Review of stroke thrombolytics

The cornerstone of acute ischemic stroke treatment relies on rapid clearance of an offending thrombus in the cerebrovascular system. There are various drugs and different methods of assessment to select patients more likely to respond to treatment. Current clinical guidelines recommend the administration of intravenous alteplase (following a brain noncontract CT to exclude hemorrhage) within 4.5 hours of stroke onset. Because of the short therapeutic time window, the risk of hemorrhage, and relatively limited efficacy of alteplase for large clot burden, research is ongoing to find more effective and safer reperfusion therapy, as well as focussing on refinement of patient selection for acute reperfusion treatment. Studies using advanced imaging (incorporating perfusion CT or diffusion/perfusion MRI) may allow us to use thrombolytics, or possibly endovascular therapy, in an extended time window. Recent clinical trials have suggested that Tenecteplase, used in conjunction with advanced imaging selection, resulted in more effective reperfusion than alteplase, which translated into increased clinical benefit. Studies using Desmoteplase have suggested its potential benefit in a sub-group of patients with large artery occlusion and salveageable tissue, in an extended time window. Other ways to improve acute reperfusion approaches are being actively explored, including endovascular therapy, and the enhancement of thrombolysis by ultrasound insonation of the clot (sono-thrombolysis).

Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: A prospective trial

AIM: To assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely.

METHODS: Eight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h).

RESULTS: Eight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1.

CONCLUSION: Combined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.

Thrombus length estimation in acute ischemic stroke: a potential role for delayed contrast enhanced CT

PURPOSE

Thrombus length has been shown to be an important determinant of recanalization using intravenous thrombolysis in hyperacute ischemic stroke. Various studies have attempted to quantify thrombus based on non-contrast CT (NCCT) or CT angiography (CTA). However, thrombus may not be seen on NCCT, and CTA may fail to delineate the distal extent of the thrombus. Contrast enhanced CT (CECT) following CTA can be used to estimate infarct core, but we investigated whether the angiographic data available on these images provided reliable information on thrombus length.

MATERIALS AND METHODS

15 consecutive patients, mean age 81 years (range 63-93), with terminal internal carotid artery or M1-middle cerebral artery occlusions underwent NCCT, CTA (bolus tracked technique), and CECT (acquired 80 s post initial CTA injection). Three radiologists assessed thrombus length on thin slice NCCT, and CTA and CECT.

RESULTS

CTA overestimated thrombus length relative to NCCT (p<0.001) and CECT (p<0.001). There was less difference between CTA and CECT estimation in patients with good collateral scores (p<0.05). There was good correlation between NCCT and CECT (Pearson's correlation coefficient=0.90, 95% CI 0.81 to 0.95, p<0.001). Inter-rater reliability assessed using intraclass correlation was 0.95 (95% CI 0.87 to 0.98) for NCCT and 0.98 (95% CI 0.94 to 0.99) for CECT.

CONCLUSIONS

CTA regularly overestimates thrombus length as the distal end of the thrombus is not delineated. This can be overcome through the use of a CECT acquisition which can reliably be used to estimate thrombus length.

MRI and magnetic resonance angiography findings in patients with multiple sclerosis mimicked by stroke

We report a 45-year-old woman who presented with a first demyelinating event with abnormalities seen on both MRI and magnetic resonance angiography that were highly suggestive of acute ischemic stroke. This report highlights the problem of differential diagnosis of acute neurological symptoms in adult subjects.

The results of aspiration thrombecomy in the endovascular treatment for iliofemoral deep vein thrombosis

Purpose

The aim of this study is to evaluate the results of aspiration thrombectomy (AT) in the endovascular treatment for iliofemoral deep vein thrombosis (DVT) through the comparison of catheter directed thrombolysis (CDT) alone group and CDT with AT group.

Methods

From November 2001 to April 2011, 100 patients received endovascular treatment with CDT alone or CDT with AT for iliofemoral DVT at Yeungnam University Medical Center. We compared procedure, clinical outcomes and complications between the two groups.

Results

The mean age of patients was 60.48 ± 14.57 years. The patients consisted of 41 men and 59 women. CDT alone and CDT with AT were performed in 29 and 71 patients, respectively. The mean procedural time of the CDT-alone group was longer than the CDT with AT group (P < 0.001) and dose of urokinase used during the procedure significantly decreased in the CDT with AT group (P < 0.001). There were no statistically significant differences in clinical outcomes between the two groups. Cases of pulmonary embolism was not noted in each group in our series, but entrapped thrombus during procedure was noted in 6 of 37 in the CDT with AT group and 0 of 9 in the CDT-alone group among 46 patients with prophylactic inferior vena cava (IVC) filter insertion.

Conclusion

In conclusion, CDT with AT is safe and effective for the treatment of an acute iliofemoral DVT. In AT treatment, prophylactic IVC filter insertion should be considered for the prevention of pulmonary embolism by floating thrombi.

The efficacy and safety of pharmacoinvasive therapy with prourokinase for acute ST-segment elevation myocardial infarction patients with expected long percutaneous coronary intervention-related delay

OBJECTIVES

To elucidate the efficacy and safety of pharmacoinvasive therapy by using prourokinase (prouk) in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Patients with STEMI often have long percutaneous coronary intervention (PCI)-related delays due to various reasons, which are associated with poor outcomes.

METHODS

A randomized study which enrolled patients from four centers in China was conducted. Patients were randomly assigned to accept routine primary PCI or prouk-PCI. The primary end points were the angiographic parameters, including thrombolysis in myocardial infarction (TIMI) flow grade, TIMI frame count, and myocardial blush grade. Secondary endpoints were incidence of major adverse cardiac events (MACE, defined as death from all causes, reinfarction, revascularization, or rehospitalization due to new or worsening congestive heart failure) at 30 days and 1 year.

