Use Of Alteplase Research Articles

Characteristics, temporal trends and outcomes of intravenous thrombolysis in Chinese patients aged>80 years who had a stroke.

To date, no large cohort study has investigated the effects of intravenous thrombolysis (IVT) in Chinese patients aged over 80 years who had a stroke. This study aimed to assess the trends in the use of alteplase, the clinical characteristics and the outcomes of Chinese patients aged above 80 years who had an acute ischaemic stroke. Data for this analysis were obtained from the China Stroke Center Alliance programme, a nationwide, multicentre, prospective registry encompassing 1751 hospitals across 31 provinces, covering the period from 1 January 2018 to 14 December 2022. The primary outcome was defined as a modified Rankin Scale (mRS) Score of 0-2 at discharge. Secondary outcomes included an mRS Score of 0-1 and independent ambulation on discharge. Safety outcomes assessed were in-hospital mortality and symptomatic intracranial haemorrhage (sICH). Out of 30 902 patients over 80 years old who qualified for thrombolysis, 8673 (median age (IQR), 84 (82-87) years) received alteplase treatment. Patients administered alteplase demonstrated improved short-term functional outcomes, such as an mRS Score of 0-2 (adjusted OR (aOR) 1.12, 95% CI, 1.06 to 1.18, p<0.001), an mRS Score of 0-1 (aOR 1.14, 95% CI, 1.08 to 1.19, p<0.001) and independent ambulation at discharge (aOR 1.14, 95% CI, 1.08 to 1.20, p<0.001). Moreover, no significant increase was observed in the risk of in-hospital mortality (aOR 1.12, 95% CI, 0.93 to 1.35; p=0.23). However, the risk of sICH was significantly higher among patients treated with alteplase (aOR 3.22, 95% CI, 2.77 to 3.75; p<0.001). IVT with alteplase in elderly patients who had a stroke resulted in improved short-term functional outcomes without elevating the risk of in-hospital mortality. Nonetheless, this population remains at a higher risk of sICH.

Streptokinase or Alteplase for Acute Limb Ischemia? A Meta-Analysis

Background: Acute limb ischemia (ALI) is a vascular emergency that necessitates prompt and effective treatment to restore blood flow and prevent limb loss. Thrombolytic therapy, particularly with agents like streptokinase and alteplase, plays a pivotal role in ALI management. This meta-analysis and systematic review aimed to compare the efficacy and safety of streptokinase and alteplase in treating ALI. Methods: A comprehensive search of PubMed, Embase, Science Direct, and the Cochrane Library databases was conducted up to August 13, 2024, to identify relevant studies. The inclusion criteria encompassed clinical trials involving patients diagnosed with ALI who received either streptokinase or alteplase as the initial thrombolytic treatment. The quality of the included studies was rigorously assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and the Methodological Index for Non-Randomized Studies (MINOR) criteria. A meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate risk ratios (RRs) with their corresponding 95% confidence intervals (CIs). Results: The final analysis included 20 studies, encompassing both qualitative and quantitative assessments. A comparative analysis of streptokinase and alteplase for limb salvage at 30 days revealed a significant advantage in favor of alteplase, with a relative risk ratio (RR) of 0.78 (95% CI 0.69-0.88, I² = 0%). Furthermore, streptokinase was associated with a higher rate of primary amputation, with an RR of 2.54 (95% CI 1.50-4.32, I² = 0%) compared to alteplase. The use of streptokinase also correlated with a higher risk of complications, including major bleeding (RR 1.75, 95% CI 0.04-84.30, I² = 77%) and minor bleeding (RR 1.41, 95% CI 0.60-3.32, I² = 0%). Conclusion: The findings of this meta-analysis underscore the superior efficacy of alteplase in achieving limb salvage in ALI, coupled with a more favorable safety profile. The preferential use of alteplase in clinical practice is recommended, particularly in patients with severe ischemia. However, careful patient selection and close monitoring are crucial when streptokinase therapy is considered.

