joinpoint regression analysis. Trends in IV thrombolysis rates in cohorts 1-3 were further investigated using generalized linear mixed-effects models adjusted for patient characteristics and accounting for hospital heterogeneity. Results: A total of 76535 patients were included in the analysis. The mean age of the patients increased from 67.3 to 69.8 years, and the median time from onset to hospital arrival increased over the 10-year period. During the study period, proportion of patients arriving at the hospital within 4.5 hours of onset and the proportion of patients potentially eligible for IV thrombolysis decreased, especially after 2016. IV thrombolysis rates significantly declined over the 10-year period in cohorts 1-3, with a pronounced decrease in the treatment rate in potentially IV thrombolysis eligible patients from 2013 to 2016 (average annual percent change [95% CI] -4.55% [-5.66% to -3.46%] in cohort 1; -2.63% [-3.95% to -1.34%] in cohort 2; -1.33% [-2.06% to -0.49%] in cohort 3). In the multivariable model, patients who arrived in 2022 were less likely to receive IV thrombolysis compared to patients who arrived in 2013 (adjusted odds ratio [95% CI], 0.83 [0.75 - 0.93]). Conclusions: Utilization of IV thrombolysis has declined over the decade in Korea, even accounting for the decline in the number of patients who are candidates for the treatment. Urgent interventions to increase IV thrombolysis rates are needed to improve acute stroke care.

Advances in the Mechanisms of Hemorrhagic Transformation and Therapeutic Agents after Intravenous Thrombolysis in Ischemic Stroke

Advances in the Mechanisms of Hemorrhagic Transformation and Therapeutic Agents after Intravenous Thrombolysis in Ischemic Stroke

Safety of intravenous thrombolysis for ischemic stroke in patients with hematologic malignancies: A single institution experience

BackgroundData on safety of thrombolysis for acute ischemic stroke (AIS) in patients with hematologic malignancy is not well established. We report our single institution experience with thrombolysis in this patient population. MethodsWe identified patients with pathology-confirmed hematologic malignancy from 2000-2022. Primary exposure was presence of AIS and receipt of intravenous (IV) thrombolysis. Primary outcome was safety of IV thrombolysis in this patient population. Safety was measured through imaging review for hemorrhagic transformation, post-stroke mortality, and modified Rankin Scale (mRS) at 90 days. ResultsAmong 45,894 patients with hematologic malignancy, 1,099 (2.4%) were identified as having a suspected AIS. Twenty (1.8%) received IV tissue plasminogen activator (tPA) for AIS, three underwent endovascular intervention, and 17 had AIS confirmed on MRI. Two patients with confirmed AIS experienced hemorrhagic transformation, one of which was symptomatic. Most patients (n=10, 59%) were functionally independent (mRS 0-2) at 90 days post-stroke, including all patients with active hematologic malignancy at the time of stroke (n=3). Four patients died within 90 days of AIS. None of these deaths were patients with active hematologic malignancy at the time of stroke. ConclusionsWithout other contraindications, IV alteplase should be considered for management of AIS in patients with hematologic malignancy. The safety profile of tPA administration in this patient population may be similar to the general population, whether underlying hematologic malignancy is active or in remission.

Blood pressure excursion on admission and intravenous thrombolysis in ischemic stroke.

