Thrombolysis In Posterior Circulation Stroke Research Articles

Endovascular Thrombectomy With and Without Preceding Thrombolysis in Posterior Circulation Stroke—Insights From STAR

Background Multiple randomized trials could not establish the noninferiority of endovascular thrombectomy (EVT) alone without preceding intravenous thrombolysis (IVT) or superiority of IVT followed by EVT in anterior circulation large‐vessel occlusion stroke. The role of prior IVT in posterior circulation large‐vessel occlusion remains controversial. Methods In this multicenter, retrospective study, patients with stroke with large‐vessel occlusion in the posterior circulation who received EVT alone or with IVT were selected from the stroke thrombectomy and aneurysm registry between 2013 and 2022. Effects of IVT followed by thrombectomy on favorable functional outcome (defined as modified Rankin scale≤3 at 90 days) and safety were investigated using multivariable logistic and linear regression models. Results Of the 588 included patients, 67% (n = 394) were treated with EVT alone and 29% (n = 170) with EVT after IVT, and 4% (n = 24) have missing values on this variable. Controlling for multiple confounding factors, IVT was not associated with a higher likelihood of favorable functional outcome at 90 days (odds ratio, 1.04 [95% CI, 0.52–2.09; P = 0.901). Thrombectomy alone did not show any safety advantages compared with those receiving IVT. Conclusion Similar functional outcomes and complication rates were seen in patients with posterior circulation large‐vessel occlusion treated with EVT alone versus EVT after IVT. Further prospective studies are required to determine the utility of IVT in posterior circulation stroke, especially in patients being directly admitted to thrombectomy centers.

IV-Thrombolysis in Ischemic Stroke With Unknown Time of Onset—Safety and Outcomes in Posterior vs. Anterior Circulation Stroke

Background: rt-PA for ischemic stroke in the unknown or extended time window beyond the first 4. 5 h after symptom onset is safe and effective for certain patients after selection by multimodal neuroimaging. However, the evidence for this approach comes mainly from patients with anterior circulation stroke (ACS), while the data on posterior circulation stroke (PCS) are scarce.Methods: Ischemic stroke patients treated with IV-thrombolysis in the unknown or extended time window between January 2011 and May 2019 were identified from an institutional registry. The patients were categorized into PCS or ACS based on clinico-radiological findings. We analyzed the hemorrhagic complications, clinical and imaging efficacy outcomes, and mortality rates by comparing the PCS and ACS patient groups. Adjusted outcome analyses were performed after propensity score matching for the relevant factors.Results: Of the 182 patients included, 38 (20.9%) had PCS and 144 (79.1%) had ACS. Symptomatic acute large vessel occlusion (LVO) was present in 123 patients on admission [27 (22.0%) PCS and 96 (78.0%) ACS]. The score on the National Institutes of Health Stroke Scale (NIHSS), the time from last seen normal, and the door-to-needle times were similar in PCS and ACS. In patients with LVO, the NIHSS score was lower [8 (5–15) vs. 14 (9–18), p = 0.005], and infarction visible on follow-up imaging was less common [70.4 vs. 87.5%; aRD, −18.9% (−39.8 to −2.2%)] in the PCS patient group. There was a trend toward a lower risk for intracranial hemorrhage (ICH) following intravenous thrombolysis in PCS vs. ACS, without reaching a statistical significance [5.3 vs. 16.9%; aRD, −10.4% (−20.4 to 4.0%)]. The incidence of symptomatic ICH [according to the ECASS III criteria: 2.6 vs. 3.5%; aRD, −2.9% (−10.3 to 9.2%)], efficacy outcomes, and mortality rates were similar in PCS and ACS patients.Conclusions: In this real-world clinical cohort, the safety and the efficacy of rt-PA for ischemic stroke in the unknown or extended time window did not show relevant differences between PCS and ACS, with a trend toward less hemorrhagic complications in PCS. The findings reconfirm the clinician in the usage of rt-PA beyond the first 4.5 h also in selected patients with PCS.

Brain Imaging Findings and Response to Intravenous Thrombolysis in Posterior Circulation Stroke.

Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischaemic stroke (ACIS) and posterior circulation ischaemic stroke (PCIS). Our aim was to evaluate the predictors for a good clinical outcome and intracerebral haemorrhage (ICH) in patients undergoing posterior circulation IVT based on the initially performed CT or MR imaging. The study cohort consisted of 1643 consecutive patients with acute ischaemic stroke (1440 ACIS, 203 PCIS cases) who underwent IVT. ICH was classified according to the European Cooperative Acute Stroke Study (ECASS)I protocol. Clinical outcome was assessed using the modified Rankin scale (mRS). Early ischaemic signs and pre-existing structural signs were assessed. Good clinical outcomes (mRS0-1) were noted in 45.3% of patients with PCIS, with a mortality rate of 14.8%. ICH was noted in 8.3%, and a large haemorrhage was found in 2.4% of patients. Some early ischaemic signs and pre-existing structural signs on initial CT/MR imaging correlated significantly with the 90-day clinical outcome. Early ischaemic signs and pre-existing structural signs should be considered during the assessment of patients with PCIS eligible for IVT. Tissue hypoattenuation on initial CT scans correlates with an increased risk of death. Similarly to anterior circulation, atrophy on initial MRI may negatively predict good clinical outcome in posterior circulation.

Do thrombolysis outcomes differ between anterior circulation stroke and posterior circulation stroke? A systematic review and meta-analysis.

It remains unclear whether thrombolysis outcomes can be influenced by the affected vascular territory (i.e. anterior circulation stroke vs. posterior circulation stroke) in stroke patients owing to the lack of randomized controlled trials. Using multiple comprehensive databases, we searched for observational studies of the safety and efficacy of intravenous thrombolytics and intra-arterial treatment with or without intravenous thrombolytics in accordance with the affected vascular territory. We performed a systematic review and meta-analysis. We evaluated symptomatic intracerebral hemorrhage, all-type intracerebral hemorrhage, mortality, and functional outcomes at three months. The recanalization rate was assessed in the intra-arterial treatment group. Twenty-one studies including a report from our own stroke registry were included through quantitative synthesis. Compared with the anterior circulation stroke group, the posterior circulation stroke group had a lower risk of ICH, including symptomatic intracerebral hemorrhage and all-type intracerebral hemorrhage, after intravenous thrombolytics and tended to have favorable functional outcomes at three months. Mortality was similar between the two groups. Regarding intra-arterial treatment, the symptomatic intracerebral hemorrhage and post-procedural recanalization rates were comparable between the two groups, although the posterior circulation stroke group had a higher mortality risk and lower tendency for a favorable functional outcome. Safety and efficacy of thrombolysis in posterior circulation stroke depends on involvement of large vessel occlusion and reperfusion modality such that intravenous thrombolytics is more effective and safer than in anterior circulation stroke; the safety and efficacy of intra-arterial treatment is comparable or lower than anterior circulation stroke. Considering the limitations of our meta-analysis, further studies are needed to provide high level evidence of a beneficial effect of intra-arterial treatment, and to identify patients' profiles associated with benefit of treatment.

Safety and Outcomes of Intravenous Thrombolysis in Posterior Versus Anterior Circulation Stroke: Results From the Safe Implementation of Treatments in Stroke Registry and Meta-Analysis.