Alteplase- and Tenecteplase-Related Errors and Risk Mitigation Strategies in the Treatment of Acute Ischemic Stroke: A Study of Event Reports From 52 Hospitals

Background: Alteplase and tenecteplase are thrombolytic agents used to treat patients with acute ischemic stroke (AIS). Despite the convenient bolus dosing of tenecteplase, its off-label use for AIS creates new patient safety challenges that are understudied. Methods: The study was conducted in two parts. In Part I, we queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports involving alteplase and tenecteplase that were submitted between 2017 and 2022. Based on results from Part I, in Part II we narrowed the query to reports submitted in 2021–2022 and applied inclusion criteria to identify reports that described a medication error involving the use of alteplase or tenecteplase to treat AIS. In Part II, all reports were reviewed and coded for stages of the medication-use process, associated factors, and event type. Results: Part I results (N=858) showed a decrease in reports of alteplase events and an increase in reports of tenecteplase events. In Part II (N=92), 52% of reports involved alteplase and 48% involved tenecteplase. Wrong dose was the most frequently coded event type for both medications at a combined 48%. Several tenecteplase-related events were attributed to unfamiliarity with the medication, confusion between indications, and incorrect use of the electronic health record (EHR) or failure to use the EHR, whereas many errors unique to alteplase occurred during the multistep calculation, preparation, and administration processes. Conclusions: Safety events involving alteplase and tenecteplase in the treatment of AIS are diverse. We present a list of potential strategies to prevent and mitigate errors involving these high-alert medications and encourage providers to adopt those that are meaningful to their workflow and practice setting.

Effects of alteplase and aspirin on functional outcomes in patients with acute ischemic stroke and mild non-disabling neurological deficit.

Investigate the effect of Alteplase and Aspirin on the functional outcomes of patients with acute ischemic stroke with mild non-disabling neurological deficit. In this single-center, randomized controlled study, we selected 60 patients with acute ischemic stroke with mild non-disabling neurological deficit admitted to our hospital from January 2021 to January 2022, and randomly divided them into the study group (n = 30) and the control group (n = 30), the control group was given the Aspirin treatment, the study group was given the Alteplase treatment, and the changes in neurological recovery, daily living ability, exercise ability, balance ability, cognitive function, and short-term prognosis outcomes were observed in these 2 groups. The factors influencing the short-term outcome of Alteplase therapy in patients with acute ischemic stroke were analyzed. The National Institutes of Health Neurological Deficit Score (NIHSS) scores at T1 and T2 of the study group were lower than those in the control group, but the scores of Barthel indicators (BI), Fugl-Meyer Motor Assessment Scale (FMA), Berg Balance Scale (BBS) and Montreal Cognitive Assessment Scale (MoCA) of the study group were higher than those in the control group, and the difference was statistically significant (P < .05). The short-term prognostic outcomes of these 2 groups were not significantly different (P > .05). The effect of the use of Alteplase or Aspirin on short-term functional outcomes in patients with acute ischemic stroke and mild non-disabling neurological deficit is not much different.

Variables Leading to Usage of Alteplase Versus Heparin Lock in Patients With Tunneled Catheters in Hemodialysis Care Project Centers, Saudi Arabia.

