Thrombolysis For Acute Ischemic Stroke Research Articles

Prevalence, risk factors, and clinical outcomes of remote intracerebral hemorrhage after intravenous thrombolysis in acute ischemic stroke: a systematic review and meta-analysis.

Hemorrhagic transformation (HT) is a common complication of alteplase treatment. However, the prevalence rate, risk factors, and clinical outcomes of remote intracerebral hemorrhage (rICH) after intravenous thrombolysis in acute ischemic stroke are not well understood. Following a previously registered protocol, the PubMed, Web of Science, and Embase databases were systematically searched to identify relevant literature up to June 2022. Cohort studies reporting thrombolysis-related rICH in patients with acute ischemic stroke were included. Random effects models were used to calculate pooled prevalence rate, mean difference (MD) or odds ratio (OR) with corresponding 95% confidence interval (CI). Fourteen studies with 52,610 patients were included in this meta-analysis. The pooled rICH prevalence was 3.2% (95% CI 3.1-3.4%). Compared to patients without intracerebral hemorrhage (ICH), those with rICH were older, more likely to be female, and had a higher proportion of prior stroke, chronic heart failure and cardioembolism, and higher diastolic blood pressure. Small vessel disease markers (e.g., white matter hyperintensities and cerebral microbleeds) werestrongly associated with rICH. The presence of rICH decreased the likelihood of favorable outcomes (OR 0.36, 95% CI 0.31-0.41) and increased the risk of mortality (OR 4.37, 95% CI 2.86-6.67). Although rICH is uncommon after intravenous thrombolysis, its presence can lead to worse functional outcomes and higher mortality in acute ischemic stroke. Patients at high risk of rICH must be identified based on potential risk factors.

PRESENTATION OF ACUTE CEREBROVASCULAR ACCIDENT IN A YOUNG ADULT WITH THROMBOTIC THROMBOCYTOPENIA PURPURA (TTP)

PRESENTATION OF ACUTE CEREBROVASCULAR ACCIDENT IN A YOUNG ADULT WITH THROMBOTIC THROMBOCYTOPENIA PURPURA (TTP)

Cost-Effectiveness of Low-Dose Compared to Standard-Dose Alteplase for Acute Ischemic Stroke in China: A Within-Trial Economic Evaluation of the ENCHANTED Study

Introduction: The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) showed that a low-dose alteplase was safe but not clearly non-inferior to standard-dose alteplase in acute ischemic stroke (AIS). Given the significant cost of this medicine, we undertook a cost-effectiveness analysis to determine the probability that low-dose is cost-effective relative to standard-dose alteplase in China. Methods: For ENCHANTED participants in China with available health cost data, cost-effectiveness and cost-utility analyses were undertaken in which death or disability (modified Rankin scale scores 2–6) at 90 days and quality-adjusted life-years (QALYs) were used as outcome measures, respectively. There was adherence to standard guidelines for health economic evaluations alongside non-inferiority trials and according to a health-care payer’s perspective. The equivalence margin for cost and effectiveness was set at USD 691 and −0.025 QALYs, respectively, for the base-case analysis. Probabilistic sensitivity analyses were used to evaluate the probability of low-dose alteplase being non-inferior. Results: While the mean cost of alteplase was lower in the low-dose group (USD 1,569 vs. USD 2,154 in the standard-dose group), the total cost was USD 56 (95% confidence interval [CI]: −1,000–1,113) higher compared to the standard-dose group due to higher hospitalization costs in the low-dose group. There were 462 (95% CI: 415–509) and 410 (95% CI: 363–457) patients with death or disability per 1,000 patients in the low-dose and standard-dose groups, respectively. The low-dose group had marginally lower (0.008, 95% CI: −0.016–0.001) QALYs compared to their standard-dose counterparts. The low-dose group was found to have an 88% probability of being non-inferior based on cost-effectiveness versus the standard-dose group. Conclusions: This health economic evaluation alongside the ENCHANTED indicates that the use of low-dose alteplase does not save overall healthcare costs nor lead to a gain in QALYs in the management of Chinese patients with AIS compared to the use of standard dose. There is little justification on economic grounds to shift from standard-of-care thrombolysis in AIS.