Background and Purpose- Posterior circulation stroke (PCS) accounts for 5% to 19% of patients with acute stroke receiving intravenous thrombolysis. We aimed to compare safety and outcomes following intravenous thrombolysis between patients with PCS and anterior circulation stroke (ACS) and incorporate the results in a meta-analysis. Methods- We included patients in the Safe Implementation of Treatments in Stroke Thrombolysis Registry 2013 to 2017 with computed tomography/magnetic resonance angiographic occlusion data. Outcomes were parenchymal hematoma, symptomatic intracerebral hemorrhage (SICH) per SITS-MOST (Safe Implementation of Thrombolysis in Stroke Monitoring Study), ECASS II (Second European Co-operative Stroke Study) and NINDS (Neurological Disorders and Stroke definition), 3-month modified Rankin Scale score, and death. Adjustment for SICH risk factors (age, sex, National Institutes of Health Stroke Scale, blood pressure, glucose, and atrial fibrillation) and center was done using inverse probability treatment weighting, after which an average treatment effect (ATE) was calculated. Meta-analysis of 13 studies comparing outcomes in PCS versus ACS after intravenous thrombolysis was conducted. Results- Of 5146 patients, 753 had PCS (14.6%). Patients with PCS had lower median National Institutes of Health Stroke Scale: 7 (interquartile range, 4-13) versus 13 (7-18), P<0.001 and fewer cerebrovascular risk factors. In patients with PCS versus ACS, parenchymal hematoma occurred in 3.2% versus 7.9%, ATE (95% CI): -4.7% (-6.3% to 3.0%); SICH SITS-MOST in 0.6% versus 1.9%, ATE: -1.4% (-2.2% to -0.7%); SICH NINDS in 3.1% versus 7.8%, ATE: -3.0% (-6.3% to 0.3%); SICH ECASS II in 1.8% versus 5.4%, ATE: -2.3% (-5.3% to 0.7%). In PCS versus ACS, 3-month outcomes (70% data availability) were death 18.5% versus 20.5%, ATE: 6.0% (0.7%-11.4%); modified Rankin Scale score 0-1, 45.2% versus 37.5%, ATE: 1.7% (-6.6% to 3.2%); modified Rankin Scale score 0-2, 61.3% versus 49.4%, ATE: 2.4% (3.1%-7.9%). Meta-analysis showed relative risk for SICH in PCS versus ACS being 0.49 (95% CI, 0.32-0.75). Conclusions- The risk of bleeding complications after intravenous thrombolysis in PCS was half that of ACS, with similar functional outcomes and higher risk of death, acknowledging limitations of the National Institutes of Health Stroke Scale for stroke severity or infarct size adjustment.

Intravenous Thrombolysis in Posterior Circulation Stroke.

Background: Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischemic stroke (ACIS) and posterior circulation ischemic stroke (PCIS). PCIS is a clinical syndrome associated with ischemia-related changes in the territory of the posterior circulation arteries. Embolism is the most common stroke mechanism in posterior circulation. PCIS represents 12–19% of all IVT-treated strokes.Methods and Results: We searched the PubMed database for assessments of intracerebral hemorrhage (ICH) and clinical outcome in PCIS patients treated with IVT. ICH occurs in 0–6.9% of posterior ischemic stroke depending on the definition of symptomatic ICH, and any ICH in 17–23.4% of posterior ischemic stroke. For patients with PCIS, 38–49% have a favorable outcome (mRS 0–1) after IVT. Better clinical outcomes occur more often in patients with PCIS than in those with ACIS. The mortality rate among PCIS patients treated with IVT ranges from 9 to 19%; it does not differ significantly between PCIS and ACIS.Conclusions: Up to date, no data about PCIS and IVT are available from RTCs. Based on limited results from retrospective clinical studies and case series, IVT is safer for use in PCIS than in ACIS. Patients with brainstem ischemia, vertebral artery occlusion, and absence of basilar or posterior cerebral artery occlusion could be considered for treatment with IVT even in borderline cases. Time to IVT in PCIS seems to be a less crucial factor than in ACIS. IVT for PCIS may be beneficial even after 4.5 h from symptom onset.

Author Correction: Predictors for Intracranial Hemorrhage Following Intravenous Thrombolysis in Posterior Circulation Stroke.

In the original publication of the article, there was a switched order of author names.

Predictors for Intracranial Hemorrhage Following Intravenous Thrombolysis in Posterior Circulation Stroke.

Intravenous thrombolysis (IVT) is a standard treatment for anterior (ACS) and posterior circulation stroke (PCS). However, due to the low occurrence of PCS and of intracranial hemorrhage (ICH) in PCS, the knowledge about ICH predictors following IVT in PCS is sparse. Our aim was to identify predictors for ICH following IVT in PCS. The set consisted of 1281 consecutive ischemic stroke (IS) patients treated with IVT, out of which 158 (103 males; mean age 65.6 ± 12.3years) had PCS. Collected data include baseline characteristics, common stroke risk factors, pre-medication, stroke severity, admission blood glucose level, blood pressure and treatment with intravenous antihypertensive therapy before and during IVT, occlusion of arteries, recanalization rate, time to treatment, and clinical outcome at day 90. Overall, 11 (7%) patients had ICH. Atrial fibrillation (p = 0.004), neurological deficit at time of treatment in the National Institutes of Health Stroke Scale (p = 0.016), decreased level of consciousness (p = 0.003), occlusion of basilar artery (p = 0.007), occlusion of PCA (p = 0.001), and additional endovascular therapy (p = 0.001) were identified by logistic regression analysis as significant predictors for ICH in PCS. Patients with ischemic lesion in the brainstem, occlusion of vertebral artery, or absence of basilar and posterior cerebral artery occlusion might be considered for treatment with IVT even in borderline cases. Those patients seem to have less frequently favorable outcomes without an increase in ICH rate. Time to IVT in PCS seems not to influence ICH risk or chances for favorable outcomes as significantly as it does in ACS.

