Thrombolysis For Acute Ischemic Stroke Research Articles

Abstract WP8: Targeted versus High-Intensity Monitoring Following Intravenous Thrombolysis in Acute Ischemic Stroke

Abstract WP8: Targeted versus High-Intensity Monitoring Following Intravenous Thrombolysis in Acute Ischemic Stroke

Abstract WP253: A Multicenter, Prospective, Randomized Controlled Trial of Endovascular Treatment with or without Intravenous ThromBolysis in Acute Ischemic Stroke of Basilar Artery Occlusion (BEST-BAO): Study Protocol

Abstract WP253: A Multicenter, Prospective, Randomized Controlled Trial of Endovascular Treatment with or without Intravenous ThromBolysis in Acute Ischemic Stroke of Basilar Artery Occlusion (BEST-BAO): Study Protocol

Abstract WP6: Associations between computed tomography biomarkers of cerebral small vessel disease and early outcomes after intravenous thrombolysis for acute ischemic stroke

Abstract WP6: Associations between computed tomography biomarkers of cerebral small vessel disease and early outcomes after intravenous thrombolysis for acute ischemic stroke

Safety and Outcomes of Intravenous Thrombolysis in Acute Ischemic Stroke with Intracranial Artery Dissection.

Intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) related to underlying intracranial artery dissection (IAD) poses potential risks, including the exacerbation of intramural hematoma and the rupture of the dissected arterial wall. However, the safety of IVT in this specific population remains uncertain. This study aimed to assess whether IAD is associated with an increased risk of intracranial hemorrhage (ICH) following IVT and to evaluate its impact on functional outcomes. This retrospective matched-pair cohort study used a nationwide inpatient database that includes discharge abstracts and administrative claims data in Japan. We included adult patients with AIS treated with IVT between July 2010 and July 2024. We excluded patients with carotid or vertebral artery dissections due to difficulties distinguishing between intracranial and extracranial involvement, those lacking premorbid/discharge modified Rankin Scale (mRS) data, and those who received intra-arterial thrombolysis. Patients with IAD were matched 1:4 with non-IAD controls based on age, sex, premorbid mRS, endovascular treatment (EVT), and teaching hospital status. We assessed ICH, functional independence at discharge (mRS 0-2), and in-hospital mortality using multivariable logistic regression with generalized estimating equations to account for clustering within matched pairs, adjusting for age, sex, premorbid mRS, body mass index, smoking history, hypertension, diabetes mellitus, atrial fibrillation, coagulopathy, Japan Coma Scale, EVT, and teaching hospital status. Of 83,139 patients with AIS treated with IVT, 242 (0.3%) had underlying IAD (median age 54 [46-67] years; 34% women). These patients were matched with 968 non-IAD controls. IAD was associated with a higher risk of ICH (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.26-8.06) and a lower likelihood of functional independence at discharge (OR, 0.51; 95% CI, 0.37-0.72), but not with increased in-hospital mortality (OR, 1.09; 95% CI, 0.50-2.38). Patients with underlying IAD may face an increased risk of ICH and a reduced chance of functional recovery following IVT compared to those without.

Thrombolytic therapy for patients with acute ischemic stroke: systematic review and network meta-analysis of randomized trials.