Effect of optimizing the nursing process of green channel on time course of intravenous thrombolysis for acute ischemic stroke

Effect of optimizing the nursing process of green channel on time course of intravenous thrombolysis for acute ischemic stroke

Alteplase for Stroke With Unknown Onset Time in Chronic Kidney Disease: A Pooled Analysis of Individual Participant Data.

Although chronic kidney disease (CKD) is associated with worse stroke outcomes, data regarding the influence of CKD on intravenous thrombolysis outcomes are scarce. We sought to assess the efficacy and safety of intravenous thrombolysis for acute ischemic stroke with unknown onset time in patients with CKD. Patients with an acute stroke of unknown onset time from the EOS trials (Evaluation of Unknown Onset Stroke Thrombolysis) collaboration were evaluated using an individual patient-level database of randomized controlled trials comparing intravenous thrombolysis with placebo/standard treatment. CKD was defined as baseline estimated glomerular filtration rate of <60 ml/min/1.73m2 Mixed-effect logistic-regression analysis was performed to evaluate treatment effects. A favorable outcome was defined as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. Baseline data on renal function were available for 688 of 843 patients. Of these, CKD was present in 146 (21%), including 69 of 351 patients receiving alteplase and 77 of 337 patients receiving placebo/standard treatment. Overall, treatment with alteplase was associated with higher odds of favorable outcome, and CKD did not modify the treatment effect (Pinteraction=0.834). A favorable outcome was observed in 31 of 69 (46%) patients with CKD in the alteplase group and in 28 of 77 (36%) patients with CKD in the control group (adjusted odds ratio, 1.19 [95% CI, 0.55-2.58]). Among patients with CKD, symptomatic intracranial hemorrhage occurred in 2 patients (3%) in the alteplase group but in none of the controls (P=0.133). At 90 days, death was reported in 3 patients (4%) in the alteplase group compared with 2 patients (3%) in the controls (P=0.539). The present analysis indicates that the benefit of alteplase does not differ between stroke patients with unknown onset time with and without CKD, although the statistical power was lacking to confirm the efficacy in subgroups. This study only applies to mild-to-moderate or predialysis CKD.

Acute ischemic stroke on anti-Xa inhibitors: Pharmacokinetics and outcomes

Background and PurposeDirect oral anticoagulant (DOAC) ingestion within 48 h is an exclusion for thrombolysis in acute ischemic stroke (AIS) patients. We aim to shed light on pharmacokinetic correlates and outcomes in patients with AIS excluded from thrombolysis due to DOAC use. MethodsThis is a single center retrospective study of consecutive patients with AIS within 4.5 h from last known normal and excluded from thrombolytic therapy due to confirmed Xa inhibitor DOAC (DOACXa) intake within the prior 48 h. We used linear regression to test the correlation between time from last DOACXa ingestion and anti-Xa level. ResultsOver a period of 2.5 years, we identified 44 patients who did not receive thrombolysis because of presumed DOAC intake within 48 h. In adjusted linear regression, there was an association between time from last DOAC ingestion and Xa level (beta = −0.69, p < 0.001). Among the 37 patients with known atrial fibrillation not receiving alteplase due to DOAC use, the 90-day mortality was 35.1% (13/37) and 77% (10/13) of deaths were stroke related. ConclusionsPatients with AIS on DOAC therapy face a heightened risk of mortality. Studies are needed to investigate the safety and efficacy of thrombolysis in such patients based on time of last DOAC ingestion and/or anti-Xa/drug level.

Intravenous Thrombolysis for Acute Ischemic Stroke during the COVID-19 Pandemic-Polish Single-Center Retrospective Cohort Study.