A hemodialysis tunneledcatheter is one option for vascular access used with hemodialysis patients; however, catheter complications such as thrombosis are still inevitable. To prevent thrombosis formation, a catheter-locking solution is instilled between dialysis sessions. Heparin is used as a default locking solution in our Hemodialysis Care Project centers, while arecombinant tissue plasminogen activator (rt-PA) such as alteplase is used to treat suspected catheter thrombosis. This study aimed to identify the clinical factors, catheter brands, and hemodialysis variables that influence the choice of use for alteplase versus heparin, for those patients with tunneled catheters, and reduce overprescribing of high-alert medication alteplase. A retrospective medical chart review study was conducted involving 230 patients with tunneled catheters; the first group of 133 patients used alteplase regularly three times a week, while the second group of 97 patients completed at least one year using the same catheter access with heparin lock only. Multivariate logistic regression and logistic regression analysis showed a significant association (p < 0.05) between different variables. Results suggest that overweight and hyperlipidemia patients are more likely to use alteplase. Patients using brand-name catheters such as Hemostar/Vas-cath (BD, Franklin Lakes, NJ) are less likely to use heparin than those using Medcompcatheters (Medcomp, Yuma, AZ). In addition, patients having a history of angioplasty would be less likely to have heparin than no angioplasty. Moreover, if the patient's fluid removal were equal to or less than 2 kg, they would be more likely to use heparin and vice versa. The study postulates that identified variables affect whether alteplase or heparin is used in hemodialysis tunneled catheters, and may be useful to increase awareness, improve practices, or judiciously control the use of alteplase within Saudi Arabia and globally.

Tenecteplase versus Alteplase before thrombectomy: A comprehensive evaluation of clinical and angiographic impact: Insights from the ETIS registry

IntroductionData on prior use of Tenecteplase versus Alteplase in acute stroke management by mechanical thrombectomy are controversial. Our primary objective was to make a comprehensive comparative assessment of clinical and angiographic efficacy and safety outcomes in a large prospective observational study. MethodsWe included stroke patients who were eligible for intravenous thrombolysis and endovascular thrombectomy between 2019 and 2021, from an ongoing registry in twenty comprehensive stroke centers in France. We divided patients into two groups based on the thrombolytic agent used (Alteplase vs Tenecteplase). We then compared their treatment times, and their angiographic (TICI scale), clinical (mRS at three months and sICH) and safety outcomes after controlling for potential confounders using propensity score methods. ResultsWe evaluated 1131 patients having undergone thrombectomy for the final analysis, 250 received Tenecteplase and 881 Alteplase. Both groups were of the same median age (75 vs 74 respectively), and had the same baseline NIHSS score (16) and ASPECTS (8). There was no significant difference for First Pass Effect (OR 0.93, 95 % CI 0.76–1.14, p = 0.75), time required for reperfusion (OR 0.03, 95 % CI 0.09–0.16, p = 0.49), or for final reperfusion status. Clinically, functional independence at 90 days was similar in both groups (OR 0.82, 95 % CI 0.61–1.10, p = 0.18) with the same risk of sICH (OR 1.36, 95 % CI 0.77–2.41, p = 0.28). However, Tenecteplase patients had shorter imaging-to-groin puncture times (99 vs 142 min, p < 0.05). ConclusionsTenecteplase showed no better clinical or angiographic impact on thrombectomy compared to Alteplase. Nevertheless, it appeared associated with a shorter thrombolysis-to-groin puncture time.

Implementing a 4% EDTA Central Catheter Locking Solution as a Quality Improvement Project in a Large Canadian Hospital.

Oncology and critical care patients often require central vascular access devices (CVADs), which can make them prone to central line-associated bloodstream infections (CLABSIs) and thrombotic occlusions. According to the literature, CLABSIs are rampant and increased by 63% during the COVID-19 pandemic, highlighting the need for innovative interventions. Four percent ethylenediaminetetraacetic acid (4% EDTA) is an antimicrobial locking solution that reduces CLABSIs, thrombotic occlusions, and biofilm. This retrospective pre-post quality improvement project determined if 4% EDTA could improve patient safety by decreasing CLABSIs and central catheter occlusions. This was implemented in all adult cancer and critical care units at a regional cancer hospital and center. Before implementing 4% EDTA, there were 36 CLABSI cases in 16months (27 annualized). After implementation, there were 6 cases in 6months (12 annualized), showing a statistically significant decrease of 59% in CLABSIs per 1000 catheter days. However, there was no significant difference in occlusions (alteplase use). Eighty-eight percent of patients had either a positive or neutral outlook, while most nurses reported needing 4% EDTA to be available in prefilled syringes. The pandemic and nursing shortages may have influenced the results; hence, randomized controlled trials are needed to establish a causal relationship between 4% EDTA and CLABSIs and occlusions.