Blood pressure (BP) excursion on admission was common in patients with acute ischemic stroke, but its influence on thrombolysis effect was not fully evaluated. Patients with acute ischemic stroke who received thrombolysis without subsequent thrombectomy were included. Admission BP excursion was defined as higher than 185/110 mmHg. Multivariate logistic regression analysis was used to evaluate the relationship between admission BP excursion and poor outcome as well as hemorrhage rates and mortality. Poor outcome was defined as a 90-day modified Rankin Scale score 3-6. Subgroup analysis was performed according to stroke severity, which was assessed by the National Institutes of Health Stroke Scale (NIHSS) score, and hypertension status. A total of 633 patients were enrolled and 240 participants (37.9%) had admission BP excursion. Admission BP excursion was associated with poor outcome [adjusted odds ratio (OR) 0.64, 95% confidence interval 0.42-0.99, P = 0.046]. No significant difference was found regarding hemorrhage rates or mortality between patients with and without admission BP excursion. In subgroup analysis, admission BP excursion was related to poor outcome in patients with NIHSS score at least 7 (adjusted OR 1.89, 95% confidence interval 1.03-3.45, P = 0.038), but not in patients with NIHSS score less than 7 (P for interaction <0.001). Admission BP excursion above the guideline thresholds did not increase postthrombolysis hemorrhage risk or mortality, but was associated with poor outcome, especially in patients with severe stroke.

Safety and efficacy of intravenous thrombolysis for ischemic stroke in an elderly patient with thrombocytopenia

Background: Strokes remain as one of the diseases with high mortality and morbidity, which can be prevented through prompt and concise treatment. Intravenous thrombolysis (IV-rTPA) is the mainstay treatment for hyperacute ischemic stroke with onsets of less than 4.5 hours. However, it has several contraindications that should be monitored, one of them being thrombocytopenia. Objectives: This case report details the use of IV-rTPA in a geriatric patient with thrombocytopenia to highlight its efficacy and safety. Case: An 85-year-old woman was admitted to the emergency ward with weakness in the left extremities, slurred speech, and upward-right gaze one hour prior to ER admission. She had a significant history of hypertension and type II diabetes mellitus. A physical examination revealed a muscle strength of +5/+1, palsy in the left 7th and 12th cranial nerves, an NIHSS score of 15, and a RACE score of 7. The laboratory result was positive for thrombocytopenia (96,000/μl). IV-rTPA was administered, and two hours later, the patient's NIHSS score raised to 11. During the IV-RTPA administration, there was minor gum bleeding, which was considered insignificant. The patient was admitted to the ICU and observed for the next 72 hours. No signs of bleeding or clinical deterioration were observed during that period. Numerous studies have confirmed IV-rTPA's efficacy in acute ischemic stroke treatment if administered before 4.5 hours of onset. Thrombocytopenia is known as a contraindication of IV-rTPA, which may increase the risk of bleeding. In this case, IV-rTPA was administered due to hyperacute onset and no known history of bleeding despite low platelet count. Conclusion: IV-rTPA may be considered if the benefits outweigh the risks, coupled with thorough monitoring of the patient's condition.

Experience with non-immunogenic staphylokinase for intravenous thrombolysis in ischemic stroke: analysis of hospital registry data

Introduction. Intravenous thrombolysis (IT) is the primary method of reperfusion therapy for ischemic stroke. Over the past couple of years, there has been a global trend towards the predominant use of the bolus forms of thrombolytic drugs that is caused by necessity to increase the reperfusion therapy rate to achieve its best outcomes.Aim. To evaluate the efficacy and safety of the use of non-immunogenic staphylokinase for IT in ischemic stroke in real-world clinical practice of the regional vascular center.Materials and methods. The clinical outcomes of the cohort of 50 patients who underwent IT with non-immunogenic staphylokinase were analysed.Results. The age of the patients ranged from 46 to 94 years and averaged 71.8 ± 10.0 years; 22% of patients were over 80 years of age. The NIHSS score at admission varied from 3 to 23 scores and averaged 11 (8-14) scores. 36% of patients had large artery occlusions. 14% of patients received a step-wise reperfusion therapy. The median door-to-needle time was 23 (18-26) minutes. 52% of patients didn’t develop any infarction area during control neuroimaging. 62% of patients required no further rehabilitation. Hospital mortality was 12%. 18% of patients developed hemorrhagic conversion mainly in the form of hemorrhagic infarction. 1 patient had a symptomatic hemorrhagic conversion. Major bleeding and angioedema were not observed.Conclusion. The analysis of 50 consecutive cases of IT in ischemic stroke using non-immunogenic staphylokinase indicates the high efficiency and safety of this method of reperfusion therapy.

