tPA For Stroke Research Articles

UTILITY OF PREDICTIVE SCORES FOR POST TPA INTRACRANIAL HEMORRHAGE IN ACUTE ISCHEMIC STROKES TO OPTIMIZE 24-HOUR POST TPA SCAN UTILIZATION

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The risk of symptomatic ICH status post tPA is variable but ranges from 2-7%. The consensus from AHA/ASA guidelines in 2018 recommend a follow up CT scan 24 hours after IV tPA, which was a component of the original NINDS tPA study. However, there is increasing evidence that the scans themselves may be unnecessary. Several scoring scales have been developed to determine which patients are at highest risk after receiving tPA. Determining the most useful scoring scale to stratify the risk of ICH may help avoid a 24 hour follow up scan. METHODS: A retrospective review of 519 consecutive acute ischemic stroke patients who received tPA at multiple hospitals in central Texas from February 2014 to January 2019. The data was gathered through chart review utilizing a data collection form that contained pertinent baseline characteristics and relevant clinical findings. Established predictive scores, RICH, THRIVE, SEDAN, were included in the data sheet. Median and IQR (inter quartile range) is reported as data showed non normal distribution. P-value is derived from Mann Whitney U test, comparing the median score (THRIVE, SEDAN, RICH) between two groups. RESULTS: Our study included a population total of 492 patients. For patients with symptomatic intracranial hemorrhage (sICH), median scores were as follows: THRIVE 4.50 (p < 0.001), SEDAN 2.00 (p < 0.001) and RICH 3.00 (p = 0.1343). Additionally, the odds ratio for symptomatic intracranial hemorrhage were as follows: THRIVE 1.48 (p < 0.001), SEDAN 1.88 (p < 0.001) and RICH 1.27 (p = 0.1291). C-statistic for THRIVE was 0.72(,(95% CI, 0.63 – 0.80) and SEDAN score was 0.65 (95% CI, 0.61 – 0.79) compared to the RICH score for s ICH. CONCLUSIONS: The Thrive score performed the best for predicting sICH over the SEDAN and RICH scores. Further utility of these scores to exclude s ICH post tPA for stroke needs a prospective study. CLINICAL IMPLICATIONS: Ultimately, determining the patients at highest risk for intracranial hemorrhage conversion after tPA is crucial to better patient outcomes. Several scoring scales have been created in order to determine which patients are at highest risk. Determining the most useful scoring scale to stratify the risk of ICH may help avoid a 24 hour follow up scan. Avoiding a 24 hour follow up scan could reduce healthcare cost, reduce radiation exposure, and reduce utilization of healthcare resources. DISCLOSURES: no disclosure on file for Zunair Afghani; No relevant relationships by Nitin Agrawal, source=Web Response No relevant relationships by Shekhar Ghamande, source=Web Response No relevant relationships by Conner Moslander, source=Web Response No relevant relationships by Jennifer Rasmussen-Winkler, source=Web Response No relevant relationships by Alfredo Vazquez Sandoval, source=Web Response No relevant relationships by Heath White, source=Web Response

Abstract NS6: Early Mobility Initiated at 12 Hours Post Thrombolytic Therapy for Stroke Increases Likelihood for Discharge to Home

Purpose: To assess patient safety and discharge outcomes of initiating early mobility after 12 hours of receiving thrombolytic therapy (tPA) for stroke at a Primary Stroke Center. Background: Patients receiving tPA are traditionally maintained on bedrest for 24 hours due to an alleged risk of increased complications or falls, however this standard is not supported by data. Prior data among patients receiving tPA supports the concept of providing early mobility before 24 hours without an increased risk of falls or other adverse response. There is also evidence that early mobility in other critical care populations has positive impact on discharge disposition and decreasing the length of stay (LOS). Methods: A validated Early Mobility Protocol was implemented within 24 hours for all patients receiving tPA for stroke with a focus to progress each patient through the stages of the mobility protocol based on clinical presentation. Data from pre-implementation (January – May 2018) and post implementation (June 2018-December 2018) were compared for outcomes, including discharge disposition, adverse responses and LOS. T-test and Chi-square were used to determine significant difference in outcomes between groups. Results: Between January to December 2018 44 patients received tPA (18 pre-implementation and 26 post implementation). For the post implementation group 18/26 early mobility was initiated with 24 hours, 4/26 were placed on comfort care and 4/26 were transferred to a comprehensive stroke center. Among the early mobility group, there were no falls or adverse physiological events. Patients that participated with early mobility were more likely to discharge home, 46.15% vs 33.33%, less likely to require post-acute services, 15.38% vs 27.78%, and less likely to require transfer to a higher level of care, 15.38% vs 33.78%. There was not a significant difference in LOS. Conclusion: Providing early mobility to patients post thrombolytic therapy between 12-24 hours does not cause an increase in adverse physiological events. Additionally, providing early mobility has a positive impact on patient discharges to home. Further study may include initiating mobility at an early timeframe to examine the correlation to LOS and discharge outcomes.