Comparison of Tetrasodium EDTA 4% with Sodium Citrate 4% as Line-Locking Solutions at 2 Tertiary Hemodialysis Centres.

The patency of central venous catheters (CVCs) in patients undergoing hemodialysis (HD) is maintained by instilling sodium citrate 4% (SC 4%) locking solution. Alteplase, a thrombolytic agent, is administered to restore function if patency is lost. To compare SC 4% with a new line-locking solution, ethylenediaminetetraacetic acid 4% (EDTA 4%), in terms of CVC patency and alteplase use. This retrospective chart review included all HD patients who were switched from SC 4% to EDTA 4% locking solution at 2 tertiary HD centres between June and December 2021. Patients were switched to EDTA 4% if they had high usage of alteplase (receiving ≥ 2 doses of alteplase in a 2-week period). For each line-locking agent, HD pump speeds and alteplase use were analyzed over 2 consecutive 12-week periods. Mean serum calcium and ionized calcium values were recorded during each period. A cost analysis was also performed. A total of 37 HD patients were switched to EDTA 4% during the study period. There was no difference in mean HD pump speed between SC 4% and EDTA 4% (307.7 vs 305.1 mL/min, p = 0.48). The number of catheter-use-days on which alteplase was required declined significantly, from 313 days with SC 4% to 94 days with EDTA 4% (p < 0.001), with an overall cost reduction of 34% ($13 183.21). The decrease in alteplase usage was primarily driven by 1 of the 2 sites. A statistically significant decrease in mean ionized calcium at site 2 (from 1.12 to 1.1 mmol/L, p = 0.037) was noted. As well, an intraluminal interaction between EDTA 4% and serum calcium caused 6 cases of low serum calcium. This study showed that use of EDTA 4% as a line-locking agent reduced alteplase usage in the CVCs of HD patients while maintaining adequate pump speed (i.e., ≥ 300 mL/min).

Improvement of Functional Outcomes in Patients with Stroke who Received Alteplase for Over 15 Years: Japan Stroke Data Bank.

The nationwide verification of intravenous thrombolysis (IVT) was rarely performed after the extension of the therapeutic time window of alteplase or after the expansion of mechanical thrombectomy (MT). We aimed to examine the long-term change in accurate real-world outcomes of IVT in patients with acute ischemic stroke (AIS) using the Japan Stroke Databank, a representative Japan-wide stroke database. We extracted all patients with AIS who received IVT with alteplase between October 11, 2005, the approval date for alteplase use for AIS in Japan, and December 31, 2020. Patients were categorized into three groups using two critical dates in Japan as cutoffs: the official extension date of the therapeutic time window for IVT to within 4.5 h of symptom onset and the publication date of the revised guideline, where the evidence level of MT was heightened. We assessed the yearly trend of IVT implementation rates and the secular changes and three-group changes in clinical outcomes at discharge. Of 124,382 patients with AIS, 9,569 (7.7%) received IVT (females, 41%; median age, 75 years). The IVT implementation rate has generally increased over time and plateaued in recent years. The proportion of favorable outcomes (modified Rankin Scale score of 0-2) increased yearly over 15 years. The results of the changes in the outcomes of the three groups were similar to those of the annual changes. We revealed that IVT implementation rates in patients with AIS increased, and the functional outcome in these patients improved over 15 years. Therefore, the Japanese IVT dissemination strategy is considered appropriate and effective.