COVID-19 has affected the entire world and has had a great impact on healthcare, influencing the treatment of patients with acute ischemic stroke (AIS). The aim of this study was to determine the impact of the COVID-19 pandemic on the care of patients with AIS. We performed a retrospective analysis of 1599 patients diagnosed with AIS and hospitalized in the authors’ institution from January 2018 to December 2021. The final sample consisted of 265 patients treated with thrombolysis without a diagnosis of COVID-19. The initiation of thrombolytic treatment during the pandemic was delayed (2:42 ± 0:51 vs. 2:25 ± 0:53; p = 0.0006). The delay was mainly related to the pre-hospital phase (1:41 ± 0:48 vs. 1:26 ± 0:49; p = 0.0014), and the door-to-needle time was not affected. There were no differences in stroke severity and patients’ outcomes. Patients with AIS were less likely to have previously been diagnosed with atrial fibrillation (16.9% vs. 26.7%; p = 0.0383), ischemic heart disease (25.3% vs. 46.5%; p = 0.0003) and hyperlipidemia (31.2% vs. 46.5%; p = 0.0264). Patients treated during the pandemic had higher glycemia (149.45 ± 54. vs. 143.25 ± 60.71 mg/dL; p= 0.0012), while no significant differences in their lipid profiles were found. Conclusions: The COVID-19 pandemic affected the treatment of AIS patients locally at our stroke center. It caused treatment delay and hindered the recognition of risk factors prior to the occurrence of AIS.

Elevated plasma syndecan-1 as glycocalyx injury marker predicts unfavorable outcomes after rt-PA intravenous thrombolysis in acute ischemic stroke.

Purpose: We aimed to examine the prognostic value of syndecan-1 as a marker of glycocalyx injury in patients with acute ischemic stroke (AIS) receiving rt-PA intravenous thrombolysis. Methods: The study included 108 patients with AIS treated with rt-PA intravenous thrombolysis and 47 healthy controls. Patients were divided into unfavorable and favorable prognosis groups based on modified Rankin Scale scores. Univariate and multivariate logistic regression analyses were used to determine risk factors affecting prognosis. Risk prediction models presented as nomograms. The predictive accuracy and clinical value of the new model were also evaluated. Results: Plasma levels of syndecan-1 were significantly higher in patients with AIS than in controls (p < 0.05). Univariate analysis indicated that higher levels of syndecan-1 were more frequent in patients with poor prognosis than in those with good prognosis (t = −4.273, p < 0.001). Syndecan-1 alone and in combination with other factors predicted patient outcomes. After adjusting for confounding factors, syndecan-1 levels remained associated with poor prognosis [odds ratio, 1.024; 95% confidence interval (CI), 1.010–1.038]. The risk model exhibited a good fit, with an area under the receiver operating characteristic curve of 0.935 (95% CI, 0.888–0.981). The categorical net reclassification index (NRI) and continuous NRI values were >0. The integrated discrimination improvement value was 0.111 (95% CI, 0.049–0.174, p < 0.001). Decision curve analysis indicated that the model incorporating syndecan-1 levels was more clinically valuable than the conventional model. Conclusion: Plasma syndecan-1 levels represent a potential marker of prognosis of AIS following intravenous thrombolysis. Adding syndecan-1 to the conventional model may improve risk stratification.

A Novel Mobilization Criteria Checklist 12 to 24 Hours After Intravenous Thrombolysis in Acute Ischemic Stroke

Purpose: This study describes the development and utilization of a novel mobilization criteria checklist that can guide clinical decision making to safely initiate very early mobilization for patients with acute ischemic stroke within 12 to 24 hours after intravenous (IV) thrombolysis. Methods: The evidence was examined, and risk factors for hemorrhagic transformation and considerations for initiating or terminating mobility within the first 12 to 24 hours were identified. The information was formatted into a mobilization criteria checklist for use in a case study 12 to 24 hours after tissue plasminogen activator (tPA), an IV thrombolytic, was given for acute ischemic stroke at a certified comprehensive stroke center. Outcomes: The tool was an additive to clinical practice and provided a clinical guide to optimize patient safety for an established institutional practice. Discussion: A mobilization criteria checklist is a helpful tool to screen for serious risk factors of hemorrhagic transformation in the first 24 hours after IV thrombolysis for acute ischemic stroke. With further development, the foundational concepts may guide future research to establish clinical practice guidelines and a standard of care to optimize the selection of patients most appropriate for mobility within 12 to 24 hours.

Tenecteplase for acute ischaemic stroke

The introduction of intravenous thrombolysis for acute ischaemic stroke has changed the outlook of stroke neurology, altering the field from a rehabilitation focus to emergency medicine. Because the treatment effect of intravenous thrombolysis in acute stroke is time dependent, stroke services globally are constantly striving to reduce the time from symptom onset to treatment by promoting stroke awareness campaigns, implementing prehospital delivery of thrombolysis in mobile stroke units, and restructuring in-hospital protocols to reduce door-to-needle time.