To systematically compare the benefits and risks of all thrombolytic agents (tenecteplase, reteplase, and alteplase) at different doses for thrombolytic therapy in patients with acute ischemic stroke (AIS). Alteplase is the cornerstone treatment for AIS, but alternative thrombolytic agents are needed. The efficacy and safety of tenecteplase and reteplase, compared to alteplase, remain unclear, as does the optimal dosing for these treatments. A systematic search was conducted in PubMed, Web of Science, SCOPUS, and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant English-language studies up to July 5, 2024. Randomized controlled trials (RCTs) comparing standard-dose alteplase with varying doses of tenecteplase or reteplase in AIS patients were included. Primary outcomes were functional outcome at 90 days, symptomatic intracranial hemorrhage, death within 90 days, and serious adverse events. Data on study characteristics, patient demographics, interventions, and outcomes were extracted, and bias risk assessed. A multivariate random-effects model was used for network meta-analysis to derive odds ratios (OR) and 95% confidence intervals (CI). Twelve RCTs were included (10 with tenecteplase, 2 with reteplase) involving 6,633 patients, all compared against 0.9 mg/kg alteplase. In comparison with alteplase, tenecteplase demonstrated OR of 1.08 for achieving an excellent functional outcome at 90 days (95% CI: 0.97 to 1.22, P = 0.17). Reteplase, on the other hand, showed a significantly higher OR of 1.55 for the same outcome (95% CI: 1.23 to 1.95, P = 0.0002). Reteplase at 18 mg + 18 mg (OR 1.6, 95% CI: 0.91-2.5) showed a higher probability of achieving an excellent functional outcome at 90 days compared to alteplase. When considering a good functional outcome at 90 days, tenecteplase had an OR of 1.03 (95% CI: 0.81 to 1.3, P = 0.82), while reteplase had an OR of 1.15 (95% CI: 0.61 to 2.19, P = 0.66). Tenecteplase at 0.25 mg/kg (OR 1.3, 95% CI: 0.79-2.5) had the highest probability of achieving a good functional outcome at 90 days. For safety outcomes, 0.25 mg/kg tenecteplase had lower incidences of symptomatic intracranial hemorrhage (OR 0.88, 95% CI: 0.35-1.8), death within 90 days (OR 0.91, 95% CI: 0.54-1.4), and serious adverse events (OR 1.0, 95% CI: 0.47-2.3) compared to alteplase, though differences were not statistically significant. Reteplase at 18 mg + 18 mg had higher incidences of death within 90 days (OR 1.2, 95% CI: 0.48-3) and serious adverse events (OR 1.4, 95% CI: 0.4-5.0) compared to alteplase, without significant differences. Subgroup analysis showed better efficacy with 0.25 mg/kg tenecteplase in Asians (OR 1.18, 95% CI 0.96-1.45, P = 0.12) than in Caucasians (OR 1.08, 95% CI 0.9-1.3, P = 0.39). This study suggests that tenecteplase and reteplase are viable alternatives to alteplase for thrombolysis in AIS. Tenecteplase at 0.25 mg/kg and reteplase at 18 mg + 18 mg may offer better efficacy compared to standard-dose alteplase, although the risk of adverse events with reteplase should be considered. Tenecteplase at 0.25 mg/kg appears to provide the best benefit-risk profile based on current evidence. Further head-to-head trials of tenecteplase and reteplase are needed to determine the optimal thrombolytic agent and dosing. https://www.crd.york.ac.uk/prospero/, PROSPERO CRD42024566146.

Association of Age, Sex and Education With Access to the Intravenous Thrombolysis for Acute Ischemic Stroke

Association of Age, Sex and Education With Access to the Intravenous Thrombolysis for Acute Ischemic Stroke

Impact of Small Vessel Disease on Patient Outcomes After Intravenous Thrombolysis for Acute Ischemic Stroke.

Individual cerebral small vessel disease (SVD) markers independently predict poor prognosis after stroke. However, the impact of a single SVD, especially cumulative SVD burden, on outcomes in acute ischemic stroke (AIS) after intravenous thrombolysis remains unclear. This study evaluated the occurrence of SVD in patients with AIS who were treated with intravenous thrombolytic therapy using multimodal magnetic resonance imaging. The study involved patients with AIS who received multimodal magnetic resonance imaging scans before receiving intravenous thrombolytic treatment with recombinant tissue plasminogen activator (rt-PA). Validated scales were used to document each SVD characteristic and measure the overall impact of SVD using an extensive scoring method. Functional outcomes were evaluated using the modified Rankin scale score within a 3-month time frame, with poor outcomes categorized as a modified Rankin scale score of ≥2. Using a logistic regression model while accounting for potential confounding variables, we examined the relation among individual SVD characteristics, the overall SVD impact, and patient outcomes. In total, 282 patients were included. Severe white matter hyperintensities and lacunas were linked to negative clinical results in patients with SVD, even after accounting for age, National Institutes of Health Stroke Scale score at admission, onset to treatment time, and hypertension (odds ratio 2.394, 95% confidence interval 1.246 to 4.6; odds ratio 2.3, 95% confidence interval 1.214 to 4.36, respectively). When evaluating the SVD global burden, a strong association between the SVD score and negative clinical results was observed, except for cases with an SVD score of 2 points. The findings suggest that the presence of pre-existing SVD, particularly characterized by the severity of white matter changes and lacunes, has a detrimental impact on the clinical outcomes of patients with ischemic stroke receiving intravenous rt-PA treatment. In conclusion, this information could be useful for predicting the prognosis of patients with stroke who underwent intravenous rt-PA therapy.