Comparison of the effectiveness of non-immunogenic staphylokinase and alteplase for intravenous thrombolysis in ischemic stroke: analysis of hospital registry data

To compare the effectiveness and safety of the use of non-immunogenic staphylokinase (NS) and alteplase (AP) for intravenous thrombolysis (IT) for ischemic stroke (IS) in real clinical practice at a regional vascular center. Data from 100 patients with IS who received IT with NS and 100 patients who received IT with AP for the period 2022-2023 were analyzed. The groups were comparable on sociodemographic parameters, cardiovascular risk factors and diseases, and stroke characteristics. Door-to-needle time was 17 (13-22) min in the NS group and 38 (33-42) min in the AP group (p<0.001). During control neuroimaging, a cerebral infarction was detected in 46% of patients in the NS group and 61% of patients in the AP group (OR 0.479 [0.263; 0.875], p=0.035). When performing IT with NS, an NIHSS score of 0 points (no neurological deficit) was observed twice as often (OR 2.202 [1.079; 4.504], p=0.023). The incidence of hemorrhagic transformation, including symptomatic, as well as hospital mortality did not differ. IT with NS is associated with a lower probability of cerebral infarction and greater positive dynamics of the neurological status in comparison with the use of AP already within the first stage of treatment and rehabilitation.

Two Cases of Thrombus Resolution Unrelated to Large Artery Atherosclerosis or Alteplase Use

Thrombus resolution is generally associated with a favorable prognosis. Patients with thrombus resolution often present with erythrocyte-rich thrombi, frequently associated with large artery atherosclerosis or alteplase use. This might explain the increased rate of cervical carotid artery occlusion and reduced incidence of atrial fibrillation in patients with thrombus resolution. However, recent reports have demonstrated that thrombus resolution can occur owing to several etiologies and various factors. We present two cases of thrombus resolution: one associated with internal carotid artery dissection and the other with a left atrial appendage thrombus. Notably, both were considered to be unrelated to large-artery atherosclerosis or alteplase use.

Caracterización farmacoterapéutica en pacientes con accidente cerebrovascular isquémico en un hospital de Soledad, Atlántico

Objective: to characterize the pharmacotherapy of patients with acute ischemic stroke (ACVi) treated with recombinant tissue plasminogen activator (rt-PA) in a hospital in Soledad - Atlántico in the period 2015-2020. Materials and methods: a retrospective descriptive observational study was carried out, for the quantitative variables the Kolmogórov – Smirnov normality test was applied. The data that complied with the assumption of normality (p&gt;0.05) were presented as means ± standard deviation, those that did not comply were presented as medians. Categorical variables were shown as frequencies or percentages. Results: 72 patients with a median age of 74 years were studied, 52.2% of the population were men, 69.4% suffered from arterial hypertension, 26.4% received platelet aggregation inhibitors, excluding heparin, and 23, 6% were administered drugs belonging to the therapeutic group of heparins. Twenty-five percent of the population developed hemorrhage: 19.4% had intracerebral hemorrhage, 4.2% developed subarachnoid hemorrhage, and 1.4% had gastrointestinal hemorrhage. Conclusion: it was possible to identify opportunities for improvement in the management of patients with stroke and in the use of alteplase. A higher percentage of bleeding complications was found compared to studies previously conducted in Colombia. Further investigations are required to corroborate the results, due to the limited number of participants and scarce data related to clinical histories.

Tenecteplase real-world data: A three phase sequential comparison.