RESULTS

One hundred and ninety-seven eligible patients were enrolled, of whom 100 were randomized to the prouk-PCI group. Significantly more patients in the prouk-PCI group than in the PCI group had an opened infarct-related artery on arrival in the catheterization laboratory (48% vs. 21%, P = 0.0002) and better TIMI frame count after PCI (33 ± 6 vs. 40 ± 10, P < 0.001). At 1-year follow-up, there was a trend that patients in the prouk-PCI group had less chances to have MACE (7.0% vs. 12.6%, P = 0.235) or be readmitted to hospital due to new or worsening congestive heart failure (1.0% vs. 4.1%, P = 0.209).

CONCLUSION

A strategy of emergent PCI preceded by fibrinolysis with prouk results in a better myocardial perfusion in infarct-related artery compared with primary PCI alone in patients with STEMI and long PCI-related delay.

Variation in clinical practice of intravenous thrombolysis in stroke in the Netherlands

In the Netherlands in 2010, 11% of patients with ischemic stroke received intravenous thrombolysis (IVT), varying from 4 to 26% between hospitals. The aim of this study was to investigate variation in clinical practice and organization of IVT in relationship to performance and outcome. In all 84 Dutch hospitals performing IVT, a stroke neurologist was approached using a web-based survey. The response rate was 82%. The study showed considerable variation. For example, door-to-needle time ranged from 25 to 80 min. High blood pressure was actively lowered before performing IVT by 57% of neurologists, while 35% chose to wait. 28% started IVT without knowledge of laboratory results. Better follow-up data are needed to see whether this variation results in differences in outcome.

Successful catheter aspiration and local low-dose thrombolysis in an acute renal artery embolism

Acute renal artery embolism (RAE) is a clinical rare condition and diagnosis of it is often delayed or missed due to both the rarity of the disease and its non-specific clinical presentation. The exact role and optimal timing of endovascular revascularization remain controversial and uncertain. This article discusses a case of acute renal artery embolism caused by atrial fibrillation. Endovascular renal thrombus aspiration combined with local low-dose thrombolysis reversed the renal ischemia with restoration of renal function despite prolonged ischemia.

Excellent rates of recanalization and good functional outcome after stent-based thrombectomy for acute middle cerebral artery occlusion. Is it time for a paradigm shift?

The natural history of untreated acute middle cerebral artery (MCA) occlusion is poor, with high rates of mortality (5-33%) and severe long-term disability (40-80% of survivors), despite therapy with intravenous tissue plasminogen activator. We analyzed outcomes in 31 consecutive patients with major ischemic stroke due to acute proximal MCA occlusion who were treated at the Hadassah-Hebrew University Medical Center from February 2010 to October 2012 by endovascular means, using the Solitaire stent (Covidien, Irvine, CA, USA) as a thrombectomy device. Patients had a mean age of 63.3±16.2 years (range, 26-92). The admission National Institutes of Health Stroke Scale score was 19.5±4.3 (median 20). Mean time from symptom onset to femoral artery puncture was 3.8±1.1 hours (median 4 hours). Mean time to recanalization was 46.9±11.1 minutes. Successful recanalization by means of stent-based thrombectomy alone was achieved in 90% of cases and reached 100% after combining definitive stent implantation in three patients. There was no arterial rupture or subarachnoid hemorrhage. Hemorrhagic transformation developed in seven patients (23%), but was symptomatic in only one. Post-procedure CT scan or MRI demonstrated >90% sparing of cortex at risk in all patients. Functional outcome at 90 day follow-up was modified Rankin Score 0-2 in 77% of all patients and 88% of patients younger than 80 years. Three patients (10%) died during hospitalization due to mesenteric event, sepsis, or pulmonary embolism. Our experience suggests that stent-based thrombectomy in selected patients for acute MCA occlusions is safe, very effective in terms of arterial recanalization, and associated with improved neurological outcome. If validated by other groups, endovascular treatment may be proposed as the therapy of choice for MCA occlusion.

Thrombolysis in the age of Primary Percutaneous Coronary Intervention: Mini-Review and Meta-analysis of Early PCI

OBJECTIVE

Primary Percutaneous Coronary Intervention (PCI) is the treatment of choice for ST-segment Elevation Myocardial Infarction (STEMI) if performed within 90 minutes from first medical contact. However, primary PCI is only available for less than 25% of patients with STEMI. Early PCI or Pharmaco-invasive strategy has evolved from facilitated PCI but with more delayed timing from thrombolysis to PCI.

AIM

Assess the safety and effectiveness of Early PCI.

PATIENTS AND METHOD

We reviewed the data of the available therapy options for patients with STEMI. Then we performed a meta-analysis for all randomized controlled trials of early PCI versus standard therapy.

RESULTS

Five studies fulfilled our inclusion criteria. Our meta-analysis showed improved cardiovascular events with early PCI compared to standard therapy (odd ratio of 0.54; 95% Confidence interval 0.47-0.7, p<0.001). There were no significant bleeding complications when doing early PCI 4 to 24 hours after successful thrombolysis.

CONCLUSION

Early PCI should be done to all STEMI patients within 24 hours after successful thrombolysis.

Understanding the reasons behind the low utilisation of thrombolysis in stroke

BACKGROUND

Thrombolysis remains the only approved therapy for acute ischaemic stroke (AIS); however, its utilisation is reported to be low.

AIMS

This study aimed to determine the reasons for the low utilisation of thrombolysis in clinical practice.

METHOD

Five metropolitan hospitals comprising two tertiary referral centres and three district hospitals conducted a retrospective, cross-sectional study. Researchers identified patients discharged with a principal diagnosis of AIS over a 12-month time period (July 2009-July 2010), and reviewed the medical record of systematically chosen samples.

