rt-PA Infusion Research Articles

ダビガトラン内服中に出血合併症なく血栓溶解療法を施行しえた心原性脳塞栓症の1例―症例報告と文献的考察

A 72-year-old male with heart failure was admitted to our hospital. Treatment with dabigatran (220 mg per day) was initiated because of atrial fibrillation. On the third day, the patient developed left-sided hemiparesis and dysarthria at 4.5 hr after the last dose of dabigatran. The activated partial thromboplastin time (APTT) was 39.1 sec, and the NIHSS (NIH Stroke Scale) was 11. An intravenous infusion of rt-PA was administered at 160 min after the onset of hemiparesis (at 7 hr after the last dose of dabigatran). Although diffusion weighted MRI revealed a minor infarction in the right lower frontal gyrus, the patient was discharged without hemorrhage (NIHSS 0), and the score on the modified Rankin scale assessed 3 months later was 0. The outcomes have been good in 8 out of 9 reported cases, including the present case; the remaining severe case developed complicating intracranial hemorrhage. Thrombolytic therapy could be safe, if it is performed more than 7 hr after the last dose of dabigatran and the APTT is less than 40 sec.

Half-Dose Recombinant Tissue Plasminogen Activator Treatment in Venous Thromboembolism

IntroductionPulmonary embolism (VTE) comes in different degrees of severity from massive pulmonary embolism to nonmassive pulmonary embolism with no symptoms or hypoxia. Thrombolytic therapy is a lifesaver especially for patients...

Simple clinical predictors of stroke outcome based on National Institutes of Health Stroke Scale score during 1‐h recombinant tissue‐type plasminogen activator infusion

An index for predictors of stroke outcome was determined based on the National Institutes of Health Stroke Scale (NIHSS) scores during 1-h intravenous administration of recombinant tissue-type plasminogen activator (rt-PA). Stroke patients with baseline NIHSS score ≥8 and occlusion at the internal carotid or middle cerebral arteries (ICA, MCA) were retrospectively studied from a prospective single-center registry. NIHSS scores and inverse change from baseline scores (ΔNIHSS) were assessed at 30min and 1h after rt-PA infusion. Patients were divided into two groups according to arterial occlusion sites: group P, ICA or proximal M1; and group D, distal M1 or M2. A modified Rankin Scale score of 2-6 at 3months was defined as an unfavorable outcome. In all 108 patients, the cutoff NIHSS score predicting unfavorable outcome was ≥12 and cutoff ΔNIHSS scores were ≤2 at both 30min and 1h. In group P (n=36), the cutoff NIHSS score was ≥14 at both 30min and 1h and cutoff ΔNIHSS scores were ≤1 at 30min and ≤2 at 1h. Unfavorable outcome was seen in all patients with NIHSS1h ≥14, ΔNIHSS30min ≤1 and ΔNIHSS1h ≤2. In group D (n=72), the cutoff NIHSS scores were ≥12 at both 30min and 1h, and cutoff ΔNIHSS scores were ≤2 at 30min and ≤7 at 1h; 90% of patients with unfavorable outcome showed ΔNIHSS1h ≤7. NIHSS and ΔNIHSS during 1-h rt-PA infusion seemed predictive of 3-month outcome when the site of arterial occlusion was identified prior to rt-PA.

Safety and Efficacy of Ultra-high-dose, Short-term Thrombolysis with rt-PA for Acute Lower Limb Ischemia

The evaluation of success and complication rates of ultra high-dose recombinant tissue plasminogen activator (rt-PA) administered over a short time frame in the treatment of acute lower limb ischemia. This was a prospective single-center study. The outcome of treatment in 97 patients with acute limb ischemia (<14 days) with the use of catheter directed rt-PA infusion was evaluated. The mean total dose of rt-PA was 54.1 mg (50-60 mg) and was administered for a mean of 2.51 hours (2-4 hours). Thrombolytic success was defined as 95% thrombolysis of an occluded segment with return of antegrade flow. Thirty-day complication and amputation-free survival rates were calculated. Thrombolytic success was achieved in 83.5%. Overall clinical success was 88.7%. The 30-day amputation-free survival rate was 93.8%. Major bleeding complications occurred in 10 patients (10.3%). There were two deaths (2.1%) and four amputations (4.1%). Long-term amputation-free survival was 70%. Administration of ultra-high doses of rt-PA over a short time period gives promising results. Such delivery improves patient tolerance by rapid restoration of limb perfusion; however further studies are required to confirm these results.