The quest to reduce stroke treatment delays at a Melbourne metropolitan primary stroke centre over the past two decades.

Reducing door-to-needle time (DNT) for intravenous thrombolysis in acute ischaemic stroke can lead to improved patient outcomes. Long-term reports on DNT trends in Australia are lacking in the setting of extension of the thrombolysis time window, addition of mechanical thrombectomy and increasing presentations. To examine 17-year trends of DNT and identify factors associated with improved DNT at a high-volume, metropolitan primary stroke centre. Retrospective study between 2003 and 2019 of all thrombolysis cases using departmental stroke database. Since most strategies were implemented from 2012 onwards, intervention period has been defined as period 2012-2019. Factors associated with DNT reduction were examined by regression modelling. Fifteen strategies were identified including alterations to 'Code Stroke' processes. One thousand, two hundred and fifty patients were thrombolysed, with 737 (58.8%) treated during the intervention period. The proportion of DNT ≤60-min rose from average of 22.5% during 2003-2012 to 63% during 2015-2018 and 71% in 2019. However, median DNT has only marginally improved from 58 to 51 min between 2015 and 2019. Faster DNT was independently associated with two modifiable workflow factors, 'Direct-to-CT' protocol (P< 0.001) and acute stroke nurse presence (P< 0.005). Over time, treated patients were older and less independent (P< 0.001), and the number of annual stroke admissions and 'Code Stroke' activations have risen by fourfold and 10-fold to 748 and 1298 by 2019 respectively. Targeted quality improvement initiatives are key to reducing thrombolysis treatment delays in the Australian metropolitan setting. Relative stagnation in DNT improvement is concerning and needs further investigation.

Stress Hyperglycemia Does Not Affect Clinical Outcome of Diabetic Patients Receiving Intravenous Thrombolysis for Acute Ischemic Stroke.

Although stress hyperglycemia represents a main risk factor for poor outcome among patients with acute ischemic stroke (AIS) undergoing recanalization therapy, we have limited information regarding a possible influence of the premorbid diabetic status on this association. We recruited consecutive patients admitted to the Udine University Hospital with AIS who were treated with intravenous thrombolysis (IVT) from January 2015 to September 2020. On the basis of the premorbid diabetic status, our sample was composed of 130 patients with and 371 patients without diabetes. The glucose-to-glycated hemoglobin ratio (GAR) was used to measure stress hyperglycemia. Patients were stratified into 3 groups by tertiles of GAR (Q1–Q3). The higher GAR index was, the more severe stress hyperglycemia was considered. Among diabetic patients we did not observe any significant association between severe stress hyperglycemia and outcome measures (three-month poor outcome: Q1, 53.7%; Q2, 53.5%; Q3, 58.7%; p = 0.854; three-month mortality: Q1, 14.6%; Q2, 9.3%; Q3, 23.9%; p = 0.165; symptomatic intracranial hemorrhage: Q1, 7.3%; Q2, 14%; Q3, 19.6%; p = 0.256). Differently, non-diabetic subjects with more severe stress hyperglycemia showed a higher prevalence of three-month poor outcome (Q1, 32.2%; Q2, 27.7%; Q3, 60.3%; p = 0.001), three-month mortality (Q1, 9.1%; Q2, 8.4%; Q3, 18.3%; p = 0.026), and symptomatic intracranial hemorrhage (Q1, 0.8%; Q2, 0.8%; Q3, 9.9; p = 0.001). After controlling for several confounders, severe stress hyperglycemia remained a significant predictor of three-month poor outcome (OR 2.1, 95% CI 1.03–4.28, p = 0.041), three-month mortality (OR 2.39, 95% CI 1.09–5.26, p = 0.029) and symptomatic intracranial hemorrhage (OR 12.62, 95% CI 1.5–106, p = 0.02) among non-diabetics. In conclusion, premorbid diabetic status seems to influence outcome in AIS patients receiving IVT. Indeed, odds of functional dependency, mortality and hemorrhagic complications were significantly increased in patients with more severe stress hyperglycemia only when they were not affected by diabetes.

Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability: A Meta-Analysis.