RESULTS

The research team reviewed a total of 521 records (48.8% females, mean age 74.4 ± 14 years, age range 5-102 years) from the 1261 AIS patients. Sixty-nine per cent of AIS patients failed to meet eligibility criteria to receive thrombolysis because individuals arrived at the hospital later than 4.5 hours after the onset of symptoms. The factors found to be positively associated with late arrival included confusion at onset, absence of a witness at onset and waiting for improvement of symptoms. However, factors negatively associated with late arrival encompassed facial droop, slurred speech and immediately calling an ambulance. Only 14.7% of the patients arriving within 4.5 hours received thrombolysis. The main reasons for exclusion included such factors as rapidly improving symptoms (28.2%), minor symptoms (17.2%), patient receiving therapeutic anticoagulation (6.7%) and severe stroke (5.5%).

CONCLUSION

A late patient presentation represents the most significant barrier to utilising thrombolysis in the acute stroke setting. Thrombolysis continues to be currently underutilised in potentially eligible patients, and additional research is needed to identify more precise criteria for selecting patients for thrombolysis.

Thrombolysis of an acute stroke presentation with an incidental unruptured aneurysm

Many patients with acute ischaemic stroke have contraindications to thrombolytic therapy. We describe a 45 yr old Afro-Caribbean female with HbSC disease whom was electively admitted for a cerebral angiogram to evaluate an intracavernous aneurysm measuring 20 mm in diameter. During the procedure, she suffered a right MCA territory ischaemic event with a NIHSS of 10. A CT angiogram demonstrated no dissection and no evidence of a major vessel occlusion. Tissue plasminogen activator (tPA) was administered intravenously within 60 minutes of symptom onset. She had clinical and haematological evidence of a painful sickle cell crisis and required manual exchange transfusion within a few hours of thrombolysis. This is the first reported case of the use of thrombolysis for acute stroke in a sickle cell crisis; and in the presence of such a large unruptured aneurysm. A registry of unusual thrombolysis cases might help clinicians in cases when there is little evidence to support decision-making.

Thrombolysis in a stroke patient on dabigatran anticoagulation: case report and synopsis of published cases

We present the case of an aphasic 77-year-old stroke patient with left distal M1 occlusion who received rt-PA for thrombolysis while on oral anticoagulant treatment with dabigatran (150 mg b.i.d.). Coagulation parameters were normal (thrombin time 20 s, aPTT 20 s, INR 1.08) and the patient improved from an NIHSS of 15 to 5 within 24 h with sonographic evidence of M1 recanalization. She did not develop intracranial bleeding complications but showed unusually large diffuse skin ecchymoses. In our report, we give an overview of all reported cases of thrombolysis under dabigatran anticoagulation and discuss the questions of medication adherence under novel oral anticoagulants (NOA) and the safety of NOA in terms of secondary intracerebral hemorrhage after stroke.

Negative fluid-attenuated inversion recovery-based intravenous thrombolysis using recombinant tissue plasminogen activator in acute stroke patients with unknown onset time

BACKGROUND

Approximately 25% of acute stroke patients were excluded from intravenous thrombolysis using recombinant tissue plasminogen activator (IV-tPA) because of unknown onset time. Recent studies have shown that patients with unknown onset time would be able to receive IV-tPA when showing no ischemia on fluid-attenuated inversion recovery (negative FLAIR). The present study evaluated the safety and feasibility of IV-tPA in patients with unknown onset time and negative FLAIR compared to those with standard IV-tPA.

METHODS

Stroke patients with unknown onset time were prospectively enrolled. Only patients with an occlusion of the internal carotid artery (ICA) and/or middle cerebral artery (M1 and M2) with a Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≥5 were analyzed. IV-tPA was performed within 3 h from the 'first found abnormal time' if the patient showed negative FLAIR. Standard IV-tPA patients were extracted from our registry as controls after having been matched by age and occluded artery to the negative FLAIR (N-F) group.

RESULTS

Twenty patients in the N-F group and 60 in the control group were included. National Institutes of Health Stroke Scale (NIHSS) scores [median 18 (interquartile range 13-20) vs. 17 (12-20), p = 0.609] and DWI-ASPECTS [9 (7-9) vs. 8 (5-9), p = 0.213] were similar between the 2 groups. ICA occlusion was seen in 35%, M1 in 50%, and M2 in 15% in both groups. None of the N-F group and 1 (2%) of the control group experienced symptomatic intracerebral hemorrhage (p = 1.000). Recanalization within 1 h after IV-tPA was achieved in 6 (30%) patients in the N-F group and 24 (40%) in the control group (p = 0.595). Recanalization at 24 h after IV-tPA was seen in 13 (65%) patients in the N-F group and 43 (72%) in the control group (p = 0.584). At 7 days, 8 (40%) in the N-F group and 28 (47%) in the control group had a dramatic recovery (defined as a ≥10-point reduction in the total NIHSS score or a score of 0 or 1) (p = 0.796). At 3 months, a favorable outcome (modified Rankin scale score, 0-2) was seen in 47% in the N-F group and 33% in the control group (p = 0.365).

CONCLUSION

IV-tPA in negative FLAIR patients with unknown onset time appears safe and feasible.

A French stroke unit experience

OBJECTIVES

Narrow therapeutic window is a major cause of thrombolysis exclusion in acute ischemic stroke. Whether prehospital medicalization increases t-PA treatment rate is investigated in the present study.

PATIENTS AND METHODS

Intrahospital processing times and t-PA treatment were analyzed in stroke patients calling within 6h and admitted in our stoke unit. Patients transferred by our mobile medical team (SAMU) and by Fire Department (FD) paramedics were compared.

RESULTS

193 (61.6%) SAMU patients and 120 (38.4%) FD patients were included within 30 months. Clinical characteristics and onset-to-call intervals were similar in the two groups. Mean door-to-imaging delay was deeply reduced in the SAMU group (52 vs. 159 min, p<0.0001) and was <25 min in 50% of SAMU patients and 14% of FD patients (p<0.0001). SAMU management was the only independent factor of early imaging (p=0.0006). t-PA administration rate was higher in SAMU group than in FD group (42% vs. 28%, p=0.04). Proportion of patients with delayed therapeutic window was higher in FD group than in SAMU group (38% vs. 26%, p<0.0001).