Intravenous thrombolysis in ischemic stroke: 10 rules for the practical neurologist

Intravenous thrombolysis (IT) with recombinant tissue plasminogen activator has remained the main method of reperfusion therapy in ischaemic stroke for a quarter of a century. The main trends in the use of IT in recent years are the expansion of the therapeutic window using additional methods of neuroimaging, reducing the number of contraindications and introduction into clinical practice of bolus forms of drugs. Providing IT to the largest number of patients should be considered a major challenge for the primary vascular department. This article presents 10 clinical rules for extending IT in stroke while ensuring its efficacy and safety: 1) conduct IT in suspected stroke; 2) conduct IT in patients over 80 (and even 90) years of age; 3) conduct IT in minor but disabling stroke; 4) conduct IT in minor vertebrobasilar stroke and central acute vestibular syndrome; 5) perform IT in cases of large artery occlusion; 6) perform IT in suspected lacunar stroke and chronic neuroimaging changes (lacunas, white matter hyperintensity, atrophy); 7) reduce door-to-needle time, use thrombolytics with bolus administration; 8) use neuroimaging options (CT perfusion, MR perfusion, MR DWI/FLAIR) to expand the therapeutic window; 9) ensure the safety of IT; 10) be prepared for complications. Increasing the frequency of IT should not be seen as a goal, but intensifying the use of this method of treatment is associated with the improvement of all areas of the diagnostic and treatment process in the clinic and the improvement of stroke outcomes.

Abstract WMP10: Sex Difference In Imaging-based Intravenous Thrombolysisfor Ischemic Stroke With Unknown Onset Time: A Pooled Analysis Of Clinical Trials

Introduction: Our prior meta-analysis reported that imaging-based intravenous thrombolysis (IVT) was safe and effective for patients who have had a stroke with an unknown onset time. The aim of this study is to investigate whether sex differences exist in clinical outcomes among this population. Methods: This is a pooled analysis of individual patient-level data acquired from the EOS project, a meta-analysis of clinical trials (PROSPERO, CRD42020166903). Patients treated with imaging-based IVT for stroke with an unknown time of onset were included. The primary outcome was a favorable functional outcome (mRS 0-1) at 90 days. Secondary outcomes were mRS shift towards a better functional outcome and death within 90 days. Sex differences were investigated using mixed-effect logistic or ordinal regression models adjusted for covariates, considering potential heterogeneity across trials. Results: Among 509 patients treated with imaging-based IVT, 204 (40.1%) were women. Compared to men, women were older (70 ± 12 vs. 67 ± 13, p=0.003), more frequently had atrial fibrillation (27.6% vs. 17.2%, p=0.005), and were taking antiplatelets prior to the onset (45.5% vs. 36.4%, p=0.045). Baseline NIHSS score was higher (8.0 (IQR 5-15) vs.6 (4-11), p&lt;0.001), and hours from last-known-well to treatment were longer (11.2 (9.3-12.9) vs. 10.3 (8.1-11.9), p&lt;0.001) in women than men. Favorable outcomes occurred in 80 (40.6%) women and in 150 (49.7%) men (p=0.047). Among women, 19 (9.6%) patients died, compared with 15 (5.0%) patients in men (p=0.042). After multivariate adjustment, female sex was not significantly associated with favorable functional outcome (adjusted odds ratio (OR) 1.01[95% confidential intervals (CI) 0.66-1.54]; p=0.97) nor death (adjusted OR 1.28 [95%CI 0.59-2.76]; p=0.59). Female sex was not associated with a significant shift towards the better functional outcome (common OR 1.07 [95%CI 0.77-1.49]; p=0.70). Conclusions: Pooled data from clinical trials show that in univariate analysis, women had numerically less good functional outcomes following imaging-based IVT among ischemic stroke patients with unknown onset time. However, this sex difference can be explained by higher age and more severe clinical status in women at stroke onset.