Abstract 485: Percutaneous Catheter-directed Local Thrombolysis of Arterial, Venous and Shunt Thrombus Using Tissue Plasminogen Activator in Critically-ill Children - A Single Center Experience

OBJECTIVE To retrospectively determine the success and complication of local catheter directed thrombolysis using recombinant tissue plasminogen activator (rTPA) in critically ill children with acute arterial, venous or shunt thrombus. BACKGROUND Local catheter directed thrombolysis is a well-described treatment modality for thrombotic events in adults, with maximal thrombolytic effect and minimal systemic sequelae. However, this treatment option in life threatening thrombosis is not well defined in pediatrics. METHOD We report an observational study in a retrospective cohort (2008-2013) of 14 cases presenting with sudden life threatening thrombosis, necessitating immediate intervention. All patients had &gt;95% vascular/shunt occlusion which was treated with percutaneous catheter-based procedure, and rTPA administration directly at site of thrombus. The efficacy, dosage, duration, additional endovascular intervention and complications of this approach are reported. RESULTS The median age was 1.7 months (range, 10 days - 29 years) and median weight was 4.4 kilograms (range, 2.2 - 101 kg). Nine (64%) patients presented with shunt (Sano or aorto-pulmonary) thrombosis, three (22%) with arterial thrombosis and two (14%) with venous thromboembolism. All patients received a local bolus of rTPA [median dose 0.24 mg/kg (range, 0.01 - 1.0 mg/kg)]. Eight (57%) received an additional infusion of rTPA [median dose 0.17 mg/kg/hr (range, 0.02 - 1.0 mg/kg/hr)] of varying duration [median 1.3 hours (range, 0.3 - 18 hours)]; one patient received a prior systemic bolus of rTPA. Anticoagulation was administered in 12 (86%) and supplementary endovascular intervention (balloon angioplasty and/or stenting) was done in 4 (28%) patients. Thrombolytic success (defined as &gt;95% return of antegrade flow) was achieved in 13 (93%). No major bleeding or other serious complication directly related to this approach occurred. CONCLUSION Catheter-directed local thrombolysis with rTPA can be accomplished rapidly in critical thrombosis, as a pragmatic alternative to surgery. This approach can offer satisfactory short term palliation without significant complications and improve outcome in children with life threatening thrombosis.