Thrombolysis for acute ischaemic stroke with tenecteplase in a developing country: challenges and experience from a prospective observational study

ContextThis study will emphasise the importance of Tenecteplase being ideally suited as a first-choice drug for thrombolysis in AIS in developing countries, considering the numerous challenges which are faced in these parts of the world.AimTo observe the effectiveness of Tenecteplase as a thrombolytic agent in AIS and also estimate the pre-hospital and in-hospital time delays in the treatment of such patients.Material and methodsEighteen patients with non-haemorrhagic strokes who presented within the window period were included. Eight patients were thrombolysed with Tenecteplase after due consent and ruling out contraindications. Reasons for the time delay, Ictus to Needle time and NIHSS scores were noted in each case.ResultsThe mean time from onset of symptoms to arrival at the hospital was 2.06 (± 1.08) h while the mean ictus to needle time was 4.29 (± 0.20) h The delay in carrying out a CT scan in these patients was 47.5 (± 16.69) min and mean time taken in procuring Tenecteplase was 27.5 (± 18.51) min. All patients were thrombolysed within 4.5 h of the onset of stroke and seven patients had statistically significant improved NIHSS scores in the post-thrombolysis period.ConclusionsThis paper highlights the constraints in the management of AIS in a developing country, where late presentation is the norm. In-hospital delays lead to diminishing window period available for thrombolysis. This paper highlights the successful use of Tenecteplase even in the late window period and emphasises Tenecteplase as a highly effective thrombolytic agent of choice in our setting. Further studies are likely to confirm these observations in the future.

Patterns and Clinical Implications of Hemorrhagic Transformation After Thrombolysis in Acute Ischemic Stroke: Results From the ENCHANTED Study.

Hemorrhagic transformation may be a potentially devastating complication of IV thrombolysis (IVT) in acute ischemic stroke, but what degree of hemorrhage indicates the greatest negative effect is not known. We aimed to define the associations between hemorrhagic transformation patterns, classified according to clinical and imaging categories, and clinical outcomes after IVT. We conducted a post hoc analysis from the international Enhanced Control of Hypertension and Thrombolysis Stroke Study. Symptomatic intracerebral hemorrhage (sICH) was defined based on established criteria, such as the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria. Asymptomatic intracerebral hemorrhage (aICH) was defined as any intracerebral hemorrhage that did not meet the criteria for sICH. Imaging subtypes of hemorrhagic transformation were assessed using the Heidelberg Bleeding Classification system. The primary outcome was death or major disability, defined by modified Rankin scale (mRS) scores 3-6 at 90 days. Secondary outcomes included death, death or disability (mRS 2-6), and poor health-related quality of life (HRQoL), defined as an overall heath utility score ≤0.7 (mean). Of the 4,370 participants, 779 (17.8%) developed any intracranial hemorrhage (ICH), with a median time from randomization to hemorrhage of 23.5 hours (interquartile range 18.92-26.07). According to the SITS-MOST criteria, 62 patients (1.4% of 4,370) were classified as sICH, and 717 patients (16.4% of 4,370) were classified as aICH. sICH per SITS-MOST criteria was associated with death or major disability (odds ratio [OR] 23.05, 95% CI 8.97-59.23), death (OR 20.14, 95% CI 11.32-35.84), death or disability (OR 61.36, 95% CI 8.40-448.01), and poor HRQoL (OR 17.87, 95% CI 7.47-42.71). Similarly, aICH per SITS-MOST criteria was also associated with death or major disability (OR 2.23, 95% CI 1.84-2.70), death (OR 1.82, 95% CI 1.39-2.38), death or disability (OR 2.29, 95% CI 1.87-2.80), and poor HRQoL (OR 1.81, 95% CI 1.50-2.18). Comparable associations were observed for sICH and aICH defined by other criteria, as well as for imaging subtypes based on Heidelberg Bleeding Classification system. All forms of post-IVT hemorrhagic transformation in acute ischemic stroke are associated with increased odds of poor clinical outcomes. Of note, aICH after IVT should not be considered clinically innocuous. ClinicalTrials.gov (NCT01422616).