Risk of intracranial hemorrhage and clinical outcome after intravenous thrombolysis in posterior circulation stroke: Results from the sits-east registry

Risk of intracranial hemorrhage and clinical outcome after intravenous thrombolysis in posterior circulation stroke: Results from the sits-east registry

Risk of Symptomatic Intracranial Hemorrhage and Clinical Outcome after Intravenous Thrombolysis in Posterior Circulation Stroke: Results from the SITS-EAST Registry (P4.276)

Risk of Symptomatic Intracranial Hemorrhage and Clinical Outcome after Intravenous Thrombolysis in Posterior Circulation Stroke: Results from the SITS-EAST Registry (P4.276)

Prolonged Low-Dose Thrombolysis in Posterior Circulation Stroke

We aimed to investigate the feasibility, preliminary safety, and efficacy of prolonged low-dose intravenous thrombolysis in posterior circulation stroke patients with a thrombus lodged in the basilar artery who were ineligible for standard rtPA administration. We retrospectively analyzed consecutively collected patients in our stroke database who suffered from a basilar artery thrombosis and were treated with prolonged (>1 h), intravenous, low-dose (≤20 mg) rtPA between 01/2005 and 11/2012. Patients included in this study (n = 14) were 68.5 years (IQR 55.5; 72.75) of age and presented with a median NIHSS of 2 (1; 5.25). Median time from symptom onset to treatment was 63 h (33; 141). A median dose of 5.21 μg/kg h (4.46; 6.25) rtPA was administered over 24 h (min 10; max 48). No patient experienced symptomatic intracerebral hemorrhage, one patient developed a spinal epidural hematoma, and two elderly patients were switched to comfort care and died. In eight patients (57%) a decrease in thrombus size or no thrombus at all was detected on control imaging. Nine patients (64%) had a favorable outcome (mRS 0-2) at day 90. Prolonged low-dose thrombolysis with rtPA may be considered as individual treatment option in selected high-risk patients with basilar artery thrombosis. Presented data may lay the groundwork to further investigate safety and efficacy in a prospective trial.

Thrombolysis in Posterior Circulation Stroke: Stroke Subtypes and Patterns, Complications and Outcome

Background: Patients with posterior circulation stroke (PCS) were underrepresented in or even excluded from the large clinical trials investigating acute therapy with thrombolysis. Therefore, the knowledge about potential benefits and risks of thrombolysis in PCS is sparse. Methods: From July 2004 until June 2007, 237 stroke patients were treated with thrombolysis within 3 h after onset of symptoms in our stroke unit. Baseline characteristics, etiology, CT/MRI stroke patterns, clinical outcome, and complications of patients with PCS were compared to those with anterior circulation stroke (ACS). Results: There were 30 patients in the PCS group; 198 had ACS. In the PCS group, less patients had a history of prior stroke (0/30 vs. 31/198 (15.7%), p = 0.02) and less were treated with platelet inhibitors (6/30 (20.0%) vs. 83/198 (41.9%), p = 0.02). Onset to treatment time was higher in the PCS group (156.2 ± 23.2 vs. 141.1 ± 30.7, p = 0.01). Small vessel disease occurred more often in PCS patients (10/30 (33.3%) vs. 12/198 (6.1%), p < 0.001), whereas stroke of undetermined cause was less frequent (5/30 (16.7%) vs. 75/198 (37.9%), p = 0.02). Correspondingly, PCS patients had more lacunar (13/30 (43.3%) vs. 15/198 (7.3%), p < 0.001) strokes on CT/MRI. Patients with PCS had significantly lower median NIHSS scores after 2 and 24 h, whereas the median NIHSS and mRS scores at discharge as well as the mRS score at the 3-month follow-up, although still lower, did not differ significantly between both groups. Outcome was similar with regard to complications and mortality. Conclusions: Patients with PCS have a higher rate of small vessel disease and lacunar stroke. In terms of potential benefits and risks of thrombolysis, we could demonstrate no significant differences between PCS and ACS. Acute PCS patients should be diagnosed and treated with the same elaborateness as ACS patients.