Role of Carotid Endarterectomy Following Intravenous Thrombolysis

placebo controlled trials. 2 Infusion of rt-PA is beneficial within 4.5 hours of stroke onset in appropriate individuals. While one may quibble with the definition of stroke requiring 24 hours, these studies excluded minor or resolving neurological symptoms suggesting that transient ischemic attacks were not treated with rt-PA during the trials. It is unknown if indications for lysis have expanded following its widespread introduction into clinical practice. How often is extracranial carotid stenosis found following rt-PA for acute strokes? Although their initial workup routinely included a duplex ultrasound, the incidence of carotid stenosis in the acute rt-PA population of their two referring institutions is unknown. Likewise, the frequency of carotid stenosis was not reported in the pooled trials validating rt-PA. 2 The low incidence of 6% in Bartoli’s report is substantially less than the 20-30% estimated by Rothwell. 3 Treatment for acute cerebral attacks has focused on intravenous rt-PA. In an effort to improve the limited success of IV rt-PA, three recent trials randomized concomitant aggressive, intracranial endovascular therapies. No significant benefit beyond rt-PA was found. 4 Bleeding is a major surgical concern. The 5 minute halflife of alteplase is unlikely to affect an operative event several days later. Aggressive antiplatelet therapy offers potential for mischief in the OR. However, the unknown risk is hemorrhagic conversion of a cerebral infarct. Eligibility for rt-PA requires a head CT to exclude hemorrhage; of note, intracerebral hemorrhage following rt-PA was reported in 33%, but most were presumably asymptomatic. 2 The one reported morbidity resulting from CEA following rt-PA therapy was attributed to hemorrhagic conversion; the dramatic finding of a floating thrombus in conjunction with a tight carotid stenosis following rt-PA therapy was the rationale for CEA at 33 hours. 3 Balancing this unknown risk against the benefits of CEA within a 2-week time frame may be the essence of the question raised by this report. Strict, intensive control of blood pressure is recommended to decrease the risk of hyperperfusion syndrome. 1e3 As lytic therapy for stroke becomes more common, vascular surgeons throughout the world will be asked to consider CEA in this setting. Since we really do not know whether post-rt-PA patients are different from those with stable strokes, and since recruitment of a sufficiently large study group is daunting, a randomized trial is unlikely. Thus, registry reports or additional reports like this are needed to establish rational guidelines for surgical intervention. While the numbers are small (N ¼ 49), the combined data presented here suggest that CEA may be beneficial.

Plasminogen Activators and Ischemic Stroke: Conditions for Acute Delivery

Appropriate acute treatment with plasminogen activators (PAs) can significantly increase the probability of minimal or no disability in selected ischemic stroke patients. There is a great deal of evidence showing that intravenous recombinant tissue PAs (rt-PA) infusion accomplishes this goal, recanalization with other PAs has also been demonstrated in the development of this treatment. Recanalization of symptomatic, documented carotid or vertebrobasilar arterial territory occlusions have also been achieved by local intra-arterial PA delivery, although only a single prospective double-blinded randomized placebo-controlled study has been reported. The increase in intracerebral hemorrhage with these agents by either delivery approach underscores the need for careful patient selection, dose-appropriate safety and efficacy, proper clinical trial design, and an understanding of the evolution of cerebral tissue injury due to focal ischemia. Principles underlying the evolution of focal ischemia have been expanded by experience with acute PA intervention. Several questions remain open that concern the manner in which PAs can be applied acutely in ischemic stroke and how injury development can be limited.

Abstract TP23: Feasibility Of The Combination Of The Restore ™ Thrombectomy Device And The Reflex ™ Access And Aspiration Catheter For The Treatment Of Acute Ischemic Stroke

Introduction: Larger distal access catheter systems for treatment of acute intracranial vessel occlusion enable both clot aspiration and introduction of flow restoration devices. We present the first clinical data of a large lumen hyperflexible intracranial distal aspiration catheter (ReFlex™ 5F, 058” ID x 125cm, Covidien, Irvine, CA) combined with the ReStore™ Thrombectomy microcatheter (Reverse Medical, Irvine, CA) for endovascular treatment of acute ischemic stroke. Patients and Methods: The ReStore™ consists of a flexible, tapered microcatheter with a braided mesh retrieval element attached to its distal segment. The retrieval element is deployed through the advancement of a guidewire or the ReAct™ stylet through the lumen to radially expand the retrieval element. Infusion of rt-PA within the thrombus is possible through small side holes of the ReStore™. Nine patients (62 y - 88 y, 5f/4m) with acute occlusion of the MCA were treated with the combination of ReStore™ and the ReFlex™ aspiration catheter within 6 hours after symptom onset. Median NIHSS score upon arrival was 16 (range 8 - 18). TICI flow in the target vessel segment was assessed prior and after recanalization procedure. Results: Thrombectomy with the combination of ReStore™ and ReFlex™ was performed as initial mechanical treatment in 8 cases. In one case, prior treatment with other stentriever systems failed, whereas the combination of ReStore™ and ReFlex™ lead to TICI 3. TICI 2b or 3 was achieved in 7 patients (77.8%); in 2 patients, TICI 2a was achieved. Immediate flow restoration while activating ReStore™ was accomplished in all 9 cases. Mean time from first angiopgraphy to first perfusion was 39.1 min (range 9-88 min). In 4 cases, additional rt-PA (10 mg) was administered directly into the thrombus through the ReStore™. In 2 cases, subsequent implantation of a permanent intracranial stent was performed. The mean number of ReStore™ activations to achieve final TICI score was 2.2 ± 1.1. One patient experienced periprocedural subarachnoid hemorrhage as a severe adverse event. Conclusion: The combination of ReStore™ and the ReFlex™ aspiration catheter is a promising new treatment option for both flow restoration and aspiration in patients suffering from acute intracranial arterial occlusion.