Abstract TMP41: Early Mobility Initiated at 12 Hours Post Thrombolytic Therapy for Stroke Increases Likelihood for Discharge to Home

Purpose: To assess patient safety and discharge outcomes of initiating early mobility after 12 hours of receiving thrombolytic therapy (tPA) for stroke at a Primary Stroke Center. Background: Patients receiving tPA are traditionally maintained on bedrest for 24 hours due to an alleged risk of increased complications or falls, however this standard is not supported by data. Prior data among patients receiving tPA supports the concept of providing early mobility before 24 hours without an increased risk of falls or other adverse response. There is also evidence that early mobility in other critical care populations has positive impact on discharge disposition and decreasing the length of stay (LOS). Methods: A validated Early Mobility Protocol was implemented within 24 hours for all patients receiving tPA for stroke with a focus to progress each patient through the stages of the mobility protocol based on clinical presentation. Data from pre-implementation (January – May 2018) and post implementation (June 2018-December 2018) were compared for outcomes, including discharge disposition, adverse responses and LOS. T-test and Chi-square were used to determine significant difference in outcomes between groups. Results: Between January to December 2018 44 patients received tPA (18 pre-implementation and 26 post implementation). For the post implementation group 18/26 early mobility was initiated with 24 hours, 4/26 were placed on comfort care and 4/26 were transferred to a comprehensive stroke center. Among the early mobility group, there were no falls or adverse physiological events. Patients that participated with early mobility were more likely to discharge home, 46.15% vs 33.33%, less likely to require post-acute services, 15.38% vs 27.78%, and less likely to require transfer to a higher level of care, 15.38% vs 33.78%. There was not a significant difference in LOS. Conclusion: Providing early mobility to patients post thrombolytic therapy between 12-24 hours does not cause an increase in adverse physiological events. Additionally, providing early mobility has a positive impact on patient discharges to home. Further study may include initiating mobility at an early timeframe to examine the correlation to LOS and discharge outcomes.

Nursing Assessment of Tissue Plasminogen Activator for Pulmonary Embolism

Nursing Assessment of Tissue Plasminogen Activator for Pulmonary Embolism

Periorbital Hemorrhage Secondary to tPA For Stroke Following Oculoplastic Surgery

Periorbital Hemorrhage Secondary to tPA For Stroke Following Oculoplastic Surgery

Intracerebral Hemorrhage after IV tPA for Stroke as Early Symptoms of ANCAAssociated Vasculitis (P6.201)

Intracerebral Hemorrhage after IV tPA for Stroke as Early Symptoms of ANCAAssociated Vasculitis (P6.201)

Plasma kallikrein mediates brain hemorrhage and edema caused by tissue plasminogen activator therapy in mice after stroke

AbstractThrombolytic therapy using tissue plasminogen activator (tPA) in acute stroke is associated with increased risks of cerebral hemorrhagic transformation and angioedema. Although plasma kallikrein (PKal) has been implicated in contributing to both hematoma expansion and thrombosis in stroke, its role in the complications associated with the therapeutic use of tPA in stroke is not yet available. We investigated the effects of tPA on plasma prekallikrein (PPK) activation and the role of PKal on cerebral outcomes in a murine thrombotic stroke model treated with tPA. We show that tPA increases PKal activity in vitro in both murine and human plasma, via a factor XII (FXII)–dependent mechanism. Intravenous administration of tPA increased circulating PKal activity in mice. In mice with thrombotic occlusion of the middle cerebral artery, tPA administration increased brain hemorrhage transformation, infarct volume, and edema. These adverse effects of tPA were ameliorated in PPK (Klkb1)–deficient and FXII-deficient mice and in wild-type (WT) mice pretreated with a PKal inhibitor prior to tPA. tPA-induced brain hemisphere reperfusion after photothrombolic middle cerebral artery occlusion was increased in Klkb1−/− mice compared with WT mice. In addition, PKal inhibition reduced matrix metalloproteinase-9 activity in brain following stroke and tPA therapy. These data demonstrate that tPA activates PPK in plasma and PKal inhibition reduces cerebral complications associated with tPA-mediated thrombolysis in stroke.