Outcomes following thrombolysis for posterior circulation stroke

P189 There is relatively less information about indications and outcome for thrombolysis in posterior circulation stroke as compared to anterior circulation stroke. Prior randomized studies either excluded this group of patients (PROACT-II), or used inclusion criteria that made enrollment less likely (NINDS rt-PA, ECASS I &amp; II). Medical records were reviewed for all patients who received intravenous (IV) or intraarterial (IA) thrombolytic therapy for posterior circulation ischemic stroke at the University of California, San Francisco between October 1993 and February 2000. NIHSS was measured at baseline, 1 day, and at discharge, and a Glasgow Coma Scale (GCS) was measured at baseline. A retrospective modified Rankin Scale (mRS) was measured at last follow-up. A mRS≤2 was considered a good outcome. Data were analyzed using the Wilcoxon rank-sum test. 20 patients received thrombolytic therapy: 9 IV rt-PA; 9 IA urokinase; 2 IA rt-PA. Mean age was 57 (range 25–87). 11 of 20 patients were treated within 12 hours (1.5 hours-16 days) of symptom onset. Mean initial NIHSS score was 20 (range 2–39), and GCS was 10 (range 3–15). One day following thrombolytic therapy the mean NIHSS was 13 (range 0–36, p&lt;0. 01), with 16 of the 20 patients having overall improvement (11 of these patients with 5 or more points) despite continued disability. No intracranial hemorrhages were observed. Six patients died of complications between 2 days and 2 weeks, and 3 of these patients were treated &gt;12 hours after stroke onset. At hospital discharge the 8 survivors treated in under 12 hrs had a mean NIHSS of 4 (range 0–13), and the 6 survivors treated beyond 12 hrs had a mean NIHSS of 10 (range 3–20, p&lt;0.10). 7 and 2 patients in the two groups, respectively, had a mRS≤2 (p&lt;0.05, compared to baseline Rankin). Ten patients had an initial GCS of 7 or less, with 9 having motor posturing at the time of presentation. Only 2 of these patients (20%) had a good outcome (ages 25 &amp; 42). Thus, thrombolysis within 12 hours may benefit patients with posterior circulation stroke. Decreased level of consciousness and lack of purposeful movement, as evidenced by a GCS≤7 or motor posturing, respectively, are predictive of poor outcome, even with thrombolytic treatment.

Outcomes following thrombolysis for posterior circulation stroke

P189 There is relatively less information about indications and outcome for thrombolysis in posterior circulation stroke as compared to anterior circulation stroke. Prior randomized studies either excluded this group of patients (PROACT-II), or used inclusion criteria that made enrollment less likely (NINDS rt-PA, ECASS I & II). Medical records were reviewed for all patients who received intravenous (IV) or intraarterial (IA) thrombolytic therapy for posterior circulation ischemic stroke at the University of California, San Francisco between October 1993 and February 2000. NIHSS was measured at baseline, 1 day, and at discharge, and a Glasgow Coma Scale (GCS) was measured at baseline. A retrospective modified Rankin Scale (mRS) was measured at last follow-up. A mRS≤2 was considered a good outcome. Data were analyzed using the Wilcoxon rank-sum test. 20 patients received thrombolytic therapy: 9 IV rt-PA; 9 IA urokinase; 2 IA rt-PA. Mean age was 57 (range 25–87). 11 of 20 patients were treated within 12 hours (1.5 hours-16 days) of symptom onset. Mean initial NIHSS score was 20 (range 2–39), and GCS was 10 (range 3–15). One day following thrombolytic therapy the mean NIHSS was 13 (range 0–36, p 12 hours after stroke onset. At hospital discharge the 8 survivors treated in under 12 hrs had a mean NIHSS of 4 (range 0–13), and the 6 survivors treated beyond 12 hrs had a mean NIHSS of 10 (range 3–20, p