Influence of renal function on blood pressure control and outcome in thrombolyzed patients after acute ischemic stroke: post-hoc analysis of the ENCHANTED trial.

The effect of renal impairment in patients who receive intravenous thrombolysis for acute ischemic stroke (AIS) is unclear. We aimed to determine the associations of renal impairment and clinical outcomes and any modification of the effect of intensive versus guideline-recommended blood pressure (BP) control in the BP arm of the International Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). We conducted a post-hoc analysis of the ENCHANTED BP arm, which involved 2,196 thrombolyzed AIS patients. Logistic regression models were used to define the association between eGFR and clinical outcomes of death, death or major disability [modified Rankin scale (mRS) scores 3-6], and major disability (mRS 3-5) at 90 days. Of the 2,151 patients with available baseline renal function data (mean age 66.9 years; 38% women), 993 (46.2%), 822 (38.2%), and 336 (15.6%) had normal (eGFR ≥ 90 mL/min/1.73 m2), mildly (60-89), and moderate-to-severely impaired (<60) renal function, respectively. Compared with patients with normal eGFR, mortality was higher in those with moderate-to-severe renal impairment (adjusted odds ratio 1.77, 95% confidence interval 1.05-2.99; p = 0.031 for trend). However, the difference in death or major disability (mRS 3-6) was not significant between groups. There was no heterogeneity in the effect of intensive versus guideline-recommended BP-lowering treatment on death by grades of renal function (p for interaction = 0.545). The presence of moderate-to-severe renal impairment is associated with increased mortality in thrombolyzed patients with AIS. Renal function does not modify the effect of early intensive BP-lowering treatment on death in this patient group.

Stress hyperglycemia is associated with early neurologic deterioration in patients with acute ischemic stroke after intravenous thrombolysis without hemorrhagic transformation.

This aimed to elucidate the impact of stress hyperglycemia on early neurological deterioration (END) in patients with acute non-cardiogenic cerebral infarction who did not experience hemorrhagic transformation following intravenous thrombolysis to identify risk factors associated with END. This retrospective case-control study analyzed data from consecutive patients who received intravenous thrombolysis for acute ischemic stroke (AIS) without hemorrhagic transformation at the Stroke Center of The Fifth Affiliated Hospital of Sun Yat-sen University from January 2018 to February 2023. END was defined as an increase of more than 2 points on the National Institutes of Health Stroke Scale (NIHSS) within 7 days of admission. A total of 250 patients (56 males, 22.4%) were included, with a mean age of 63.34 ± 12.90 years. Of them, 41 were classified into the END group and 209 into the non-END group. Stress hyperglycemia ratio (SHR) demonstrated a significant correlation with END (r=-0.003, P = 0.003). HbA1c (OR = 0.68, 95% CI: 0.481-0.921) and SHR (OR = 0.00, 95% CI: 0.0-0.051) were independently associated with END. Receiver-operating characteristic (ROC) curve analysis indicated that SHR had a sensitivity of 79.9%, specificity of 88.8%, and an area under the curve (AUC) of 0.857 for predicting END. SHR was significantly associated with END in patients with acute non-cardioembolic cerebral infarction who did not undergo hemorrhagic transformation after intravenous thrombolysis.

Tenecteplase versus alteplase for acute stroke within 4·5 h of onset (ATTEST-2): a randomised, parallel group, open-label trial