Abstract WMP34: Use of Intravenous Tissue Plasminogen Activator in Patients Without a Stroke (Stroke Mimics): Findings From the get With the Guidelines Stroke Registry

Background: The necessity for rapid evaluation and treatment with intravenous tissue plasminogen activator (tPA) in acute ischemic stroke may increase the risk of administrating tPA to patients without a stroke (“stroke mimics”). Methods: Using data from the Get With The Guidelines Stroke Registry from 2009 to 2015, we identified 90,746 patients treated with tPA within 4.5 hours of symptom onset. We documented use of tPA in stroke mimics, defined as patients initially thought to have a stroke but without a final diagnosis of one, and compared patient characteristics and outcomes between tPA-treated mimics vs. ischemic strokes. Results: Overall, only 0.8% (728) of all tPA cases were given to stroke mimics, ranging from 0.2% in 2009 Q1 to 1.3% in 2015 Q1. The most common documented diagnoses in tPA-treated mimics were migraine (15.6%), functional disorder (9.4%), and seizure (7.2%). Compared with tPA-treated true stroke patients, tPA-treated mimics were younger (median 52 vs. 72 years), had lower prevalence of atrial fibrillation, coronary artery disease, dyslipidemia, hypertension, heart failure, had less severe National Institute of Health Stroke Scale (median 7 vs. 10), but higher prevalence of prior stroke/transient ischemic attack (34.4% vs. 25.5%), all p&lt;0.001. The door-to-needle times were similar in stroke mimics and true stroke groups (median 68 vs. 68 minutes, p=0.82). Rates of symptomatic intracranial hemorrhage (sICH) were quite rare in stroke mimic patients (0.4%, 3/728) as compared with 4.3% (3846/90018) in patients with an ischemic stroke; adjusted OR for sICH (0.19, 95% CI 0.06-0.58). The in-hospital mortality rate was significantly lower in tPA-treated stroke mimics as compared with ischemic stroke patients (0.6% vs. 7.3%, adjusted OR 0.16, 95% CI 0.06-0.43). Conclusions: In this large nationwide cohort of patients treated with tPA, only 1 in 125 patients who received tPA for presumed stroke was a false positive and complication rates associated with tPA administration to stroke mimics were quite low. Nonetheless, there still may be opportunities to continue to improve the rapid and accurate diagnosis and treatment of ischemic stroke.

Abstract TP241: High-yield Interventions Reduce Time to tPA in Ischemic Stroke

Introduction: Tissue plasminogen activator (tPA) reduces disability from ischemic stroke, but this benefit is time dependent. Guidelines recommend a door-to-tPA time of &lt; 60 mins. We retrospectively evaluated the effect of eight interventions on door-to-tPA time at a large safety net public hospital. Hypothesis: High-yield interventions would significantly reduce door-to-tPA times, especially a stroke code activation system. Methods: From Jan 2008 to Dec 2014, all patients (n=537) presenting to our emergency department (ED) with possible stroke and for whom tPA was considered were entered into a database. Critical ischemic stroke times were recorded and compared annually (physician at bedside, labs resulted, CT scan read, tPA given). Interventions to reduce time to tPA were introduced intermittently (Figure). Mean time to tPA was compared for the six-month period before and after each intervention was implemented. Student’s t-test was used with significance at p&lt;0.05. Results: The mean time to tPA improved from 2008 (98.9 min) to 2014 (60.0 min; p&lt;0.001). This was largely driven by reductions in mean times from ED physician evaluation to head CT read (-35.3 min; p&lt;0.0001) and from ED physician to neurologist evaluation (-23.3 min; p&lt;0.0001). The interventions associated with the greatest reductions in mean time to tPA were an ED stroke pharmacist/giving tPA in the CT scanner (-17.5 min) and conducting monthly multidisciplinary stroke peer reviews (-15.9 min). Conclusions: A safety net public hospital significantly reduced its time to tPA for stroke through a combination of interventions, including multidisciplinary stroke peer reviews and infusing tPA in the CT scanner.