Randomized controlled trials for the use of alteplase in acute ischemic stroke have excluded or had little representation of patients with prestroke disability, and the benefit of alteplase in this population remains uncertain. We performed a systematic review and meta-analysis to examine the outcomes of thrombolysis in patients with premorbid disability. We performed a systematic review in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines and retrieved studies reporting intravenous thrombolysis (IVT) in patients with prestroke disability (modified Rankin Scale score, 3-5) with acute ischemic stroke, either compared with untreated patients or treated patients without premorbid disability. The primary outcome was the return to premorbid disability at 90 days. Secondary outcomes included rate and odds ratio of favorable functional outcome at 90 days (modified Rankin Scale score 0-2 or return to premorbid modified Rankin Scale), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Eight articles were included involving 103 988 patients. Patients with disability treated with IVT had better odds of returning to baseline function compared with those who did not receive IVT (odds ratio, 7.26 [95% CI, 2.51-21.02]). Mortality and rates of sICH were not significantly different between patients with disability treated with IVT and those not treated, although there were numerically more sICHs in the IVT group. Return to baseline function was not significantly different between patients with and without prestroke disability (odds ratio, 1.46 [95% CI, 0.75-2.83]). The rates of sICH were not significantly different in patients with and without premorbid disability. However, mortality was 3× higher in patients with premorbid disability than in those without premorbid disability (38.2% versus 12.6%). The use of IVT in patients with disability was associated with better outcomes compared with patients who did not receive IVT without statistically significant added risks of sICH or mortality. When compared with those without disability, there was no significant difference in the return to baseline function or sICH. High-quality data comparing treated versus untreated patients with premorbid disability are needed to clarify this issue. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

P.063 Thrombolysis for acute ischemic stroke in patients with pre-morbid disability: a meta-analysis

Background: Randomized-controlled trials of thrombolysis in ischemic stroke have poorly represented patients with pre-stroke disability and the benefit of thrombolysis in this population remains uncertain. We performed a systematic review and meta-analysis to examine the outcomes of thrombolysis in patients with pre-morbid disability. Methods: In accordance with MOOSE guidelines, we retrieved studies reporting intravenous thrombolysis (IVT) in patients with pre-stroke disability (mRS=3-5) with ischemic stroke, either compared to untreated patients or to treated patients without pre-morbid disability. Primary outcome was the return to pre-morbid disability at 90-days. Results: 8 articles were included involving 103,988 patients. Patients with disability treated with IVT had better odds of returning to baseline function compared to those who did not receive IVT (OR=7.26, 95%CI=2.51-21.02). Mortality and sICH were not significantly different between patients with disability receiving IVT or not. Favourable outcomes (mRS=0-2 or return to pre-morbid mRS) and sICH were not significantly different between patients with and without disability. Mortality was three times higher in those with pre-morbid disability treated with IVT (38.2% versus 12.6%). Conclusions: Thrombolysis in patients with disability was associated with better outcomes compared to patients not receiving IVT. High-quality data comparing treated versus untreated patients with pre-morbid disability is needed to clarify this issue.

Effect of mechanical thrombectomy with vs. without intravenous thrombolysis in acute ischemic stroke.

The results of mechanical thrombectomy (MT), wi-thout or with intravenous thrombolysis, were evaluated and compared in 178 patients with acute ischemic stroke (AIS) due to large vessel occlusions (LVO) at Bach Mai Hospital. A total of 178 patients with AIS due to LVO were assigned to undergo MT alone (MT-alone group) or MT preceded by intravenous alteplase (the combined group), at a dose of 0.9 mg per kilogram, administered within 4.5 hours after symptom onset (combined group). The successful recanalization rate (assessed as thrombolysis in cerebral infarction [TICI] classification of 2b-3) and the incidence of good clinical recovery outcomes (modified Rankin Scale [mRS] ≤2) after 3 months were analyzed in both groups and compared. A total of 178 patients were enrolled (median age, 65 years; 55% men; median National Institutes of Health Stroke Scale [NIHSS]: 14.3). Favorable outcomes were reported in 76 patients (66.7%) in the MT-alone group and 42 patients (65.6%) in the com-bined group, with no significant between-group difference (P = 0.31 for noninferiority). However, MT alone was associated with a lower percentage of patients with successful reperfusion after MT compared with the combined group (87.7% vs. 90.6%). Mortality at 90 days was 12.2% (14 patients) in the MT-alone group and 17.2% (11 patients) in the combined group. The incidence of symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.3%] vs. 1 [1.6%]; P = 0.42). Among patients with AIS due to LVO in our study, MT alone was noninferior in terms of functional outcomes compared with MT preceded by the administration of intravenous alteplase within 4.5 hours after symptom onset.