Nursing Home Admission and Initiation of Domiciliary Care After Ischemic Stroke – The Importance of Time to Thrombolysis

ObjectivesThere is a paucity of data on the risk of nursing home admission or domiciliary care initiation according to time to intravenous thrombolysis for ischemic stroke. We investigated the association between time to intravenous thrombolysis and the composite of nursing home admission or domiciliary care initiation in patients with acute ischemic stroke. Materials and MethodsIn this nationwide cohort study, all stroke patients treated with intravenous thrombolysis (2011–2015) and alive at discharge were identified from the Danish Stroke Registry and other nationwide registries. The composite of nursing home admission or domiciliary care initiation one year post-discharge according to time to thrombolysis was examined with multivariable Cox regression. ResultsThe study population comprised 4,349 patients (median age 67 years [25th-75th percentile 57–75], 65.2% men). The median National Institutes of Health Stroke Scale score at presentation was 5, and the median time from symptom-onset to initiation of thrombolysis was 143 min. The absolute 1-year risk of the composite endpoint was 14.0% (95%CI, 11.5–16.8%) in the ≤90 min group, 16.6% (15.1–18.1%) in the 91–180min group, and 16.0% (14.0–18.2%) in the 181–270 min group. Compared with thrombolysis ≤90 min, time to thrombolysis between 91–180 min and 181–270 min was associated with a significantly higher risk of the composite endpoint (hazard ratio 1.31 [1.04–1.65] and 1.47 [1.14–1.91], respectively). ConclusionsIn patients admitted with ischemic stroke, increasing time to thrombolysis was associated with a greater risk of the composite of nursing home admission or domiciliary care initiation. Continued efforts to shorten the time delay from symptom-onset to initiation of thrombolysis are warranted.

A new nomogram for individualized prediction of the probability of hemorrhagic transformation after intravenous thrombolysis for ischemic stroke patients

BackgroundA reliable scoring tool to detect the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis for ischemic stroke is warranted. The present study was designed to develop and validate a new nomogram for individualized prediction of the probability of hemorrhagic transformation (HT) in patients treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA).MethodsWe enrolled patients who suffered from acute ischemic stroke (AIS) with IV rt-PA treatment in our emergency green channel between August 2016 and July 2018. The main outcome was defined as any type of intracerebral hemorrhage according to the European Cooperative Acute Stroke Study II (ECASS II). All patients were randomly divided into two cohorts: the primary cohort and the validation cohort. On the basis of multivariate logistic model, the predictive nomogram was generated. The performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration plot.ResultsA total of 194 patients with complete data were enrolled, of whom 131 comprised the primary cohort and 63 comprised the validation cohort, with HT rate 12.2, 9.5% respectively. The score of chronic disease scale (CDS), the global burden of cerebral small vascular disease (CSVD), National Institutes of Health Stroke Scale (NIHSS) score ≥ 13, and onset-to-treatment time (OTT) ≥ 180 were detected important determinants of ICH and included to construct the nomogram. The nomogram derived from the primary cohort for HT had C- Statistics of 0.9562 and the calibration plot revealed generally fit in predicting the risk of HT. Furthermore, we made a comparison between our new nomogram and several other risk-assessed scales for HT with receiver operating characteristic (ROC) curve analysis, and the results showed the nomogram model gave an area under curve of 0.9562 (95%CI, 0.9221–0.9904, P < 0.01) greater than HAT (Hemorrhage After Thrombolysis), SEDAN (blood Sugar, Early infarct and hyper Dense cerebral artery sign on non-contrast computed tomography, Age, and NIHSS) and SPAN-100 (Stroke Prognostication using Age and NIHSS) scores.ConclusionsThis proposed nomogram based on the score of CDS, the global burden of CSVD, NIHSS score ≥ 13, and OTT ≥ 180 gives rise to a more accurate and more comprehensive prediction for HT in patients with ischemic stroke receiving IV rt-PA treatment.