Abstract T P303: Early Mobility after Thrombolysis for Stroke is Safe and Improves Outcomes

Purpose: To evaluate safety and outcome of mobilizing patients to their functional ability within 24 hours of receiving thrombolytic therapy (IV tPA) for stroke at two Primary Stroke Centers. Background: Bed rest for 24 hours after tPA for stroke is the national standard of care, though there are no data to support this practice. Additionally, tPA patients are not typically mobilized early due to a perceived risk of increased complication or falls. However, data show that early mobility in other critical care populations improves outcomes and shortens length of stay (LOS). Studies to date among tPA-treated patients suggest favorable outcomes but with small clinical trial data. Methods: A validated Stroke Early Mobility Assessment Protocol was implemented within 24 hours in all patients receiving tPA for stroke and mobilizing them to their highest functionally safe level. Data from pre (Jan 2009-June 2012) and post (July 2012-March 2014) implementation were compared for safety and outcome, including complications, falls, discharge destination, and LOS. Chi square and t-tests were used to determine significant differences in outcomes before and after implementation. Results: Between 2009 and 2014, 331 stroke patients received tPA (177 pre-implementation and 154 post). Among those receiving tPA after implementation, 129 were mobilized per protocol, 16 were not, and 8 were placed on comfort care. There were no falls among tPA patients pre or post implementation. Post implementation patients mobilized early were more likely to be discharged home, 56.5% vs. 40.1%, and less likely to expire or discharge to hospice, 9.6% vs 4.5% (p&lt;0.01). There was no significant change in symptomatic hemorrhagic complications or LOS. Conclusion: Using a validated protocol, early mobilization of patients after tPA does not cause an increase in falls or neurologic or other complications. Early mobilization may improve the likelihood of discharge to home and reduce in-hospital mortality, but does not change LOS. Future analyses will include multivariate models to determine the direct relationship between early mobilization and outcomes among ICU patients receiving tPA.

103 Predicting Poor Outcomes After tPA for Stroke: A Topological Analysis of the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study and the Specialized Programs of Translational Research in Acute Stroke Registry

103 Predicting Poor Outcomes After tPA for Stroke: A Topological Analysis of the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study and the Specialized Programs of Translational Research in Acute Stroke Registry

Standard-Dose Intravenous Tissue-Type Plasminogen Activator for Stroke Is Better Than Low Doses

It remains uncertain whether lower dose intravenous tissue-type plasminogen activator (tPA) for stroke is as effective and safe as the standard dose. We analyzed data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China). Patients who were treated within 4.5 hours after symptom onset were included. These patients were divided into 5 groups according to tPA doses given: <0.5, 0.5 to 0.7, 0.7 to 0.85, 0.85 to 0.95, and ≥0.95 mg/kg. Symptomatic intracranial hemorrhage, mortality, and 90-day outcome assessed by modified Rankin scale were analyzed. A total of 919 patients were enrolled. Among them, 9 had <0.5 mg/kg, 75 had 0.5 to 0.7 mg/kg, 131 had 0.7 to 0.85 mg/kg, 678 had 0.85 to 0.95 mg/kg, and 26 had ≥0.95 mg/kg. Because of sample sizes, only 0.5 to 0.7, 0.7 to 0.85, and 0.85 to 0.95 mg/kg groups were compared. Median tPA doses were 0.64, 0.79, and 0.90 mg, respectively. After adjustment for the baseline variables, there were no significant differences in mortality(5.41% versus 8.66% versus 7.36%; P=0.695) and symptomatic intracranial hemorrhage (0% versus 3.82% versus 1.46%; P=0.106). The 0.5 to 0.7 mg/kg group had less excellent recovery outcome (modified Rankin scale, 0-1) than 0.85 to 0.95 mg/kg group (41.89% versus 53.83%; odds ratio=0.58; P=0.031) at 90 days. The 0.70 to 0.85 mg/kg group had less functional independence outcome (modified Rankin scale, 0-2) than 0.85 to 0.95 mg/kg group (54.33% versus 64.51%; odds ratio=0.66; P=0.036) at 90 days. Our study suggests that standard-dose intravenous tPA for stroke had more favorable outcome without increasing the risk of symptomatic intracranial hemorrhage than low-dose tPA. For Asian people, 0.9 mg/kg should be the optimal dose of tPA to treat acute ischemic stroke.