Tenecteplase has potential benefits over alteplase, the standard agent for intravenous thrombolysis in acute ischaemic stroke, because it is administered as a single bolus and might have superior efficacy. The ATTEST-2 trial investigated whether tenecteplase was non-inferior or superior to alteplase within 4·5 h of onset. We undertook a prospective, randomised, parallel-group, open-label trial with masked endpoint evaluation in 39 UK stroke centres. Previously independent adults with acute ischaemic stroke, eligible for intravenous thrombolysis less than 4·5 h from last known well, were randomly assigned 1:1 to receive intravenous alteplase 0·9 mg/kg or tenecteplase 0·25 mg/kg, by use of a telephone-based interactive voice response system. The primary endpoint was the distribution of the day 90 modified Rankin Scale (mRS) score and was analysed using ordinal logistic regression in the modified intention-to-treat population. We tested the primary outcome for non-inferiority (odds ratio for tenecteplase vs alteplase non-inferiority limit of 0·75), and for superiority if non-inferiority was confirmed. Safety outcomes were mortality, symptomatic intracranial haemorrhage, radiological intracranial haemorrhage, and major extracranial bleeding. The trial was prospectively registered on ClinicalTrials.gov (NCT02814409). Between Jan 25, 2017, and May 30, 2023, 1858 patients were randomly assigned to a treatment group, of whom 1777 received thrombolytic treatment and were included in the modified intention-to-treat population (n=885 allocated tenecteplase and n=892 allocated alteplase). The mean age of participants was 70·4 (SD 12·9) years and median National Institutes of Health Stroke Scale was 7 (IQR 5-13) at baseline. Tenecteplase was non-inferior to alteplase for mRS score distribution at 90 days, but was not superior (odds ratio 1·07; 95% CI 0·90-1·27; p value for non-inferiority<0·0001; p=0·43 for superiority). 68 (8%) patients in the tenecteplase group compared with 75 (8%) patients in the alteplase group died, symptomatic intracerebral haemorrhage (defined by SITS-MOST criteria) occurred in 20 (2%) versus 15 (2%) patients, parenchymal haematoma type 2 occurred in 37 (4%) versus 26 (3%) patients, post-treatment intracranial bleed occurred in 94 (11%) versus 78 (9%) patients, significant extracranial haemorrhage occurred in 13 (1%) versus six (1%) patients, respectively, and angioedema occurred in six (1%) participants in both groups. Tenecteplase 0·25 mg/kg was non-inferior to 0·9 mg/kg alteplase within 4·5 h of symptom onset in acute ischaemic stroke. Easier administration of tenecteplase, especially in the context of interhospital transfers, indicates that tenecteplase should be preferred to alteplase for thrombolysis in acute ischaemic stroke. The ATTEST-2 population was large and representative of thrombolysis-eligible patients in the UK and, together with findings from other trials, provides robust evidence supporting the introduction of tenecteplase in preference to alteplase. The Stroke Association and British Heart Foundation.

Analysis of door-to-needle time for thrombolysis in acute ischaemic stroke using statistical process control charts

BackgroundThrombolysis should be administered as soon as possible to suitable patients with acute ischaemic stroke. We introduced a new protocol for patients who had a stroke to achieve reduced door-to-needle...

Before, during, and after: An Argument for Safety and Improved Outcome of Thrombolysis in Acute Ischemic Stroke with Direct Oral Anticoagulant Treatment.

Direct oral anticoagulants are the primary stroke prevention option in patients with atrial fibrillation. Anticoagulant use before stroke, however, might inhibit clinician comfort with thrombolysis if a stroke does occur. Resuming anticoagulants after ischemic stroke is also problematic for fear of hemorrhage. We describe extensive literature showing that thrombolysis is safe after stroke with direct anticoagulant use. Early reinstitution of direct anticoagulant treatment is associated with lower risk of embolic recurrence and lower hemorrhage risk. The use of direct anticoagulants before, during, and after thrombolysis appears to be safe and is likely to promote improved outcomes after ischemic stroke. ANN NEUROL 2024;96:871-886.

A new standard for thrombolysis in acute ischaemic stroke

A new standard for thrombolysis in acute ischaemic stroke

Abstract 192: Angioedema Following Lifesaving Thrombolysis In Acute Ischemic Stroke