Tenecteplase for Thrombolysis in Acute Ischemic Stroke and Its Outcome—An Indian Experience

Background: Stroke has been a growing concern with increasing morbidity and mortality worldwide. Tenecteplase has been approved in India as a newer thrombolytic, in acute ischemic stroke, since 2016. Very few studies have been reported to know the efficacy of Tenecteplase in AIS compared to alteplase. Aim: This study was done to understand the efficacy and related complications of Tenecteplase in AIS. Methods: In this prospective study, we took 112 people with AIS who received Tenecteplase, admitted between August 2018 and August 2020. After obtaining ethical approval, we tabulated patients’ data and did the statistical analysis using an unpaired t test, Analysis of Variance, and chi-square test. A P value of &lt;.05 using a 2-tailed test was considered significant for all statistical analyses. Results: Out of 112 patients, 67.9% were male and 32.1% were female, with a mean age of 60.7 years. We classified stroke by using the TOAST classification. About 62.5% are classified as large atherosclerotic type, 14.3% cardioembolic, and 17.0% lacunar strokes. A total of 82.1% had a middle cerebral artery region stroke. The mean door to needle time was 76.7 min with a standard deviation of 33.3. The primary outcome was met in 47.3%, and the secondary result was achieved in 59.8%. Intracerebral hematoma was the most commonly observed complication. Mortality accounted for 9.8% of the total population. Conclusions: Tenecteplase is the newer thrombolytic agent with good efficacy. More studies are needed globally to understand regional differences and effectiveness.

Urinary Kallidinogenase plus rt-PA Intravenous Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Purpose This research is aimed at systematically assessing the safety and effectiveness of intravenous thrombolysis (IVT) with rt-PA plus human urinary kallidinogenase (HUK) for acute ischemic stroke (AIS). Methods The data were obtained through rigorous searching of both domestic and foreign databases from inception to 2021.7.1. Randomized controlled trials (RCTs) were included for the comparison of the efficacy of IVT plus HUK. The Cochrane risk of bias (RoB) tool and Review Manager software 5.3 were responsible for RoB assessment and statistical analyses, respectively. Results A total of 18 articles were retrieved, including 2676 AIS patients treated with IVT within the time window. The control group used standardized rt-PA IVT, and the test group added HUK. After 14 days of combined application of HUK, the National Institute of Health Stroke Scale (NIHSS) score was significantly better in moderate stroke patients using the combination treatment versus those with IVT alone (mean difference (MD) = −3.13; 95% confidence intervals (CI): -3.40,-2.86; P < 0.00001); the NIHSS score was also statistically in severe stroke patients with combined treatment than in those with IVT alone, but the degree of recovery of patients varied greatly. After 90 days of treatment, the NIHSS (MD = −1.93; 95% CI: -2.51,-1.34; P < 0.00001) and Barthel index (BI) scores (MD = 22.23; 95% CI: 18.96, 25.49; P < 0.00001) of patients plus HUK were significantly better than those of patients with IVT alone, with fewer adverse events during treatment (Relative Risk (RR) = 0.66; 95% CI: 0.47, 0.92; P = 0.02). Conclusions For AIS patients with IVT within the time window, HUK plus rt-PA IVT could significantly improve the neurological function recovery after 14 days and the quality of life after 90 days and reduce the adverse reactions of IVT. This trial is registered with CRD42021226975.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Cardiac Myxoma: A Case Series and Pooled Analysis.