The New Zealand (NZ) Central Region Stroke Network, serving 1.17 million catchment population, changed to tenecteplase for stroke thrombolysis in 2020 but was forced to revert to Alteplase in 2021 due to a sudden cessation of drug supply. We used this unique opportunity to assess for potential before and after temporal trend confounding. In NZ all reperfused patients are entered prospectively into a national database for safety monitoring. We assessed Central Region patient outcomes and treatment metrics over three time periods: alteplase use (January 2018-January 2020); during switch to tenecteplase (February 2020-February 2021) and after reverting to alteplase (February 2021-December 2022) adjusting regression analyses for hospital, age, onset-to-needle, NIHSS, pre-morbid mRS and thrombectomy. Between January 2018 and December 2022, we treated 1121 patients with Alteplase and 286 with tenecteplase. Overall, patients treated with tenecteplase had greater odds of favorable outcome ordinal mRS [aOR = 1.43 (95% CI = 1.11-1.85)]; shorter door-to-needle (DTN) time [median 52 (IQR 47-83) vs 61 (45-84) minutes, p < 0.0001] and needle to groin (NTG) times [118 (74.5-218.5) vs 185 (118-255); p = 0.02)]. Symptomatic intracerebral hemorrhage (sICH) rate was lower in tenecteplase group [aOR 0.29 (0.09-0.95)]. Findings similarly favored tenecteplase when comparing tenecteplase to only the second alteplase phase. There was no inter-group difference when comparing the two alteplase phases. Our results suggest that previously reported benefits from tenecteplase in a real-world setting were not likely attributable to a temporal confounding.

The use of alteplase, although safe, does not offer clear clinical advantages when mild stroke is non-disabling.

It is unknown whether alteplase is effective and safe in patients with mild acute ischemic stroke (AIS). Determining whether symptoms are "disabling" or not is a crucial factor in the management of these patients. This study aimed to investigate the efficacy and safety of alteplase in patients with mild, non-disabling AIS. We included all consecutive patients admitted for AIS at our institution from January 2015 to May 2022 who presented a baseline NIHSS score of 0-5 and fit the criteria to receive intravenous thrombolysis. In order to select only subjects with non-disabling AIS, we excluded patients who scored more than 1 point in the following NIHSS single items: vision, language, neglect, and single limb. Patients who scored at least 1 point in the NIHSS consciousness item were excluded as well. This study is a retrospective analysis of a prospectively collected database. After the application of the exclusion criteria, we included 319 patients, stratified into patients receiving and not receiving alteplase based on non-disabling symptoms. The two groups were comparable regarding demographic and clinical data. Rates of a 3-month favorable outcome, defined as a 3-month mRS score of 0-1, were similar, being 82.3% and 86.1% in the treated and untreated patients, respectively. Hemorrhagic complications and mortality occurred infrequently and were not affected by alteplase treatment. This observational study suggests that the use of alteplase, although safe, is not associated with a better outcome in highly selected patients with non-disabling AIS.

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

P59: Treatment of Impella 5.5 Purge Dysfunction with Tissue Plasminogen Activator Prevents Subsequent Pump Exchanges

Background: The Impella 5.5 is a temporary, percutaneous left ventricular assist device (VAD) that contains a purge system to prevent blood from entering the motor housing. Acute pump failure can occur if purge flow is significantly disrupted and can be predicted by changes in purge pressure or flow rate. The use of alteplase (tPA) in a temporary purge solution is one intervention used to salvage pumps at risk of failure. We share our center’s experience using tPA to treat purge dysfunction in the Impella 5.5 population. Methods: We retrospectively reviewed all Impella 5.5 patients implanted at a single academic center from November 2020 to January 2023 (n=90). Cases were identified by tPA use in the purge system and purge dysfunction was verified by EMR documentation of a notable change in purge pressure or flow rate. Results: tPA was used to treat purge system dysfunction in 10 patients (11.1%) supported for an average of 25 days (Table 1). Nine patients (90%) had dextrose and sodium bicarbonate purge solution with systemic bivalirudin anticoagulation, and one patient had dextrose and heparin purge solution with systemic heparin anticoagulation. On average, purge dysfunction requiring tPA use occurred on post-operative day 13 and required 10 ± 9 mg of tPA in solution. Nine patients (90%) had successful restoration of baseline purge pressure and flow following tPA administration, while the other patient was transitioned to comfort measures shortly after and success could not be determined. No patients required a pump exchange for continued purge dysfunction. Of those treated with tPA, 6 patients (55%) survived to discharge. Other than an incidental finding in one patient questionable for subarachnoid hemorrhage that not impacting clinical care, there were no other major bleeding events or strokes within 48 hours of tPA administration. Conclusion: In cases of identified purge dysfunction prior to pump failure, tPA is an effective intervention for resolution and return to baseline purge function in the Impella 5.5 device preventing the need for surgical pump exchange.