Abstract TP17: Magnetically Enhanced Diffusion (MED) for Improved Efficacy of Thrombolytic Therapy in Acute Ischemic Stroke_A Prospective First in Man Clinical Study

BACKGROUND: Preclinical studies have shown that the MED system developed by Pulse Therapeutics, Inc. appears efficient in delivering co-administered agents by affecting the fluid dynamics in targeted occluded arteries. The system is an adjunct to IV rt-PA, and is composed of biologically-safe magnetic particles and a portable magnet system for use in the ED. Preclinical studies support strong efficacy and safety of the MED technology. The primary objective of this feasibility study is to establish the safety (sICH at 24 hours post onset) of the technology when used as an adjunct to IV rt-PA for moderate-to-large (10≤NIHSSS≤24, occlusion confirmed by CTA) ischemic strokes within three hours of acute onset. METHODS: 10 subjects with moderate-to-large ischemic strokes between ages 18-80 will be enrolled at 2 centers in Australia (Box Hill and John Hunter hospitals). All candidates must possess an intracranial arterial occlusion of the middle cerebral, anterior cerebral, internal carotid, posterior cerebral or distal basilar artery confirmed by CTA or MRA, and must be administered rt-PA within 3 hours of acute onset. Artery selection is input into the MED system and the magnet energized for the entirety of the rt-PA infusion, plus 30min. The primary endpoint is safety as assessed by incidence and evaluation of any adverse effects associated with the investigational procedure compared with historical controls treated with rt-PA alone. The secondary endpoint is the degree of recanalization (partial and complete) and reperfusion as measured by CTA at 2-4hrs and MRI at 24±6hrs post MED therapy. TIMI Grade Flow of 2 or 3 will be considered responsive to treatment. CONCLUSIONS: This feasibility trial will attempt to establish the safety (sICH) and recanalization efficacy of the MED technology as an adjunctive therapy to standard-dose IV rt-PA. As of August 2012, Box Hill and John Hunter hospitals have enrolled 2 patients.

Risk Factors for Intracranial Hemorrhage in Acute Ischemic Stroke Patients Treated With Recombinant Tissue Plasminogen Activator

Recombinant tissue plasminogen activator (rtPA) is an effective treatment for acute ischemic stroke but is associated with an increased risk of intracranial hemorrhage (ICH). We sought to identify the risk factors for ICH with a systematic review of the published literature. We searched for studies of rtPA-treated stroke patients that reported an association between a variable measured before rtPA infusion and clinically important ICH (parenchymal ICH or ICH associated with clinical deterioration). We calculated associations between baseline variables and ICH with random-effect meta-analyses. We identified 55 studies that measured 43 baseline variables in 65 264 acute ischemic stroke patients. Post-rtPA ICH was associated with higher age (odds ratio, 1.03 per year; 95% confidence interval, 1.01-1.04), higher stroke severity (odds ratio, 1.08 per National Institutes of Health Stroke Scale point; 95% confidence interval, 1.06-1.11), and higher glucose (odds ratio, 1.10 per mmol/L; 95% confidence interval, 1.05-1.14). There was approximately a doubling of the odds of ICH with the presence of atrial fibrillation, congestive heart failure, renal impairment, previous antiplatelet agents, leukoaraiosis, and a visible acute cerebral ischemic lesion on pretreatment brain imaging. Little of the variation in the sizes of the associations among different studies was explained by the source of the cohort, definition of ICH, or degree of adjustment for confounding variables. Individual baseline variables were modestly associated with post-rtPA ICH. Prediction of post-rtPA ICH therefore is likely to be difficult if based on single clinical or imaging factors alone. These observational data do not provide a reliable method for the individualization of treatment according to predicted ICH risk.