Background and PurposeAcute ischemic stroke (AIS) is a major life-threatening consequence of cardiac myxoma (CM) and leads to a poor prognosis. Although intravenous thrombolysis (IVT) is the first-line treatment for AIS, its efficacy and safety in CM-AIS have not been established. Currently, there are only limited data from case reports. Our study aimed to investigate the clinical characteristics of CM-AIS and evaluate the safety and efficacy of IVT for CM-AIS patients.MethodsFourteen CM-AIS patients who received IVT between January 2016 and December 2021 were identified from our multicenter stroke registry databases. Clinical, neuroimaging and outcome data were analyzed. We then performed a pooled analysis of the published literature from inception to December 2021.ResultsOf the 14 CM-AIS patients, nine were treated with IVT alone, and five were treated with bridging therapy (BT). The median age was 51.5 years, and 57.1% were female. The median onset-to-needle time was 160 min. The median National Institute of Health Stroke Score (NIHSS) decreased from 15.5 at presentation to 13 24 h after IVT. Very early neurological improvement (VENI) was observed in one patient. Hemorrhagic transformation (HT) was observed in five (35.7%) patients, and only one patient was symptomatic (7.1%). Three-month favorable outcomes were achieved in six patients (66.7%) who underwent IVT alone and three patients (60%) who received BT, which resulted in a total proportion of favorable outcomes of 64.3%. None of the patients died at 3 months follow-up. Forty-seven cases (15 BT patients) were included for the pooled analysis. The median NIHSS score was 16.5, and VENI was observed in 10 (21.3%) patients. HT was detected in 11 patients (23.4%), and four (8.5%) patients were symptomatic. Favorable outcomes at 3 months were achieved in 61.7% of patients, 56.3% of patients who underwent IVT alone, and 73.3% of patients who received BT. The 3-month mortality rate was 4.3%.ConclusionsIVT is a potentially safe and efficient treatment for CM-AIS patients. Further studies with larger sample sizes are required to provide more evidence on the safety and efficacy of IVT and BT in CM-AIS patients.

Thrombolysis for Acute Ischemic Stroke in Patients with versus without Pre-morbid Disability: A Meta-analysis (P1-1.Virtual)

Thrombolysis for Acute Ischemic Stroke in Patients with versus without Pre-morbid Disability: A Meta-analysis (P1-1.Virtual)

Relationship between carbon dioxide combining power and the short-term prognosis in acute ischemic stroke patients after thrombolysis

To investigate the effect of venous blood carbon dioxide binding capacity (CO2-CP) on the short-term prognosis of patients with acute ischemic stroke (AIS) after thrombolytic therapy. A total of 86 AIS inpatients who received thrombolytic therapy in the emergency department of Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from April 2019 to May 2021 were analyzed retrospectively. According to the venous blood CO2-CP levels at admission, the patients were divided into two groups: low CO2-CP group (CO2-CP < 23 mmol/L, n = 52) and high CO2-CP group (CO2-CP ≥ 23 mmol/L, n = 34). The CO2-CP levels and changes between the two groups before and after thrombolytic therapy were compared. The National Institutes of Health Stroke scale (NIHSS) score was used to evaluate the improvement rate of patients after thrombolytic therapy [NIHSS score at admission-NIHSS score at discharge)/NIHSS score at admission ×100%] and in-hospital death was also recorded. The correlation between CO2-CP levels and prognosis of patients with AIS during emergency visit was analyzed, the receiver operator characteristic curve (ROC curve) was drawn and the area under the ROC curve (AUC) was calculated to evaluate the predictive value of CO2-CP in the prognosis of AIS patients. The CO2-CP levels of low CO2-CP group and high CO2-CP group after thrombolytic therapy were significantly higher than those before treatment (mmol/L: 23.08±2.34 vs. 20.46±1.51, 25.24±2.16 vs. 23.94±1.07, both P < 0.05). The differences of CO2-CP before and after treatment in low CO2-CP group were significantly higher than those in high CO2-CP group (mmol/L: 2.62±0.83 vs. 1.30±1.09, P < 0.05). The improvement rate of CO2-CP levels in the high CO2-CP group (NIHSS improvement rate > 45%) was significantly higher than that in the low CO2-CP group [85.29% (29/34) vs. 23.08% (12/52)], while the mortality in the low CO2-CP group was significantly higher than that in the high CO2-CP group [11.54% (6/52) vs. 0% (0/34), P < 0.05]. The AUC of CO2-CP for the prognosis of patients with AIS thrombolysis was 0.820, the 95% confidence interval (95%CI) was 0.727-0.924, P = 0.000 1. AIS patients with CO2-CP levels less than 23 mmol/L have a poor short-term prognosis, which has certain predictive and clinical reference value for choosing thrombolytic time in emergency stroke patients.