Introduction Orolingual angioedema is a recognized adverse effect of tissue plasminogen activator (tPA) treatment in the setting of acute ischemic stroke (AIS). Although its incidence is relatively low (0.1‐0.7%), the reaction is generally mild but may trigger life‐threatening airway occlusion and necessitate rapid intubation. This is the first study to examine the differences in complications, management, and outcomes of AIS patients with and without tPA‐induced angioedema. Methods The National Inpatient Sample (NIS) was queried by ICD‐9‐CM/ICD‐10‐CM codes to identify AIS patients treated with tPA who experienced subsequent angioedema. Baseline characteristics, treatment, complications, and functional outcomes were analyzed through multivariate regression and compared through a propensity score matching (PSM) analysis. Results This study examined 99,935 patients diagnosed with AIS and administered tPA between 2010 and 2019. AIS patients with tPA‐induced angioedema were younger (67.44 years vs 69.32 years, p &lt; 0.01), less likely to be white (53.83% vs 66.48%, p &lt; 0.01), and presented with higher acute stroke severity scores (0.69 vs 0.63, p &lt; 0.01) than non‐angioedema AIS patients. Following PSM analysis, patients with angioedema had higher rates of tracheostomy (5.7% vs 0.49%, p &lt; 0.01) and lower rates of endovascular mechanical thrombectomy (4.72% vs 9.63%, p &lt; 0.01). Angioedema patients were observed to have similar rates of decompressive hemicraniectomy (p = 0.16), pneumonia (p = 0.06), sepsis (p = 0.82), acute kidney injury (p = 0.05), acute myocardial infarction (p = 0.43), cardiac arrest (p = 0.56), poor functional outcome (p = 0.25), and in‐hospital mortality (p = 0.32). Patients who developed angioedema were also observed to have longer LOS (7.34 days vs 5.41 days, p &lt; 0.01). Conclusion There appears to be no difference in complication risk, functional outcome, and in‐hospital mortality between AIS patients with and without tPA‐induced angioedema. The observed increase in LOS may be attributed to the increased rates of tracheostomy following oropharyngeal swelling. Airway instability may also preclude AIS patients with angioedema from mechanical thrombectomy, offering one explanation for the observed difference in intervention rates. Further research is needed to better understand the impact of tPA‐induced angioedema on interventions and outcomes of patients with acute ischemic stroke. Abbreviations Nationwide Inpatient Sample (NIS), acute ischemic stroke (AIS), tissue plasminogen activator (tPA), mechanical thrombectomy (MT), propensity score matching (PSM), deep vein thrombosis (DVT), pulmonary embolism (PE), urinary tract infection (UTI), length of stay (LOS)

Abstract 319: IV Thrombolysis Administration for Acute Ischemic Stroke After Cervical Epidural Injection: A Case Report

Introduction Intravenous (IV) thrombolysis with recent lumbar puncture is a relative contraindication due to the potential for development of epidural hematoma. While there have been case reports of uncomplicated IV thrombolysis after lumbar puncture or epidural anesthesia, there is limited data overall regarding the safety of IV thrombolysis for acute ischemic stroke (AIS) in patients who have undergone a neuraxial procedure. To our knowledge, there are no reported cases of successful IV thrombolysis after cervical epidural injection (CEI). Methods This is a case report. Results An 83‐year‐old male with past medical history of hyperlipidemia and prior stroke with residual right arm weakness presented for worsening right arm weakness and new symptoms of right leg weakness. Neurological exam also revealed aphasia and right facial droop. Patient presented within the time window for IV thrombolysis. However, the patient received a CEI earlier that day, which was confirmed to be around C7 level and considered uncomplicated with additional clinical observation that the dura was not punctured. Non‐contrast CT head showed no evidence of intracranial hemorrhage. CT angiogram of the head and neck showed an occlusion of the proximal aspect of the left internal carotid artery. Neurointerventional radiology was consulted to discuss the safety of IV thrombolysis given the recent epidural steroid injection. After extensive discussion regarding indication, risks, and benefits of IV thrombolysis with the patient and his son, informed consent was obtained, and IV Tenecteplase (TNK) was administered. The patient was then transferred to a thrombectomy capable center, where he received a balloon angioplasty and stenting to the left ICA with TICI 2b revascularization. MRI confirmed acute left frontal infarct. The patient remained stable without complications from the TNK and was discharged home on optimal medical management with antiplatelet therapy. Conclusion We present a case report of safe and successful administration of IV thrombolysis for AIS after recent CEI with resulting favorable recovery. The decision for IV thrombolysis was made after confirmation that the dura was not punctured. Further studies are necessary to establish the safety for IV thrombolysis after neuraxial procedures, such as epidural injections or epidural anesthesia.