Adherence to Guidelines by Emergency Medical Services During Transport of Stroke Patients Receiving Intravenous Thrombolytic Infusion

The "drip and ship" paradigm among acute ischemic stroke (AIS) patients has resulted in expansion of thrombolytic treatment in patients eligible for intravenous (IV) recombinant tissue plasminogen activator (rt-PA). It remains controversial whether the settings within the emergency medical services (EMS) transport are adequate for IV rt-PA infusion. We sought to determine EMS adherence to guidelines during the transport of drip and ship AIS patients treated with IV rt-PA while being transferred to comprehensive stroke centers (CSCs) and the effect of nonadherence on outcome upon discharge. A retrospective evaluation of patients transferred to our CSC was conducted to determine the rates of adherence to quality parameters during EMS transport with infusion of IV rt-PA. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 1 upon discharge. Among the 40 patients studied (55% men; mean age 71.9 ± 13.9 years), 38 patients received vital sign monitoring at 10- to 20-minute intervals. The mean transit time was 37.7 ± 20.2 minutes. Of the 39 patients with blood pressure (BP) monitoring, 7 patients had at least 1 episode of BP elevation above the recommended parameters (>180/105 mm Hg); only 1 of those was treated with an antihypertensive agent. Five of the 40 patients were considered to have worsened between the outside ED and CSC ED evaluations without IV rt-PA discontinuation during transfer. The rate of favorable outcome of patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP >180/105 mm Hg without antihypertensive treatment was similar to those who experienced neither event (41.7% and 35.7%; P = .736). Efforts are required to improve EMS adherence to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of the "drip and ship" paradigm.

My worst case with sonothrombolysis

This article presents the case of a 63-year-old man with an acute ischemic stroke due to extracranial thrombosis of the left internal carotid artery, associated with about 70% stenoses of the right common and internal carotid arteries. The patient was treated with rtPA associated with a temporal transcranial ultrasound examination (TCCS) for an hour during a rtPA infusion. During the transcranial monitoring the left middle cerebral artery (LMCA) was rated between 2 and 3 on the TIBI scale. At the 24th hour two small ischemic zones and two intracranial hematomas were detected. No new symptoms were added. There are data showing that transcranial ultrasound monitoring (TCD and TCCS) and microbubble administration in acute ischemic stroke patients are associated with an early recanalization and a high rate of hemorrhagic transformation but do not seem to increase the risk of a symptomatic intracranial hemorrhage. According to CLOTBUST TCD alone is safe in acute ischemic stroke patients. TCCS alone is also tested in a smaller study. In the presented case report an association between the transtemporal insonation and the hematomas is possible but not probable.

Thromboaspiration in a Patient With Persisting Intracranial Occlusion After Intravenous Thrombolysis: A Case Report