CONCLUSION

Prehospital transfer medicalization promotes emergency room bypass, direct radiology room admission and high thrombolysis rate in acute ischemic stroke.

Epidemiology and registry studies of stroke in Japan

Stroke is the most prevalent cardiovascular disease in Japan. This review introduces two epidemiologic studies and four registry studies of stroke in Japan. The Hisayama Study was begun as a population-based prospective cohort study of cerebrovascular and cardiovascular diseases in 1961 in the town of Hisayama. Most of the deceased subjects of the study underwent autopsy examinations from the beginning of the study. Changes in stroke trends in the last 50 years were clarified by comparison of data from different study cohorts registered every 13 to 14 years. The Suita Study was based on a random sampling of Japanese urban residents. Several reports from this study showed the significance of pre-hypertension, as well as hypertension, as a risk factor for stroke by itself and in combination with other underlying characteristics. In addition, the Japan Multicenter Stroke Investigators' Collaboration (J-MUSIC), the Japan Standard Stroke Registry Study, the Fukuoka Stroke Registry, and the Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI) rt-PA Registry are explained as registry studies involving Japanese stroke patients.

Rupture of aneurysms in the immediate post-coiling period

PURPOSE

We present a series of cases featuring re-rupture of posterior communicating artery aneurysms in the immediate post-coiling period, where clots obscured the neck of the aneurysm during the procedure. We report on the incidence of re-rupture and discuss possible mechanisms behind this phenomenon.

METHODS

This study included 462 aneurysms over a 10-year period which were treated with endovascular coiling. 137 of these were ruptured aneurysms. Radiographic and clinical information pertaining to the patients was collected. The immediate post-coiling period was defined as ≤3 days following the procedure.

RESULTS

The incidence of re-rupture in the immediate post-coiling period was 1.4% (2/137). Of these two, one received recombinant tissue plasminogen activator and both received acetylsalicylic acid. One patient presented with adjacent hematoma on re-rupture. In both cases, clot obscured the aneurysm neck during the procedure.

CONCLUSIONS

Re-rupture of intracranial aneurysms in the immediate post-coiling period is an exceedingly rare complication, and the events leading to it have not been discussed at length. Repeat treatment, follow-up imaging and close observation are merited in the setting of re-rupture of a posterior communicating artery aneurysm.

Expression of the recombinant plasminogen activator (reteplase) by a non-lytic insect cell expression system

Reteplase is a potent thrombolytic agent which is widely used in the management of acute myocardial infarction and stroke. It belongs to the third generation of the thrombolytic drugs and has been derived from native human tissue plasminogen activator by removing three domains of it and keeping the Kringle 2 and Serine protease domains. However, the high cost of this drug, has limited the application of this drug especially in the developing and third world countries. The most laborious steps in the bacterial production of this drug is its purification and refolding steps which keep the process yield low and the cost high. Therefore, in the present study we evaluated the expression of reteplase by a non-lytic insect cell expression system. Following cloning and transfection procedures, recombinant Sf9 insect cell clones expressing the reteplase protein were selected. Primarily, the expression was verified by dot-blot analysis and subsequently it was confirmed by Western Blotting showing a band of about 45 kD on nitrocellulose membrane. The biological activity of the expressed protein was also evaluated and showed to be about 29 IU/ml. This confirmed the possibility of expression and the correct folding of the expressed protein. Hence, optimization of the expression followed by purification of the protein could be the next steps of the study.

Design of a standard Iranian protocol of Intravenous thrombolysis with tissue plasminogen activator: A national project

Standard protocols should be established for treating eligible stroke patients with tissue plasminogen activator (TPA) (recommendation class I, level of evidence B). The Iranian standard protocol of Intravenous Thrombolysis with recombinant Tissue Plasminogen Activator (IVTTPA) is the best possible and easy to use method for performing intravenous thrombolysis in Iran. This protocol overcomes problems and limitations of IVTTPA in Iran. The protocol achieves the best selection criteria and assessment method of IVTTPA for our residents and neurologists. This protocol was provided in Persian language and could be easily downloaded from Google site by writing Thrombolysis and Iran in Persian.

Pulmonary embolism, part II: Management

Acute pulmonary embolism (PE) bears a significant burden on health and survival. Rapid and accurate risk stratification and management are of paramount importance to ensure the highest quality of care. This present article summarizes currently available and emerging management strategies for the disease. The authors not only review current evidence regarding early therapy of acute PE, including supportive care, anticoagulation, thrombolysis, surgical and catheter-based treatment, but also the possible role of mechanical circulatory support in PE. The authors also discuss complications related to PE and its management.

Reversal of large ischemic injury on hyper-acute diffusion MRI

Reversal of early ischemic injury on diffusion-weighted MRI (DWI) occurs rarely. In a stroke patient who abruptly developed stupor and left hemiparesis, DWI scanned 78 min after onset demonstrated a large ischemic injury in the right hemisphere with a DWI-ASPECTS (Albert Stroke Program Early Computed Tomography Score) of 5 points, although baseline brain CT was perfectly normal. MR angiography (MRA) showed an occlusion of the right middle cerebral artery trunk, and the patient received intravenous thrombolysis 105 min after onset. A second MRA 30 h later showed complete vessel recanalization, and DWI demonstrated a perfect reversal of the initial large ischemic injury, associated with very small thrombus-fragmented cortical surface infarctions. Outcome at 3 months was a modified Rankin Scale score of 0, and the fluid-attenuated inversion recovery image showed only a small final infarction at the cortical surface. Hyper-acute DWI-defined large ischemic injury may very rarely represent a nearly perfect reversible area, and it may be a therapeutic target.