Thrombolysis implementation intervention and clinical outcome: a secondary analysis of a cluster randomized trial

BackgroundMultiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the “Thrombolysis ImPlementation in Stroke (TIPS)” study, which aimed to improve rates of intravenous thrombolysis in Australia.MethodsA posthoc analysis was conducted using individual-level patient data. Excellent (Three-month post treatment modified Rankin Score 0–2) and poor clinical outcome (Three-month post treatment modified Rankin Score 5–6) and post treatment parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups.ResultsThere was a non-significant higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73–3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73–2.44) during the active-and post-intervention period respectively, for the intervention compared to the control group. A non-significant lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56–2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61–3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active- (odds ratio: 0.53; 95% CI: 0.21–1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36–2.52).ConclusionThe TIPS multi-component implementation approach was not effective in reducing the odds of post-treatment severe disability at 90 days, or post-thrombolysis hemorrhage.Trial registrationClinical Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN12613000939796.

Variants of WNT7A and GPR124 are associated with hemorrhagic transformation following intravenous thrombolysis in ischemic stroke.

AimsThe canonical Wnt signaling pathway plays an essential role in blood‐brain barrier integrity and intracerebral hemorrhage in preclinical stroke models. Here, we sought to explore the association between canonical Wnt signaling and hemorrhagic transformation (HT) following intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients as well as to determine the underlying cellular mechanisms.Methods355 consecutive AIS patients receiving IVT were included. Blood samples were collected on admission, and HT was detected at 24 hours after IVT. 117 single‐nucleotide polymorphisms (SNPs) of 28 Wnt signaling genes and exon sequences of 4 core cerebrovascular Wnt signaling components (GPR124, RECK, FZD4, and CTNNB1) were determined using a customized sequencing chip. The impact of identified genetic variants was further studied in HEK 293T cells using cellular and biochemical assays.ResultsDuring the study period, 80 patients experienced HT with 27 parenchymal hematoma (PH). Compared to the non‐PH patients, WNT7A SNPs (rs2163910, P = .001, OR 2.727; rs1124480, P = .002, OR 2.404) and GPR124 SNPs (rs61738775, P = .012, OR 4.883; rs146016051, P < .001, OR 7.607; rs75336000, P = .044, OR 2.503) were selectively enriched in the PH patients. Interestingly, a missense variant of GPR124 (rs75336000, c.3587G>A) identified in the PH patients resulted in a single amino acid alteration (p.Cys1196Tyr) in the intracellular domain of GPR124. This variant substantially reduced the activity of WNT7B‐induced canonical Wnt signaling by decreasing the ability of GPR124 to recruit cytoplasmic DVL1 to the cellular membrane.ConclusionVariants of WNT7A and GPR124 are associated with increased risk of PH in patients with AIS after intravenous thrombolysis, likely through regulating the activity of canonical Wnt signaling.

Hemorrhagic risk after intravenous thrombolysis for ischemic stroke in patients with cerebral microbleeds and white matter disease

ObjectivesAim of this study was to evaluate the association between cerebral microbleeds (CMBs) and white matter disease (WMD) with intracerebral hemorrhage (ICH) after intravenous thrombolysis (IVT) with rt-PA. We also evaluated whether CMBs characteristics and WMD burden correlate with symptomatic ICH and outcome.MethodsWe included acute ischemic stroke (AIS) patients treated with IVT. The number and location of CMBs as well as severity of WMD were rated analyzing pre- or post-treatment MRI. Multivariable regression analysis was used to determine the impact of CMB and WMD on ICH subgroups and outcome measures.Results434 patients were included. CMBs were detected in 23.3% of them. ICH occurred in 34.7% of patients with CMBs. Independent predictors of parenchymal hemorrhage were the presence of CMBs (OR 2.724, 95% CI 1.360–5.464, p = 0.005) as well as cortical-subcortical stroke (OR 3.629, 95% CI 1.841–7.151, p < 0.001) and atherothrombotic stroke subtype (OR 3.381, 95% CI 1.335–8.566, p = 0.010). Either the presence, or number, and location of CMBs, as well as WMD, was not independently associated with the development of SICH. No independent association between the presence, number, or location of CMBs or WMD and outcome measures was observed.ConclusionsThe results of our study suggest that the exclusion of eligible candidates to administration of IV rt-PA only on the basis of CMBs presence is not justified. The clinical decision should be weighed with a case-by-case approach. Additional data are needed to evaluate the benefit-risk profile of rt-PA in patients carrying numerous microbleeds.