The last few years have been characterized by a rapid diffusion of endovascular treatments aimed at achieving arterial recanalization in patients with acute ischemic stroke. Clinical trials have shown higher rates of arterial recanalization being achieved by the Penumbra System (PS) as compared to standard treatment, i.e. systemic thrombolysis by recombinant tissue plasminogen activator (rtPA). This case-report enhances the relevance of strict patient monitoring during and after rtPA administration in order to consider urgent mechanical thrombectomy as additional treatment in highly selected cases. A 69-year-old woman presented with sudden onset of left hemiparesis and slurred speech. Systemic rtPA was administered with marked clinical improvement. Ultrasound study performed during rtPA infusion suggested intracranial occlusion. Diffusion-weighted MRI was negative for acute ischemia, perfusion-weighted imaging detected a wide region of hypoperfused tissue in the right middle cerebral artery (MCA) territory, and MR angiography detected right proximal MCA occlusion. After the initial clinical improvement, the patient deteriorated. Clot aspiration by the PS and complete recanalization were achieved in 56 minutes. The patient was discharged with mild left hemiparesis, and she had excellent recovery at 6 months. Acute endovascular treatment by the PS proved successful in this patient experiencing clinical fluctuations due to persisting intracranial artery occlusion after systemic thrombolysis. Strict patient monitoring by MRI and ultrasound studies may allow prompt mobilization of the interventional radiology team thus offering an increased chance of favourable outcome and preventing more invalidating strokes in patients known to benefit poorly by systemic thrombolysis. doi:10.4021/jnr84w

Angioedema After tPA: What Neurointensivists Should Know

Angioedema is an underappreciated and potentially life-threatening complication of intravenous (IV) recombinant tissue plasminogen activator (rt-PA). Patients taking angiotensin converting enzyme (ACE) inhibitors are at increased risk of this rare complication. Case report. A 74 year-old woman taking lisinopril for hypertension was treated with IV rt-PA for right hemispheric acute ischemic stroke. Shortly after completion of the rt-PA infusion, she developed asymmetric angioedema involving the tongue and left lower lip. No emergent airway intervention was needed. Following treatment with epinephrine, antihistamines, and corticosteroids, the edema resolved within 24 h. The patient made an excellent recovery from the ischemic stroke. Orolingual angioedema can complicate rt-PA treatment of acute stroke and is often ipsilateral to the side of hemiparesis. Neurointensivists should be aware of this possibility, which is increased in patients taking ACE inhibitors. Epinephrine can be given safely in this scenario. Identification of high risk features may help guide decisions regarding early definitive airway management.

Abstract 69: Does Advanced Imaging Delay Time to Administration of Intravenous rt-PA in the Acute Ischemic Stroke Patient?

Background: Faster administration of intravenous recombinant tissue plasminogen activator (IV rt-PA) is associated with better outcomes in acute ischemic stroke (AIS) patients. Cerebral imaging is essential to determine inclusion and exclusion criteria, yet there are no universal imaging protocols for the AIS patient. Furthermore, multimodal imaging can lead to longer times of acquisition and interpretation. We assess the change in treatment times in our institution before and after modification of our imaging protocol. Methods: We performed a retrospective analysis comparing time to Computed Tomography (CT) interpretation and time to IV rt-PA treatment in AIS patients at our institution for three months before and after implementing imaging protocol changes. We defined these groups as the multimodal imaging group which received Non-contrast Computed Tomography of the head (NCCTH), CT Arteriogram (CTA), and CT Perfusion (CTP), versus the NCCTH only group. We performed statistical analysis using Fisher exact test comparing treatment groups in goal time to CT interpretation (&lt; 45 minutes from time of arrival to Emergency department (ED) to completion of CT interpretation) and rt-PA administration (&lt; 60 minutes from time of arrival to ED to initiation of rt-PA infusion). Results: During the six month period, we identified 110 AIS patients who underwent activation of our emergent CT protocol. The multimodal group contained 43 patients while the NCCTH only group contained 67. The mean Time to CT interpretation was 130 (range 11-557) in the multimodal group vs. 87 (12-361) in the NCCTH only group with 16% vs. 37% receiving CT evaluation within 45 minutes of presentation (p=0.02). The mean Time to IV rt-PA administration was 72 minutes (range 19-138) in the multimodal group and 60 minutes (32-94) in the NCCTH only group with 29% vs. 50% receiving IV TPA within 60 minutes (p=0.02). Conclusion: The use of multimodal imaging may provide useful information for AIS treatments beyond IV rt-PA; however, such advanced imaging was a source of delay for treatment at our institution. Streamlining the imaging protocol at our institution has improved our achievement of rt-PA administration time goals.