Loss of Penumbra by Impaired Oxygen Supply? Decreasing Hemoglobin Levels Predict Infarct Growth after Acute Ischemic Stroke: Stroke: Relevant Impact of Hemoglobin, Hematocrit and Transfusion (STRAIGHT) - An Observational Study

Background

The association of mortality and poor outcome with reduced levels of hemoglobin (Hb) and hematocrit (Hct) in patients admitted for ischemic stroke was recently demonstrated. The mechanisms behind this have remained unclear.

Aims

Here, we aimed to investigate a putative association between low Hb and Hct levels and infarct growth.

Methods

All consecutive patients who received intravenous thrombolysis based on multimodal magnetic resonance imaging during the years 1998–2009 were screened. Laboratory data as well as admission magnetic resonance images and follow-up computed tomography scans of 257 patients were assessed. Overall, data of 100 patients were of sufficient quality and further analyzed.

Results

Decrease in Hb and Hct as well as perfusion-weighted imaging volume, mismatch volume, and final infarct size on follow-up computed tomography were associated with infarct growth. A linear regression model revealed Hb decrease (β = 0.23, p = 0.02) to be a predictor of infarct growth, independent of mismatch volume (β = 0.27, p = 0.004) and minimum sodium (β = -0.21, p = 0.03), and adjusted to the non-predicting variables age, National Institute of Health Stroke Scale score, maximum leucocytes and C-reactive protein, blood glucose, and Hct decrease.

Conclusion

Hb levels that decrease after admission independently predict infarct growth in thrombolyzed stroke patients. The clinical implications of this relationship remain to be investigated.

Improvements in recanalization with modern stroke therapy: a review of prospective ischemic stroke trials during the last two decades

INTRODUCTION

A number of recent trials evaluating intra-arterial therapies for acute ischemic stroke have been completed. We present a review of prospective acute ischemic stroke trials reported in a peer-reviewed forum during the last 20 years to provide insight into the general direction of this rapidly evolving field.

METHODS

Prospective trials evaluating acute stroke intra-arterial therapies since 1999 were included, with the National Institute of Neurological Disorders and Stroke rtPA trial published in 1995 as a baseline comparator. Patient presenting factors and outcome data were analyzed based on year of publication and best-fit lines and linear regression analyses were generated.

RESULTS

Thirteen prospective trials were included. Regression analyses demonstrated no appreciable change in the median NIH Stroke Scale score of subjects at the time of enrollment since 1995 (p=0.44) and no appreciable improvements in good outcome based on a modified Rankin score of 0-2 at 90 days (p=0.66) or mortality at 90 days (p=0.55). A significant increase in time from onset of symptoms to treatment among enrolled patients was noted from 1995 to 2012 (p=0.03). In addition, a significant improvement in recanalization/reperfusion was noted over the last two decades (p=0.02).

CONCLUSIONS

This review of prospective acute ischemic stroke trials since 1999 indicates a substantial improvement in revascularization in the setting of a significant increase in time to therapy onset, but no appreciable change in good functional outcome.

Pharmacoinvasive Management

The goal of treatment of patients with ST-segment elevation myocardial infarction (STEMI) is timely restoration of myocardial blood flow. Primary percutaneous coronary intervention (PCI) remains the treatment of choice for STEMI patients, as shown in multiple clinical trials. However, because of logistic constraints, timely primary PCI may not be possible for many STEMI patients, most of whom are treated with fibrinolysis. Debate continues as to whether, and when, patients treated with fibrinolysis should undergo subsequent PCI. Current data support the strategy of early routine PCI after fibrinolysis rather than the conservative standard-care approach or rescue PCI for failed lysis.

Telemedicine: The Future of Global STEMI Care

Telemedicine is an innovative tool in the setting of ST-elevation myocardial infarction (STEMI), because it addresses the greatest challenge-delivering optimal reperfusion therapies in a timely manner. Telemedicine targets delays related to geography, distance, and stated prehospital systems of care. Integration of telemedicine into prehospital STEMI management has been shown to yield cost-effective improvements in patient care. Despite socioeconomic constraints, a standard prehospital network based on telemedicine is globally feasible. This article proposes 2 models that enable the use of telemedicine in the STEMI management protocol.

Diagnostic neuroradiology: Ready for the neuro-interventional age?

Acute cerebral ischemia or stroke is currently considered an emergency for which therapeutic options are available if the therapeutic window of 4.5 h is respected. Imaging modalities have progressed greatly over the last few decades, rendering ischemia detectable in the first hours after the event. However, in order for treatment to be efficacious it is necessary to speed up all the processes before the start of therapy. Thus, one must decrease the time to arrival at the hospital and to the radiological method that is to be employed (be it computed tomography or magnetic resonance imaging); only then will the medical or interventional techniques available fulfill their potential.

Isolated protein S deficiency presenting as catastrophic systemic arterial and subsequently venous thrombosis

Isolated protein S deficiency is an inherited condition having proven association with venous thromboembolism. There is controversy regarding clear association between protein S deficiency and arterial thrombosis. It is therefore necessary to bring focus to this uncommon clinical condition and highlight the probable association with arterial thrombosis facilitating timely diagnosis of this condition. We describe a 48-year-old male with stroke and pulmonary thromboembolism with chronic deep vein thrombosis secondary to isolated protein S deficiency, managed with thrombolysis and long-term anticoagulation.

Uncertainties in managing myocardial infarction associated with infective endocarditis

Embolic myocardial infarction is an uncommon but increasingly recognised complication of infective endocarditis. This complication has a high mortality rate and is deemed a relative contraindication to thrombolytic therapy. The present article describes an episode of acute myocardial infarction associated with infective endocarditis. Systemic thrombolytic therapy was administered, which resulted in resolution of cardiac ischemia but was complicated by a fatal intracerebral bleed. There are a number of published cases describing the use of systemic thrombolysis, primary percutaneous intervention and early valvular surgery in this circumstance, but the optimal course of treatment for myocardial infarction in the context of infective endocarditis remains to be elucidated. Additional guidance for those who are likely to encounter this condition in clinical practice would be welcomed.