Intravenous thrombolysis in ischemic stroke: clinical predictors of efficacy and safety

Introduction. Systemic thrombolysis with recombinant tissue plasminogen activator is the “gold standard” of reperfusion therapy, having the maximum level of evidence in European and North American guidelines for the treatment of patients with acute ischemic stroke (IS). Objective: to determine factors of individual efficacy and safety of systemic thrombolysis in patients with IS aiming to establish personalized approach to its optimization. Materials and methods. The study included 396 patients with IS, of whom 196 patients underwent systemic thrombolysis with recombinant tissue plasminogen activator and 200 patients formed the control group. A prospective non-randomized study was conducted in parallel groups to estimate efficacy and safety of systemic thrombolysis with recombinant tissue plasminogen activator. The primary endpoint of the study was functional independence of patients measured with a modified Rankin scale 3 months after the stroke. Results. We confirmed improvement of the functional outcome in patients with IS who underwent systemic thrombolysis. We also showed no effect of thrombolytic therapy on the mortality rates. Decreased wakefulness, presence of aphasia, hemiplegia, congestive heart failure, type 2 diabetes, postinfarction cardiosclerosis were shown to be clinical factors associated with an unfavorable prognosis of the disease after systemic thrombolysis. We found higher likelihood of death in patients with decreased level of consciousness (OR 3.1 (1.1–8.8); p=0.03), as well as with paresis (OR 6.8 (2.2–20.9); p<0.001), hemiplegia (OR 6.5 (2.0–21.4); p=0.002), and chronic heart failure (OR 2.4 (1.1–5.3); p=0.03). Conclusion. Adequate analysis of neurological symptoms and clinical and anamnestic data upon admission of a patient with IS allows to predict the effectiveness of thrombolysis and may be important in treatment planning and in choosing reperfusion methods.

Lipoproteinuria as an independent predictor of unfavorable outcome after intravenous thrombolysis in ischaemic stroke

Patients with proteinuria and declined glomerular filtration rate (GFR) are at high risk of developing stroke. Purpose of this study was to review and analyze available literature to identify role of proteinuria along with decreased GFR as one the of predictors of unfavorable outcome of ischaemic stroke in patients receiving intravenous thrombolysis therapy in routine clinical practice. Proteinuria is an independent predictor of negative outcome after intravenous thrombolysis treatment in ischaemic stroke, which demonstrates significant impact of chronic kidney disorders in effectiveness of thrombolytic therapy.

缺血性卒中静脉溶栓后症状性颅内出血研究进展 Progress of Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Ischemic Stroke

缺血性卒中静脉溶栓后症状性颅内出血研究进展 Progress of Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Ischemic Stroke

Intravenous thrombolysis for ischemic stroke in the Veneto region: the gap between eligibility and reality.