Abstract 2878: Compliance to Guidelines by Emergency Medical Services in “Drip and Ship” Patients with In-transit Intravenous Thrombolytic Infusion

Background: The “drip and ship” paradigm among acute ischemic stroke (AIS) patients has resulted in expansion of thrombolytic treatment in patients eligible for intravenous (IV) recombinant tissue plasminogen activator (rt-PA). However, it remains controversial whether the settings are adequate for IV rt-PA infusion within the EMS transport by emergency medical technicians (EMTs). Objective: To determine compliance to guidelines during transport of AIS patients treated with IV rt-PA using “drip and ship” paradigm while being transferred to comprehensive stroke centers (CSCs) from referring facilities and determine its effect on outcome upon discharge. Methods: A retrospective evaluation of patients transferred to our CSCs from June 2009 to July 2011 was conducted to determine the quality of care provided by EMTs after IV rt-PA was initiated at referring facilities. Quality parameters audited include frequency of blood pressure (BP) monitoring, interventions for elevated BPs, and discontinuation of IV rt-PA in the event of neurologic deterioration. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 1 at time of discharge. Results: Among the 30 patients included in this study (53% men, mean age 72.6±14.2 years), 28 patients received vital sign monitoring at 10 to 20 minute intervals; the other two either underwent monitoring at less frequent intervals or did not receive any vital sign monitoring. The mean transit time was 37.4±16.9 minutes. Of the 29 patients with BP monitoring, 9 patients had at least one episode of BP above the recommended parameters (&gt;180/105 mmHg) while being treated with IV rt-PA; only one of those was treated with an anti-hypertensive agent. No neurologic deterioration was reported during transit by EMS but 3 of the 30 patients were considered to have worsened between the outside ED and CSC ED evaluations. The rates of favorable outcome between patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP &gt;180/105 mmHg without treatment was similar to those who experienced neither event (50% and 45%, p=0.55). Conclusion: Efforts are required to improve compliance to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of “drip and ship” paradigm.

Relationship of Obesity to Recanalization after Hyperacute Recombinant Tissue-Plasminogen Activator Infusion Therapy in Patients with Middle Cerebral Artery Occlusion

This was a retrospective analysis of factors related to recanalization after hyperacute recombinant tissue-plasminogen activator (rt-PA) infusion therapy in patients with middle cerebral artery occlusion. Of the 50 patients (39 males and 11 females; mean age 70 ± 11 years) with cerebral infarction who were able to undergo diffusion-weighted magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the head within 24 hours of starting rt-PA infusion therapy while hospitalized at our center between April 2007 and October 2010, 23 patients (18 males and 5 females; mean age 71 ± 9.4 years) with hyperacute cerebral infarction with findings of obstruction in the proximal segment of the middle cerebral artery (MCA-M1) served as subjects. Of the 23 patients with MCA occlusion, 13 (57%) were recanalized. Analysis of factors related to recanalization revealed a significant difference (P = .019) for obesity (body mass index >25 kg/m(2)), with significantly more obese patients in the nonrecanalized group than in the recanalized group. The study revealed no significant differences in other factors between the 2 groups. The results suggest that obesity may be involved in recanalization after hyperacute rt-PA infusion therapy in patients with MCA occlusion.

