rt-PA For Acute Stroke Research Articles

Analysis of Safety and Efficacy of the Early Initiation of Antithrombotic Secondary Prevention in Patients Treated with Intravenous Thrombolysis for Acute Ischemic Stroke.

Background and Objectives: Current guidelines and the alteplase product insert recommend that antithrombotic therapy be avoided within 24 h of intravenous thrombolytic therapy with rt-PA in acute ischemic stroke. Therefore, the rate of stroke recurrence is unclear in terms of early neurological deterioration, which we could prevent with the early administration of antithrombotic therapy. We do not know the effect of early antithrombotic therapy after intravenous thrombolysis with rt-PA in acute stroke on the outcome in patients after 90 days either. Design: Prospective monocentric observational cohort study. Methods: Data were collected from consecutive patients treated with alteplase for acute ischemic stroke between January 2015 and January 2023. We examined functional outcome at 90 days, including the risk of symptomatic intracranial hemorrhage and mortality rate as safety indicators and stroke recurrence events in both early and standard antithrombotic therapy at 24 h after intravenous thrombolysis. Results: A total of 489 patients were included, of which 278 (56.9%) were men. Of these, 407 (83.2%) patients received early antithrombotic therapy. No symptomatic intracranial hemorrhage occurred in any participants. There was a significantly higher number of patients with an excellent outcome (mRS 0-1) in early antithrombotic treatment (211 (53.1%) versus 28 (34.6%) in standard antithrombotic treatment (p = 0.002, OR 0.47, 95% CI: 0.28-0.76). Conclusions: Early antithrombotic treatment after intravenous therapy in patients with acute ischemic stroke revealed no safety concerns compared with standard antithrombotic therapy and resulted in a significantly higher proportion of patients with an excellent functional outcome.

The Role of Leukoaraiosis on Outcomes and Recombinant Tissue-Plasminogen Activator-Related Symptomatic Intracerebral Hemorrhages in Acute Stroke

Background and Purpose: We aimed to assess whether severe leukoaraiosis (LA) is associated with outcomes and symptomatic intracerebral hemorrhages (sICH) in patients who were treated with recombinant tissue-plasminogen activator (rt-PA) for acute stroke. Methods: We analyzed the data of anterior circulation stroke patients who were treated with rt-PA at our stroke center during 2009–2016. LA was scored according to the van Swieten scale (VSS) on computed tomography (CT) and dichotomized into groups as absent or moderate versus severe LA. We used the safe implementation of thrombolysis in stroke definition for sICH and the modified Rankin Scale (mRS) scores at 3 months after rt-PA were recorded. Results: Of 302 patients, 47 (15.6%) showed severe LA (VSS >4) on CT. The overall sICH rate was 3.6%. Moreover, sICH was significantly more frequent in patients with severe LA (n = 5 of 47; 10.6%) than in patients with absent/moderate LA (n = 6 of 255; 2.4%; P = 0.017). In addition, patients with severe LA had higher baseline glucose level (P = 0.006) and systolic blood pressure (P = 0.005) compared to patients with absent/moderate LA. Patients with severe LA were more likely to have a poor outcome (mRS: 3–6) compared to those without severe LA (P = 0.009). Conclusion: The presence of severe LA on CT increases the risk of sICH and poor outcome in patients treated with rt-PA for acute stroke.

Recombinant tissue plasminogen activator (rt‐PA) utilisation by rural clinicians in acute ischaemic stroke: A survey of barriers and enablers

This paper identified barriers which prevent rural health care providers from utilising rt-PA in acute ischaemic stroke and proposes possible support mechanisms to increase its utilisation. This descriptive study uses data from anonymous surveys distributed to health care providers involved in acute stroke patient care in three rural hospitals with rt-PA pathways. Saturation sampling was used. Surveys gathered self assessed ratings of experience, practice environment, attitudes, existing support, barriers and possible enablers regarding rt-PA use in acute stroke. Physicians reported the strongest barriers to the use of rt-PA in acute stroke as pre-hospital delays (91%), risk of intracerebral haemorrhage (ICH) (73%) and clinical diagnostic uncertainty (60%). They reported high levels of confidence in the support received from their stroke units (90%). Nurses identified a poor level of stroke education and knowledge on rt-PA utilisation in acute stroke. A third of nurses could correctly list six different stroke signs. The risk of ICH following rt-PA administration in stroke was also a significant barrier for nurses. Response rate from physicians was 26% (10/38) and 19% (13/69) for nurses. To reduce barriers to rt-PA utilisation in rural facilities physicians require education on the calculated risk of ICH as well as exposure and experience to improve their ability to confidently diagnose stroke patients who are eligible for rt-PA treatment. Education for nurses on symptoms of stroke and rt-PA utilisation and administration is recommended.