Abstract 94: Blacks Arrive Later After Stroke Onset Than Whites in Chicago

Objective: To assess if ethnic disparities exist in the use of intravenous tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) at primary stroke centers (PSCs) in Chicago, Illinois. Background: Ethnic disparities in stroke care include observed differences in stroke incidence, severity, mortality, acute management, and rehabilitation. There are less data regarding race disparities in the use of emergency medical services (EMS) and delivery of tPA. Methods: A retrospective analysis of the Get With The Guidelines (GWTG) Stroke registry was performed using a benchmark group of 11 PSCs that collected data on stroke admissions in 2012. We analyzed use of EMS, time from onset to arrival, tPA use, door to needle (DTN) time, and documented reasons for not administering tPA between blacks and white stroke patients. Results: In 2012, there were 2,682 stroke patients admitted to Chicago PSCs. The mean age was 65.2 years with 54.3% women, 50.4% black, and 38.5% white. Among ED arriving ischemic stroke patients, 12% received tPA; however, it differed by race (whites: 21.6% vs. black: 8.3%; p&lt;0.001). Use of EMS (whites: 55.8% vs. blacks: 51.6%, p=0.172) did not differ by race but pre-notification was less frequent for black patients arriving by EMS (59.5% vs. 78.5%, p&lt;0.001). Time from onset to ED arrival was longer in blacks (median 152.5 minutes vs. 85 minutes in whites), even among those using EMS (blacks: median 100.5 minutes vs. whites: 66 minutes). Among thrombolysed patients, DTN times were similar (81 vs. 83 minutes) between groups. However, blacks who did not receive tPA but presented in the 4.5 hour window were less likely to have documented contraindications to thrombolysis (67.1% vs. 82.5%, p=0.008) and more likely to have in-hospital delays (33.3% vs. 17.4%, p=0.243) compared to whites. Conclusions: At Chicago’s PSCs, blacks are much less likely than whites to receive tPA for stroke despite similar proportions accessing EMS. While some of this disparity may be accounted for stroke severity and type of stroke symptoms, delays in calling EMS and differences in pre-hospital notification and hospital evaluation are potential targets for public and professional education.

Abstract T P182: Post-tPA ICH: INSTINCT Community Hospitals vs Pooled Analysis Data

Background: The threat of ICH limits community physician use of tPA in stroke. Only the PH2 subtype, however, independently causes clinical deterioration. We explored ICH characteristics in the community-based INSTINCT trial and compared PH2 incidence rates in INSTINCT to the pooled analysis (PA) of the ECASS, ATLANTIS, NINDS and EPITHET trials. Methods: Secondary analysis of tPA-treated patients in the INSTINCT trial, a prospective, cluster-randomized, controlled trial conducted at 24 randomly selected Michigan community hospitals. Medical records of all tPA-treated strokes from 2007 to 2010 were initially reviewed by an independent physician panel to identify any evidence of possible ICH. In a second stage, 2 vascular neurologists, blinded to clinical data, independently categorized each possible ICH using ECASS criteria. Disagreements resolved by consensus. All images within 72h post-tPA were reviewed, with classification based on the most severe category. Data from pooled subjects with OTT of ≤180 minutes served as a historical control in the comparison. IRB approved. Results: Neuroimaging was obtained from 23 of 24 INSTINCT sites, with 462 tPA-treated subjects. 85 (18.4%) were identified at initial review as a possible ICH. 82/85 (96%) had post-treatment neuroimaging available. At second-stage review, 19 had no identified hemorrhage, leaving 63/462 (13.6%) with an ICH. ICH subtype is presented in Table 1. In the PA cohort, 464 tPA-treated subjects had OTT ≤ 180 minutes. 161 (34.7%; 95% CI 30.5, 39.1) had an ICH, with 22 (4.7%; 95% CI 3.1%, 7.1%) identified as PH2. In the comparison, the difference did not reach significance (1.1%; 95% CI -1.6%, 3.8%; p = 0.42). Conclusions: The overall INSTINCT ICH rate was low. Incidence of PH2 was not different from rates reported by investigators in large clinical research trials. This supports the safety of community treatment of stroke.