Intravenous thrombolysis (IVT) is the treatment of choice for most patients with acute ischemic stroke. According to the recently updated guidelines, IVT should be administered in absence of absolute exclusion criteria. We aimed to assess the proportion of ischemic strokes potentially eligible and actually treated with IVT, and to explore the reasons for not administering IVT. We prospectively collected and analyzed data from 1184 consecutive ischemic stroke patients admitted to the 22 Stroke Units (SUs) of the Veneto region from September 18th to December 10th 2017. Patients were treated with IVT according to the current Italian guidelines. For untreated patients, the reasons for not administering IVT were reported by each center in a predefined model including absolute and/or relative exclusion criteria and other possible reasons. Out of 841 (71%) patients who presented within 4.5h of stroke onset, 704 (59%) had no other absolute exclusion criteria and were therefore potentially eligible for IVT according to the current guidelines. However, only 323 (27%) patients were eventually treated with IVT. Among 861 (73%) untreated patients, 480 had at least one absolute exclusion criterion, 283 only relative exclusion criteria, 56 only other reasons, and 42 a combination of relative exclusion criteria and other reasons. Our study showed that only 46% (323/704) of the potentially eligible patients were actually treated with IVT in the SUs of the Veneto region. All healthcare professionals involved in the acute stroke pathway should make an effort to bridge this gap between eligibility and reality.

STARTING-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis for Stroke.

Symptomatic intracerebral hemorrhage (sICH) is a rare but the most feared complication of intravenous thrombolysis for ischemic stroke. We aimed to develop and validate a nomogram for individualized prediction of sICH in intravenous thrombolysis-treated stroke patients included in the multicenter SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register). All patients registered in the SITS-ISTR by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was sICH per the European Cooperative Acute Stroke Study II definition (any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline or death <7 days). On the basis of multivariate logistic model, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver-operating characteristic curve and calibration of risk prediction model by using the Hosmer-Lemeshow test. A total of 15 949 patients with complete data for generating the nomogram was randomly dichotomized into training (3/4; n=12 030) and test (1/4; n=3919) sets. After multivariate logistic regression, 10 variables remained independent predictors of sICH to compose the STARTING-SICH (systolic blood pressure, age, onset-to-treatment time for thrombolysis, National Institutes of Health Stroke Scale score, glucose, aspirin alone, aspirin plus clopidogrel, anticoagulant with INR ≤1.7, current infarction sign, hyperdense artery sign) nomogram. The area under the receiver-operating characteristic curve of STARTING-SICH was 0.739. Calibration was good (P=0.327 for the Hosmer-Lemeshow test). The STARTING-SICH is the first nomogram developed and validated in a large SITS-ISTR cohort for individualized prediction of sICH in intravenous thrombolysis-treated stroke patients.

Successful intravenous thrombolysis for ischemic stroke after reversal of dabigatran anticoagulation with idarucizumab: a case report

BackgroundNon-vitamin K antagonist oral anticoagulants, including dabigatran, are currently widely used for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. Recently, idarucizumab, a monoclonal antibody fragment for immediate reversal of dabigatran-induced anticoagulation, has been introduced into the market to be used in life-threatening bleeding or urgent surgery, allowing for rapid normalization of clotting parameters. The use of idarucizumab is not yet well established in patients presenting with acute ischemic stroke on dabigatran who are candidates for thrombolytic therapy.Case presentationWe report the case of a 71-year-old hypertensive Caucasian woman with non-valvular atrial fibrillation treated with dabigatran 150 mg twice daily, who presented with acute ischemic stroke causing right-sided hemiparesis and aphasia. Two hours after presentation to the emergency department, a decision was made to administer idarucizumab for achieving complete reversal of any potential anticoagulant effect of dabigatran and, in the absence of any contraindications, our patient underwent successful thrombolysis. At discharge, our patient was able to walk unassisted and had only residual aphasia. Twenty days later, she had completely recovered motor function of her right side, with further progressive improvement of aphasia. Repeat cranial computed tomography confirmed the absence of hemorrhage, and anticoagulant therapy with dabigatran 150 mg twice daily was resumed.ConclusionsOur case report adds to the evidence that idarucizumab administration is safe in the setting of patients with atrial fibrillation treated with dabigatran who develop acute ischemic stroke requiring thrombolysis.