Brainstem Hyperperfusion Syndrome After Intravenous Thrombolysis: A Case Report

Recombinant tissue plasminogen activator (rtPA)-associated hyperperfusion syndrome in brainstem after acute stroke has not yet been reported. The current report demonstrates that rtPA-associated hyperperfusion syndrome can be a cause of clinical deterioration following improvement (DFI) after rtPA in acute stroke. We observed a transient DFI in a 59-year-old man with acute ischemic stroke who received rtPA. The phenomenon was assessed by magnetic resonance imaging (MRI) with diffusion-weighted image (DWI) and a series of transcranial Doppler scan evaluating changes in the basilar arterial flow. We demonstrated a reversible hyperintensity at pons on DWI as well as a transient increase in basilar arterial flow on Doppler scan suggesting the occurrence of vasogenic edema and hyperperfusion at brainstem. rtPA-associated hyperperfusion can occur at brainstem causing transient neurological deficits. It can be a cause of DFI in addition to reocclusion after recanalization.

Utilization and outcome of thrombolytic therapy for acute stroke in Pakistan

Our objective was to identify the outcome of patients treated with tissue plasminogen activator (r-tPa) in Pakistan and compare these data to available regional and international data. The charts of all patients treated with r-tPa for acute stroke at two centers in Pakistan (Aga Khan University, Karachi and Liaquat National hospital, Karachi) were retrospectively reviewed. We identified 21 patients. The utilization of tPa at Aga Khan Hospital was 18/1,185 patients (1.5%) from 2005 to 2007 while at Liaquat National Hospital was 3/575 patients (0.52%) over 1 year (2007). Mean time interval between stroke onset and start of r-tPa infusion was 169 min. Three patients (14%) developed fatal hemorrhage and two (10%) developed non-fatal hemorrhage. Four patients (19%) died. We identified protocol violations in seven patients (33%). In conclusion, the utilization of thrombolytic therapy is low and complication rate is high. Interventions for training physicians are needed.

Predictors of Good Outcome After rt-PA for Ischemic Stroke

Clinicians who administer rt-PA for acute stroke often wonder who benefits. In this study, researchers asked what factors predispose to a good outcome

Reversal of warfarin-induced anticoagulation with factor VIIa prior to rt-PA in acute stroke

Thrombolytics for stroke are contraindicated if a patient’s prothrombin time (PT) is above 15. Recombinant factor VII (rVIIa) has been approved for the rapid reversal of warfarin-induced coagulopathy. Since rVIIa can reverse coagulopathy quickly, it might be useful to correct PT elevations in patients who are eligible for thrombolytics. A 71-year-old, right-handed woman with a history of left hemispheric ischemic stroke presented to our emergency department with new onset of left arm and leg weakness, facial droop, visual field blurring, and dysarthria. The symptoms began initially at 9:15 am and en route to the hospital, she became quadriplegic. Upon arrival, the patient was oriented and had mild dysarthria and bilateral facial droop, left greater than right. Strength was 0/5 in all extremities and deep tendon reflexes were 2+ in the right limbs and 1+ in the left. NIH Stroke Scale score was 20. The patient’s previous ischemic …

Prediction of hospital disposition after thrombolysis for acute ischemic stroke using the National Institutes of Health Stroke Scale.

Early determination of discharge destination after acute stroke may promote earlier rehabilitation and reduce costs by shortening the duration of hospitalization. To determine whether the National Institutes of Health Stroke Scale (NIHSS) score predicts disposition in stroke patients treated with thrombolysis. Cohort study. Academic and community hospitals from 3 countries. Five hundred forty-six patients with acute ischemic stroke treated with recombinant tissue plasminogen activator (rt-PA). Medical records were reviewed for demographic information, vascular risk factors, location of stroke, initial NIHSS score, acute hospital disposition, and complications of symptomatic or asymptomatic intracerebral hemorrhage (ICH). Discharge destination to home, acute rehabilitation, or nursing facility. In multinomial regression analysis, increasing NIHSS score was a robust and independent predictor of discharge to rehabilitation or nursing facilities, roughly doubling for each 5-point increment. Patients who developed symptomatic ICH were never discharged to home, but asymptomatic ICH had no significant independent effect on disposition. Stroke severity as determined by the admission NIHSS score is the major independent predictor of disposition after hospitalization and treatment with rt-PA for acute stroke in a broad-based population. However, symptomatic ICH after rt-PA is a catastrophic event that may preclude discharge to home.