Successfully intravenous thrombolytic therapy in systemic lupus erythematosus-related ischemic stroke: A case report.

Stroke is a relatively frequent complication occurring in patients with systemic lupus erythematosus (SLE). The increasing number of patients with Ischemic Stroke secondary to SLE aroused the clinician's concern. SLE thrombosis markers, diagnostic high-resolution magnetic resonance image (HR-MRI), and therapeutic interventions for acute ischemic stroke were recently coming into focus perspectives from the field. A 42-year-old female with slurred speech and numbness in her left limb was admitted to our hospital. Magnetic resonance imaging (MRI) revealed right thalamic infarction with diffusion-weighted lesions. Prior to admission, the patient had a National Institute of Health Stroke Scale (NIHSS) score of 3. In light of the clinical manifestation, the American Heart Association/American Stroke Association (AHA/ASA) Guidelines for Intravenous Thrombolysis in Acute Ischemic Stroke (2019) should be referred to. The patient was treated with thrombolytic alteplase (rt-PA). The patient was hospitalized for 2 weeks and discharged after his symptoms improved. After thrombolysis, the NIHSS score of the patient decreased to zero. The computed tomography scan was reexamined 24 hours later, and no acute changes or hemorrhage were identified in the infarcted area. Subsequent imaging and serological analyses indicated that HR-MRI of the responsible vessel was negative, but the infarction in this patient was still regarded as being caused by vasculitis of the right posterior cerebral artery in the region supplying the thalamus. This is the first case of successful intravenous thrombolytic therapy with rt-PA in a patient with SLE secondary to stroke with an NIHSS score of 3. This provides further evidence for expanding the reference of indications with rt-PA intravenous thrombolysis.

Effect of Heparin Reversal by Protamine Sulfate on the Outcome of Thrombolysis in Acute Ischemic Stroke after Percutaneous Coronary Intervention

Abstract Background Acute ischemic stroke (AIS) after percutaneous cardiac catheterization (PCI) is a known complication with incidence reports of ranges between 0.2% and 0.5%. It is associated with an in-hospital mortality rate of 20%, with markedly increased long-term mortality (1). Administration of Intravenous thrombolysis (IVT) is the recommended standard of care in acute ischemic stroke during the first 4.5 hours from stroke onset. However, current guidelines exclude intravenous thrombolysis in heparinized patients with partial thromboplastin time (PTT) greater than 40 seconds (2) Protamine is an efficient antidote known for the anticoagulant effect of heparin, and it can neutralize its effect within 5 minutes (3). Aim of the Work To assess the safety of IVT after heparin reversal by protamine sulfate in ischemic Stroke patients After PCI. Patient and Method The total number of patients who developed early IP stroke (within 4.5 hours from the end of PCI) was 42. All of them received loading antiplatelets before PCI. Results out of 21 patients received IVT after heparin reversal by protamine, no patient had died, 2 cases had non symptomatic intracranial hemorrhage (ICH), with significant improvement in stroke parameters and shorter length of stay Conclusion IVT following heparin reversal by protamine in appropriately selected AIS patients appears to be safe from a symptomatic ICH standpoint and may be beneficial. Extreme caution is warranted in applying these results to routine clinical practice. Rather, we suggest that thrombolysis may still be considered in AIS patients on therapeutic heparin who are not candidates for MT

The Changing Landscape of Intravenous Thrombolysis for Acute Ischaemic Stroke

Intravenous thrombolysis remains the most accessible and effective reperfusion therapy available to patients with acute ischaemic stroke. Treatment with intravenous thrombolysis improves the odds of favourable functional outcome with the unacceptably low risk of haemorrhagic complications. Even in the current era of endovascular thrombectomy, intravenous thrombolysis remains the backbone of acute stroke treatment due to its accessibility and relative ease of administration. Since intravenous alteplase was first approved for acute ischaemic stroke in the mid 1990s, there have been significant advances in expanding the indication and time window for treatment, in addition to transitioning towards tenecteplase use for stroke thrombolysis. In this review, we will provide a narrative on the use of thrombolysis in acute ischaemic stroke including an up-to-date discussion on recent advances in thrombolytic therapy.