Malpractice Lawsuits Relating to Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review.

Medical-legal claims for malpractice relating to the use of alteplase for acute ischemic stroke (AIS) are usually for failure to treat rather than for complications. The advent of mechanical thrombectomy (MT) as a standard of AIS treatment has added a new dimension to the medical-legal landscape as there is a need for the delivery of a higher level of care creating the potential for delays and errors associated with such treatment. Information on causes of malpractice related to mechanical thrombectomy (MT) is currently lacking. We conducted a systematic review of legal databases (Westlaw, LexisNexis, Google Scholar Case Law, and VerdictSearch) to identify medical malpractice cases with and without verdicts filed in the United States up to March 31, 2021 which pertained to performance or non-performance of MT for AIS. We collected various case characteristics, case outcomes, and root causes for malpractice claims. We found 25 cases, 16 of which alleged failure to treat with MT, 8 for harm due to delay in treatment and 1 case that alleged complications. Root causes included delay in vascular imaging, communication breakdowns, and transportation delays. Eight cases had an outcome in favor of the defendant, 9 in favor of the plaintiff, and 8 remained to be determined. As with alteplase, malpractice allegations regarding MT for AIS are largely for failure to treat or delay in treatment as opposed to complications. Addressing root causes of diagnostic delay, communication breakdowns, and transportation delays may reduce subsequent malpractice risk.

VIsion Salvage Using Intra-Ophthalmic Arterial Alteplase Combine with Nimodipine in Central Retinal Artery Occlusion (VISION).

To investigate the efficacy and safety of selective intra-ophthalmic arterial combined nimodipine and alteplase infusion in patients with central retinal artery occlusion (CRAO). Non-randomized, prospective interventional study. All patients with CRAO who presented at our institute within 24 hours from CRAO onset from August 2020 to July 2022 were included. Intra-arterial nimodipine and alteplase were given selectively into the ophthalmic artery. Visual acuity was recorded during and after the procedure. Change in best corrected visual acuity (BCVA) 1 month post-treatment, relative to baseline, was set as the primary outcome measure. Significant improvement in vision and adverse events are reported as secondary outcomes. Nine patients with non-arteritic CRAO were enrolled. A total of nine patients with CRAO underwent selective intra-ophthalmic arterial nimodipine and alteplase injection. Overall, BCVA had statistically significantly improved by 0.78 logarithm of the minimum angle of resolution (logMAR) at 1 month compared with baseline (95% confidence interval: (-1.24, -0.31), p-value = 0.001). Seven (77.8%) patients had significant visual improvement (≥0.3 logMAR) at 1-month post-treatment. There were minor adverse events during administration of the nimodipine, including chemosis and headache, which resolved after the discontinuation of nimodipine. There were also asymptomatic thromboembolic events in 2 patients (22.2%) after the intervention procedure, without any morbidity or mortality. The use of selective intra-ophthalmic arterial combined nimodipine and alteplase was efficacious in improving BCVA at 1 month for patients with non-arteritic CRAO presenting between 24 hours from onset, with minor adverse events but no serious adverse events.