Successful aspiration and thrombolytic therapy for acute superior mesenteric artery occlusion

To report a case of acute superior mesenteric artery (SMA) embolism successfully treated with aspiration and pharmacological thrombolysis. A 74-year-old female was admitted to the hospital with acute abdominal pain 5 hours in duration. Computed tomography angiography revealed a complete embolic occlusion distal to the first jejunal branch of the SMA. Aspiration and local continuous thrombolysis with urokinase resulted in near complete revascularization of the mesenteric flow after 4 hours and almost complete restoration after 20 hours. The patient made a complete recovery and continues to do well on warfarin therapy after treatment. Aspiration and thrombolytic therapy can be an alternative treatment modality in surgical high risk patient.

Intra-arterial thrombolysis using double devices: mechanicomechanical or chemicomechanical techniques

Objective

To optimize the recanalization of acute cerebral stroke that were not effectively resolved by conventional intraarterial thrombolysis (IAT), we designed a double device technique to allow for rapid and effective reopening. In this article, we describe the feasibility and efficacy of this technique.

Methods

From January 2008 to September 2009, twenty patients with acute cerebral arterial occlusion (middle cerebral artery : n=12; internal carotid artery terminus : n=5; basilar artery : n=3) were treated by the double device technique. This technique was applied when conventional thrombolytic methods using drug, microwires, microcatheters and balloons did not result in recanalization. In the double device technique, two devices are simultaneously placed at the lesion (for example, one microcatheter and one balloon or two microcatheters). Chemicomechanical or mechanicomechanical thrombolysis was performed simultaneously using various combinations of two devices. Recanalization rates, procedural time, complications, and clinical outcomes were analyzed.

Results

The initial median National Institute of Health Stroke Scale (NIHSS) was 16 (range 5-26). The double device technique was applied after conventional IAT methods failed. Recanalization was achieved in 18 patients (90%). Among them, 55% (11 cases) were complete (thrombolysis in cerebral infarction 2B, 3). The median thrombolytic procedural time including the conventional technique was 135±83.7 minutes (range 75-427). Major symptomatic hemorrhages (neurological deterioration ≥4 points in NIHSS) developed in two patients (10%). Good long term outcomes (modified Rankin Scale ≤2 at 90 days) occurred in 25% (n=5) of the cases. Mortality within 90 days developed in two cases (10%).

Conclusion

The double device technique is a feasible and effective technical option for large vessel occlusion refractory to conventional thrombolysis.

IV Thrombolysis-Bridging and Endovascular Treatment for Occlusive Internal Carotid Artery Dissection with Tandem Occlusion

Compared to other etiologies of ischemic stroke, occlusive internal carotid artery dissection responds worse to intravenous (IV) thrombolysis. Intracranial tandem occlusion is a predictor of poor outcome. A direct endovascular approach has been proposed as a safe and probably superior alternative to IV thrombolysis. However, it may lead to considerable treatment delays. We used rapidly initiated IV thrombolysis-bridging and subsequent endovascular treatment in two patients with severe hemispheric ischemia due to occlusive internal carotid artery dissection with tandem occlusion and achieved good outcomes. Minimizing recanalization times likely improves patient outcome and IV thrombolysis-bridging may be a reasonable strategy to achieve this. The positive initial results obtained with endovascular approaches and IV thrombolysis-bridging in this patient group deserve further scientific exploration.

Guidelines for the treatment of acute ischaemic stroke

INTRODUCTION

Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies.

DEVELOPMENT

Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible.

CONCLUSION

Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.

Hypoperfusion of an entire cerebral hemisphere - stroke or postictal deficit?

The clinical differential diagnosis between ischemic stroke and postictal deficit is sometimes challenging. If the clinical presentation is inconclusive, perfusion imaging can help to identify stroke patients for thrombolysis therapy. However, also epileptic phenomena may alter cerebral perfusion. Hypoperfusion spreading beyond the borders of cerebrovascular territories is usually considered suggestive of an etiology other than stroke. We present a patient whose clinical symptoms suggested a postictal deficit rather than an acute stroke. CT perfusion imaging showed hypoperfusion of the entire left cerebral hemisphere covering all vascular territories. CT angiography revealed occlusions in the ipsilateral internal carotid artery and in the circle of Willis as the cause of the global hypoperfusion. The patient was treated with i.v. thrombolysis and recovered with moderate disability. This is the first description of hyperacute ischemia of an entire cerebral hemisphere and its treatment with thrombolysis. It demonstrates the potential of modern neuroimaging in identifying atypically presenting strokes and shows that i.v. thrombolysis can be effectively and safely used to treat such potentially fatal insults.

Thrombolytic stroke treatment of a 12-year-old girl with intracranial fibromuscular dysplasia

Fibromuscular dysplasia, predominantly found in adult women, is a rare disease of small and middle-sized arteries of the kidney and brain. We present a case of a 12-year-old girl with acute ischemic stroke, due to fibromuscular dysplasia of the distal internal carotid artery and the proximal middle cerebral artery, which was successfully treated with t-PA.

Fibrinolytic therapy in acute stroke

Acute ischemic stroke is a major cause of morbidity and mortality in Europe, North America, and Asia. Its treatment has completely changed over the past decade with different interventional approaches, such as intravenous trials, intra-arterial trials, combined intravenous/intra-arterial trials, and newer devices to mechanically remove the clot from intracranial arteries. Intravenous thrombolysis with tissue plaminogen activator (tPA) within 4.5 hours of symptoms onset significantly improved clinical outcomes in patients with acute ischemic stroke. Pharmacological intra-arterial thrombolysis has been shown effective until 6 hours after middle cerebral artery occlusion and offers a higher rate of recanalization compared with intravenous thrombolysis, whereas combined intravenous/ intra-arterial thrombolysis seems to be as safe as isolated intravenous thrombolysis. The more recent advances in reperfusion therapies have been done in mechanical embolus disruption or removal. Merci Retriever and Penumbra System have been approved for clot removal in brain arteries, but not as a therapeutic modality for acute ischemic stroke since it is no clear whether mechanical thrombectomy improves clinical outcome in acute stroke. However, mechanical devices are being used in clinical practice for patients who are ineligible for tPA or who have failed to respond to intravenous tPA. We summarize the results of the major thrombolytic trials and the latest neurointerventional approaches to ischemic stroke.