Thromboaspiration in a Patient With Persisting Intracranial Occlusion After Intravenous Thrombolysis: A Case Report

The last few years have been characterized by a rapid diffusion of endovascular treatments aimed at achieving arterial recanalization in patients with acute ischemic stroke. Clinical trials have shown higher rates of arterial recanalization being achieved by the Penumbra System (PS) as compared to standard treatment, i.e. systemic thrombolysis by recombinant tissue plasminogen activator (rtPA). This case-report enhances the relevance of strict patient monitoring during and after rtPA administration in order to consider urgent mechanical thrombectomy as additional treatment in highly selected cases. A 69-year-old woman presented with sudden onset of left hemiparesis and slurred speech. Systemic rtPA was administered with marked clinical improvement. Ultrasound study performed during rtPA infusion suggested intracranial occlusion. Diffusion-weighted MRI was negative for acute ischemia, perfusion-weighted imaging detected a wide region of hypoperfused tissue in the right middle cerebral artery (MCA) territory, and MR angiography detected right proximal MCA occlusion. After the initial clinical improvement, the patient deteriorated. Clot aspiration by the PS and complete recanalization were achieved in 56 minutes. The patient was discharged with mild left hemiparesis, and she had excellent recovery at 6 months. Acute endovascular treatment by the PS proved successful in this patient experiencing clinical fluctuations due to persisting intracranial artery occlusion after systemic thrombolysis. Strict patient monitoring by MRI and ultrasound studies may allow prompt mobilization of the interventional radiology team thus offering an increased chance of favourable outcome and preventing more invalidating strokes in patients known to benefit poorly by systemic thrombolysis. J Neurol Res. 2012;2(1):33-35 doi: https://doi.org/10.4021/jnr84w

Prediction of thrombus resolution after intravenous thrombolysis assessed by CT-based thrombus imaging

The degree of thrombus resolution directly indicates the effectiveness of a thrombolytic drug. We investigated the degree of thrombus resolution and factors associated with thrombus resolution after intravenous (IV) recombinant tissue plasminogen activator (rt-PA) using thin-section noncontrast computed tomography (NCT). Thin-section NCTs were performed before and immediately after IV rt-PA infusion in acute stroke patients. The thrombus volume and Hounsfield unit were measured using three-dimensional imaging software. Immediate recanalisation was assessed immediately after IV rt-PA infusion using CT angiography. During a three-year study period, 130 patients were prospectively enrolled. On baseline thin-section NCT, no thrombi were found in 30 patients (23%). Among the 100 patients with confirmed thrombus, the median volume decreased by 20% on the follow-up NCT. The thrombus was completely resolved in 8%. Of note, an increase in thrombus volume was observed in 20 patients. Independent predictors of thrombus resolution were total rt-PA dose, thrombus location in the M2 segment of the middle cerebral artery, and time from baseline to follow-up NCT. Thrombus resolution increased by 9% per each 10-mg increase in rt-PA (p = 0.045). Immediate complete recanalisation was achieved in 12% of patients. Total dose of rt-PA was independently associated with complete recanalisation [odds ratio [OR] 4.52, 95% confidence interval [CI] 1.345-15.184) and good functional outcome at three months (modified Rankin scale score <3, OR 2.34, 95% CI 1.104-4.962). In conclusion, rt-PA dose was associated with the degree of thrombus resolution, immediate complete recanalisation, and good outcome at three months. CT-based thrombus imaging may be helpful in determining thrombolysis effectiveness.

Intermittent Broca’s aphasia management in an emergency unit: from theory to practice

Although Broca's aphasia (BA) may mimic different neurological illness, its sudden onset often requires an emergency approach. In this paper, the management of a case of intermittent BA occurred in a young woman without history of neurological, cardiovascular and arrhythmic diseases is discussed. Diffusion-weighted magnetic resonance imaging showed two areas of hypoperfusion in the terminal branches of the left medial cerebral artery not previously diagnosed by computed tomography. Although there were no eligibility criteria for thrombolysis, patient received intravenous treatment with recombinant tissue-type plasminogen activator (rt-PA) over 1 h and at the end of rt-PA infusion aphasia completely disappeared without neurological sequelae. Transesophageal echocardiography revealed a thrombus in the left atrial appendage not previously detected by transthoracic echocardiography. In the month following the cardioembolic stroke, heart rhythm was monitored for 30 days by an external loop recorder and during this test two episodes of silent lone atrial fibrillation were collected.