New Large Analysis Finds More Rapid Use of tPA for Stroke Leads to Better Outcomes

New Large Analysis Finds More Rapid Use of tPA for Stroke Leads to Better Outcomes

In Historic Joint Policy Document, the AAN and ACEP Endorse Clinical Policy on tPA for Stroke

In Historic Joint Policy Document, the AAN and ACEP Endorse Clinical Policy on tPA for Stroke

New Data Support Expanded Use Of tPA for Stroke

New Data Support Expanded Use Of tPA for Stroke

TPA for stroke – Are we ready to remove the barriers?

Click here to view the accompanying paper in this issue.

Attitudes and Beliefs of Michigan Emergency Physicians Toward Tissue Plasminogen Activator Use in Stroke

Background and Purpose— The objective of this study was to determine the baseline proportion of emergency physicians with favorable attitudes and beliefs toward intravenous tissue plasminogen activator (tPA) use in a cohort of randomly selected Michigan hospitals. Methods— Two hundred seventy-eight emergency physicians from 24 hospitals were surveyed. A confidential, self-administered, pilot-tested survey assessing demographics, practice environment, attitudes, and beliefs regarding tPA use in stroke was used. Main outcome measures assessed belief in a legal standard of care, likelihood of use in an ideal setting, comfort in use without a specialist consultation, and belief that science on tPA use is convincing. ORs with robust 95% CIs (adjusted for clustering) were calculated to quantify the association between responses and physician- and hospital-level characteristics. Results— One hundred ninety-nine surveys completed (gross response rate 71.6%). Ninety-nine percent (95% CI: 97.8 to 100) indicated use of tPA in eligible patients represented either acceptable or ideal patient care. Twenty-seven percent (95% CI: 21.7 to 32.3) indicated use of tPA represented a legal standard of care. Eighty-three percent (95% CI: 78.5 to 87.5) indicated they were “likely” or “very likely” to use tPA given an ideal setting. When asked about using tPA without a consultation, 65% (95% CI: 59.3 to 70.7) indicated they were uncomfortable. Forty-nine percent (95% CI: 43.0 to 55.0) indicated the science regarding use of tPA in stroke is convincing with 30% remaining neutral. Characteristics associated with favorable attitudes included non-emergency medicine board certification; older age, and a smaller hospital practice environment. Conclusions— In this cohort, emergency physician attitudes and beliefs toward intravenous tPA use in stroke are considerably more favorable than previously reported.

Acute myocardial infarction following intravenous tissue plasminogen activator for acute ischemic stroke: An unknown danger

Thrombolysis with intravenous tissue (IV) plasminogen activator (tPA) is considered for patients with acute ischemic stroke falling within the described inclusion criteria defined by The National Institute of Neurological Disorders and Stroke (NINDS) rtPA trial. Complications of IV thrombolysis with tPA are commonly related to hemorrhage, anaphylaxis, or arterial occlusion. We describe two cases of acute myocardial infarction (MI) following IV tPA infusion for acute stroke. One of the patients had underlying ischemic heart disease (IHD) while the other did not have any prior IHD. Both had presented with acute ischemic stroke within the window period of thrombolysis and had no contraindications for thrombolysis. Both the patients succumbed due to myocardial infarction and cardiovascular collapse due to new onset arrhythmias. Acute MI immediately following IV tPA for stroke is a rare but serious complication. The disruption of intracardiac thrombus and subsequent embolization to coronary arteries may be an important mechanism in the occurrence of MI after administration of tPA for acute ischemic stroke. As both the patients succumbed before the arrangement for coronary angiography, the demonstration of intracardiac or intracoronary thrombus was not possible. But clinically, the presence of chest pain with elevated troponin levels and ST segment elevation pointed to MI. We suspect that fragmentation and lysis of intracardiac thrombus may result in MI after use of tPA for acute ischemic stroke, though the remote possibility of simultaneous occurrence of two atherosclerotic events MI and stroke exists.