The Comparison of Outcome between Thromboaspiration and Aggressive Mechanical Clot Disruption in Treating Hyperacute Stroke Patients

OBJECTIVE

Stroke is the third leading cause of death in the Republic of Korea. Time is the most important factor in hyperacute stroke. Yet, there had been no protocol for mechanical thrombolysis. We have treated patients with hyperacute stroke by mechanical thrombolysis for 3 years. In current study, we analyzed the outcome of mechanical thrombolysis.

METHODS

From March 2008 to February 2011, 36 patients were treated with mechanical thrombolysis. Initially we treated the patients by aggressive mechanical clot disruption (AMCD) who were admitted within 6 hours after the symptom onset. If revascularization was not achieved, balloon angioplasty was performed, followed by stenting or temporary endovascular bypass was performed. The result in 15 cases was not so successful. Since then, we started using the thromboaspiration method as the first line treatment of the mechanical thrombolysis.

RESULTS

After using the thromboaspiration, we had better results in recanalization rate, modified Rankin Score (mRS) and reperfusion injury compared to AMCD. The recanalization rate was 80.85%, mRS is 2.85, and there was only 0.09% hemorrhagic formation.

CONCLUSION

Even though thromboaspiration is not statistically significant due to the limited numbers of patients enrolled in this study, we think it is a good way in mechanical thronbolysis for hyperacute stroke.

Inter-rater reliability of modified Alberta Stroke program early computerized tomography score in patients with brain infarction

BACKGROUND

The Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) was used to detect significant early ischemic changes on brain CT of acute stroke patients. We designed the modified ASPECTS and compared it to the above system based on the inter-rater reliability.

METHODS

A cross-sectional validation study was conducted based on the inter-rater reliability. The CT images were chosen from the stroke data bank of Ghaem hospital, Mashhad in 2010. The inclusion criteria were the presence of middle cerebral artery territory infarction and performance of CT within 6 hours after stroke onset. Axial CT scans were performed on a third-generation CT scanner (Siemens, ARTX, Germany). Section thickness above posterior fossa was 10 mm (130 kV, 150 mAs). Films were made at window level of 35 HU. The brain CTs were scored by four independent radiologists based on the ASPECTS and modified ASPECTS. The readers were blind to clinical information except symptom side. Cochrane Q and Kappa tests served for statistical analysis.

RESULTS

24 CT scans were available and of sufficient quality. Difference in distribution of dichotomized ≤7 and >7 ASPECT scores between four raters was significant (Q=13.071, df=3, p=0.04). Distribution of dichotomized <6 and ≥6 scores based on modified ASPECT system between 4 raters was not significantly different (Q=6.349, df=3, p=0.096).

CONCLUSIONS

Modified ASPECT method is more reliable than ASPECTS in detecting major early ischemic changes in stroke patients candidated to tPA thrombolysis.

Leukoaraiosis on magnetic resonance imaging is related to long-term poor functional outcome after thrombolysis in acute ischemic stroke

OBJECTIVE

Leukoaraiosis (LA) has been suggested to be related to the poor outcome or the occurrence of symptomatic intracerebral hemorrhage (sICH) after acute ischemic stroke. We retrospectively investigated the influences of LA on long-term outcome and the occurrence of sICH after thrombolysis in acute ischemic stroke (AIS).

METHODS

In this study, we recruited 164 patients with AIS and magnetic resonance image (MRI)-detected thrombolysis. The presence and extent of LA were assessed using the Fazekas grading system. The National Institutes of Health Stroke Scale score was used to assess the baseline measure of neurologic severity, and the modified Rankin Scale score assessment was used up to 1 year after thrombolysis.

RESULTS

Of 164 subjects, 56 (34.2%) showed LA on MRI. Compared to the 108 patients without LA, the patients with LA were of much older age (p<0.01), had a higher prevalence of hypertension (p<0.01), and had a much poorer outcome at 90 days (p=0.05) and 1 yr (p=0.01) after thrombolysis. There were no significant differences in sICH between patients with and without LA on MRI. In univariate analysis for the occurrence of poor outcome at 90 days after thrombolysis, the size of ischemic lesion on diffusion weighted images (DWI), [odds ratio (OR), 1.03; 95% confidence interval (95% CI), 1.01-1.04; p<0.01], recanalization (OR, 0.03; 95% CI, 0.01-0.10; p<0.01), sICH (OR, 12.2; 95% CI, 1.54-95.8), neurologic severity (OR, 1.17; 95% CI, 1.09-1.25; p<0.01), blood glucose level (OR, 1.01; 95% CI, 1.00-1.02; p=0.03), and the presence of LA on MRI (OR, 2.01; 95% CI, 1.04-3.01; p=0.04) were statistically significant. In multivariate analysis, neurologic severity (OR, 1.14; 95% CI, 1.04-1.24; p<0.01), recanalization (OR, 0.03; 95% CI, 0.01-0.11; p<0.01), lesion size on DWI (OR, 1.02; 95% CI, 1.01-1.03; p=0.02), serum glucose level (OR, 1.01; 95% CI; 1.01-1.02; p=0.03), and the presence of LA on MRI (OR, 3.2; 95% CI, 1.22-8.48; p<0.01) showed statistically significant differences. These trends persisted up to 1 yr after thrombolysis.

CONCLUSION

In this study, we demonstrated that the presence of LA on MRI might be related to poor outcome after use of intravenous tissue plasminogen activator in AIS.