Emergency Physician Administration of rt-PA in Acute Stroke: Five-year Analysis of Treatment and Outcome

Emergency Physician Administration of rt-PA in Acute Stroke: Five-year Analysis of Treatment and Outcome

Management of Acute Ischemic Stroke

Prior to 1995 no proven therapy existed for acute ischemic stroke. In 1996 the U.S. Food and Drug Administration approved the use of intravenous rt-PA in acute stroke based largely on the results of a two-part trial sponsored by the National Institutes of Health and National Institute of Neurological Disorders and Stroke (NIH/NINDS). Five years following approval, however, thrombolytic treatment remains underutilized, occurring in only 1 to 2% of all stroke patients. The medical community is now being called upon to organize systems capable of delivering acute stroke care in a time-urgent manner not previously contemplated. Critical care specialists may be called upon to treat stroke occurring in hospitalized patients or to continue care initiated in the emergency department. This article briefly reviews the pathogenesis of cellular injury in stroke and its initial evaluation and care and then focuses on the data involving thrombolytic reperfusion. Special attention is given to postthrombolytic critical care issues as these represent an important determinant in patient outcome. Secondary stroke prevention strategies and complication management are discussed along with general intensive care issues for the stroke patient.

The Canadian Activase for Stroke Effectiveness Study (CASES): Interim results

39 Background Therapy for acute stroke using rtPA was approved in Canada in February 1999. The Canadian Activase for Stroke Effectiveness Study Group was formed to study the use of rtPA in Canada in a 30-month post-marketing study. Purpose To both prospectively assess the safety of rtPA in the Canadian context and to examine whether the efficacy of rtPA for acute stroke, demonstrated in the NINDS trial, can be translated into effectiveness in routine clinical practice across Canada. Methods The CASES group is a collaboration among the Canadian Stroke Consortium (CSC), the Canadian Stroke Society, the Heart & Stroke Foundation of Canada, Hoffman-LaRoche Canada and physicians across the country. Centres across the country were registered and recruitment is ongoing. The study protocol has been approved by the research ethics board at each centre. Demographics, stroke risk factors, blood pressure, biochemistry, hematology, and CT scans are being collected. NIHSS and mRS scores are being collected prospectively. Outcomes will be monitored at discharge and at 3 months. Results In the first 20 months,72 centres are registered and 525 patients have been treated. The median NIHSS score is 14 (range 2–35). 30% of patients have minimal or no neurological deficit (NIHSS 0–1)and 47% are independent (mRS 0–2) at 90 days. The symptomatic hemorrhage rate is 4.0% (95%CI 2.5% to 6.0%). Multivariate analysis has failed to identify predictors of symptomatic ICH. The rate of protocol violations is 10%, the majority of which are time window violations. Based upon a phone survey of hospitals in Canada with CT scanners, the data set is 75% complete. Conclusions CASES is an ongoing prospective evaluation of the effectiveness of rtPA in acute stroke. The symptomatic hemorrhage rate is low (4.0%). Alteplase for ischemic stroke is safe and effective in Canada.

The Canadian Activase for Stroke Effectiveness Study (CASES): Interim Results

39 Background Therapy for acute stroke using rtPA was approved in Canada in February 1999. The Canadian Activase for Stroke Effectiveness Study Group was formed to study the use of rtPA in Canada in a 30-month post-marketing study. Purpose To both prospectively assess the safety of rtPA in the Canadian context and to examine whether the efficacy of rtPA for acute stroke, demonstrated in the NINDS trial, can be translated into effectiveness in routine clinical practice across Canada. Methods The CASES group is a collaboration among the Canadian Stroke Consortium (CSC), the Canadian Stroke Society, the Heart & Stroke Foundation of Canada, Hoffman-LaRoche Canada and physicians across the country. Centres across the country were registered and recruitment is ongoing. The study protocol has been approved by the research ethics board at each centre. Demographics, stroke risk factors, blood pressure, biochemistry, hematology, and CT scans are being collected. NIHSS and mRS scores are being collected prospectively. Outcomes will be monitored at discharge and at 3 months. Results In the first 20 months,72 centres are registered and 525 patients have been treated. The median NIHSS score is 14 (range 2–35). 30% of patients have minimal or no neurological deficit (NIHSS 0–1)and 47% are independent (mRS 0–2) at 90 days. The symptomatic hemorrhage rate is 4.0% (95%CI 2.5% to 6.0%). Multivariate analysis has failed to identify predictors of symptomatic ICH. The rate of protocol violations is 10%, the majority of which are time window violations. Based upon a phone survey of hospitals in Canada with CT scanners, the data set is 75% complete. Conclusions CASES is an ongoing prospective evaluation of the effectiveness of rtPA in acute stroke. The symptomatic hemorrhage rate is low (4.0%). Alteplase for ischemic stroke is safe and effective in Canada.

30 An open multicenter study of the safety and efficacy of various doses of rt-PA in acute stroke: Interim results

30 An open multicenter study of the safety and efficacy of various doses of rt-PA in acute stroke: Interim results