Abstract WP2: Benefit Of Alteplase And Lacunar Stroke: A Post-hoc Analysis Of The Shine Trial

Introduction: Small subcortical infarcts, synonymous in the literature with lacunar or small vessel disease infarcts, occur in roughly a quarter of all ischemic stroke. While the use of alteplase and other thrombolytics is well known to improve outcomes for acute ischemic stroke, the role of thrombolytics in the acute management of this infarct subtype is not entirely proven. We hypothesized that the use of alteplase in the hyperacute management of small vessel infarcts improved long-term outcomes. Methods: We performed a post-hoc analysis of the Stroke Hyperglycemia Insulin Network Effort (SHINE) dataset. We included only those with an etiologic diagnosis of lacunar stroke. The primary exposure was guideline-based administration of alteplase. The primary outcome was 90-day functional outcome by mRS 0 - 2 (good) versus 3 - 6 (poor). Insulin treatment arms were combined as no differential treatment effect was demonstrated in the original SHINE publication. Standard descriptive and logistic regression analysis, adjusted for age, arrival blood glucose, and NIH Stroke Scale, were used for data interpretation. Results: We included 258 SHINE participants who were diagnosed with a lacunar infarct: mean age 65 ± 13 years, 53% (138/258) were men, and 57.7% (150/258) received alteplase. Demographic data including age, sex, and presenting variables including NIH Stroke Scale score, systolic blood pressure, and blood glucose levels did not differ between those who received alteplase and those who did not. Those who received alteplase were more likely to be within the good outcome group (OR 1.89, 95%CI 1.03 - 3.47, p = 0.039). Conclusion: The administration of intravenous alteplase for reported lacunar stroke increased the likelihood of a good outcome by nearly 2-fold. Lacunar infarcts, a radiographic outcome of small subcortical infarcts, are unique in pathogenesis compared to cardioembolic and large-artery atheromatous disease. Despite these differences, our findings support the use of acute thrombolytic therapy within this patient population. Future studies are needed to assess the response between small subcortical infarcts subtypes (e.g. branch atheromatous disease, subcortical microembolism, lipohyalinosis) and acute reperfusion therapy.

Abstract WMP8: Tenecteplase Versus Alteplase For Acute Ischemic Stroke: Treatment Outcomes From A Large Northwest Us Stroke Registry

Introduction: The American Stroke Association Guidelines on acute ischemic stroke (AIS) thrombolytic treatment endorse the use of tenecteplase (TNK) weakly (IIb) based on moderate quality (B-R) evidence. The use of alteplase for AIS is strongly recommended (I) with high quality (A) of evidence. Despite this, many healthcare systems have transitioned to the use of TNK based on limited clinical trial data. Our study presents real world outcome data comparing AIS patients treated with TNK vs alteplase. Methods: Data were retrospectively abstracted from AIS patients treated with IV thrombolytic (IVT) or IVT and endovascular therapy (EVT) discharged between 1/1/2019-6/30/2022 . Patients were grouped into alteplase w/wo thrombectomy and TNK w/wo thrombectomy. Primary outcomes were discharge disposition, complications (sICH, serious systemic hemorrhage), door to needle and door to device times, treatment complications and post-EVT TICI score. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) are reported for likelihood to receive IVT within 45 minutes and 30 minutes of arrival for the IVT group, adjusting for sex, race, admit NIHSS, and previous stroke. Results: 3733 patients were included in the IVT group: 90.7% received alteplase, 9.3% received TNK. 814 patients received IVT and EVT: 90% received alteplase and 10% received TNK. In the IVT group, the median [Q1, Q3] DTN for alteplase was 48 [35, 66] minutes TNK was 45.5 [34.75, 63.25] (p=0.067). There was no significant difference in the likelihood of receiving IVT within 45 minutes and 30 minutes between the two drugs. Patients with higher admit NIHSS were more likely to receive IVT within 45 minutes (AOR 1.031 95% 1.021, 1.041 p&lt;0.0001) and within 30 minutes (AOR 1.025 95% 1.013, 1.037 p&lt;0.0001). There were no significant differences found in median DTN, DTD or TICI score for patients receiving both IVT and EVT. There were no significant differences in complications for any group. Conclusion: In our study there were no differences in benefit, risk, or treatment logistics between alteplase and tenecteplase when used in treating acute ischemic stroke. Recanalization of large vessel occlusion prior to endovascular thrombectomy was not analyzed but will be the subject of study in this cohort.