Ultrasound-Enhanced Thrombolysis: EKOS EndoWave Infusion Catheter System

The purpose of the EKOS EndoWave Infusion Catheter System is to enhance catheter-directed thrombolysis by accelerating the fibrinolytic process with the application of ultrasound. Improving the efficiency of the thrombolytic process reduces the treatment time and total lytic dose delivered, thereby lowering the overall cost of therapy and the risk of an associated bleeding complication.

Differentiating pharmacologic agents used in catheter-directed thrombolysis

The use of catheter-directed thrombolysis is a proven treatment for arterial ischemia, deep vein thrombosis, and severe pulmonary embolism. For arterial ischemia, thrombolysis has resulted in improved amputation-free survival and fewer subsequent surgeries to reestablish blood flow to the ischemic limb. The management of patients with thromboembolic diseases is complex, and the multiple thrombolytic drugs available to choose from compound this complexity. Although some believe the available thrombolytic agents are interchangeable, real biochemical differences exist that may prove otherwise. This article describes these pharmacologic differences and how they may affect the clinical practice of catheter-directed thrombolysis.

The kurashiki prehospital stroke scale is a prehospital scale that can predict long-term outcome of patients with acute cerebral ischemia

Background and Purpose

Our aim was to confirm the clinical relationship between the Kurashiki Prehospital Stroke Scale (KPSS) scored by paramedics and favorable outcomes in patients with modified Rankin scale (mRS) scores of 0–1 assessed 3 months after symptom onset.

Methods

We enrolled patients with acute stroke and transient ischemic attack showing symptoms on admission. Paramedics transferred patients to our hospital after estimating stroke severity using the KPSS. After categorizing patients into either the mRS 0–1 group (favorable outcome) or the mRS 2–6 group (no favorable outcome), we compared the background data between the two groups. We assessed KPSS scores predictive of a favorable outcome. Multivariate regression modeling was conducted to identify factors independently associated with a favorable outcome.

Results

The study cohort comprised 147 patients with a premorbid status of mRS 0–1: 69 patients (47%) of them were in the mRS 0–1 group and 78 (53%) in the mRS 2–6 group at the follow-up 3 months after symptom onset. The median KPSS score was lower in the mRS 0–1 group than in the mRS 2–6 group (1 vs. 4, p < 0.001). After classifying the 147 patients into KPSS tertiles with thresholds of 2 and 4, the frequency of mRS 0–1 gradually decreased with increasing KPSS score (lower KPSS, 67.2%; middle KPSS, 47.6%, and higher KPSS, 21.3%; p < 0.001). KPSS score <3 was able to predict a favorable outcome with 67% sensitivity and 71% specificity, and independently associated with mRS 0–1 (odds ratio, 3.0; 95% confidence interval, 1.2–7.3; p = 0.015).

Conclusion

KPSS score <3 apparently presents a reasonable cutoff for predicting a favorable outcome in patients with acute cerebral ischemia.

Intravenous Thrombolysis for Embolic Stroke due to Cardiac Myxoma

Cardiac myxoma is a rare but curable cause of ischemic stroke. Current guidelines do not address the use of intravenous thrombolysis for embolic stroke caused by cardiac myxoma. The risk of hemorrhage due to occult tumor emboli or microaneurysms is a major concern. We describe a 45-year-old man who had an embolic stroke in the left middle cerebral artery. The initial National Institutes of Health Stroke Scale (NIHSS) score was 16. He received intravenous thrombolysis 2 h and 52 min after stroke onset. No intracranial hemorrhage developed. A cardiac mass was found in the left atrium and removed surgically 84 h after stroke. Pathological study showed a myxoma with extensive hemorrhage and thrombus over the surface. At the 3-month follow-up, the NIHSS score was 9 and the modified Rankin scale score was 3. Our experience with this patient supports the hypothesis that intravenous thrombolysis may be safely used in the treatment of embolic stroke due to cardiac myxoma.

A large portal vein: a rare finding of recent portal vein thrombosis

Acute portal vein thrombosis (PVT) is rarely encountered by clinicians. The most common manifestation of acute PVT is sudden onset of abdominal pain. A computed tomography scan without contrast often shows a high-density material in the portal vein. After injection of contrast agents, absence of luminal enhancement and enlargement of the obstructed portal vein are shown. In this case report, we demonstrated a rare computed tomography finding in which the diameter of the main portal vein was enormously distended to 3-fold that of the aorta in a patient with recent PVT. Despite thrombolysis and anticoagulation were immediately given, portal venous recanalization was not achieved in the patient. After 5 years, variceal bleeding and ascites occurred and liver function had persistently deteriorated. Finally, he died of progressive liver failure. Considering this case, we suggest that an early decision for invasive interventional treatment might be necessary to both increase the rate of portal venous recanalization and improve prognosis, as anticoagulation and thrombolysis therapy failed to recanalize recent PVT.

Use of bivalirudin for heparin-induced thrombocytopaenia after thrombolysis in massive pulmonary embolism: a case report

A 68-year-old man was referred to the emergency department 6 h after onset of sudden acute dyspnoea. Immediate ECG showed sinus tachycardia with the typical S1-Q3-T3 pattern and incomplete right bundle branch block. The echocardiogram showed the presence of mobile thrombus in the right atrium, a distended right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Lung spiral computed tomography (CT) showed bilateral pulmonary involvement and confirmed the picture of a thrombotic system in the right atrium and caval vein. Thrombolytic treatment with recombinant tissue plasminogen activator (rt-PA) and heparin (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Six hours after thrombolysis bleeding gums and significant reduction in platelet count (around 50,000) were observed. Heparin was discontinued and bivalirudin (0.1 mg/kg bolus and 1.75 mg/kg per h infusion) plus warfarin was initiated and continued for 5 days until the international normalised ratio (INR) was within the therapeutic range (2.0–3.0) for 2 consecutive days, with concomitant platelet count normalisation. Lung spiral and lower abdominal CT before discharge did not show the presence of clots in the pulmonary arteries of the right and left lung. This case suggests that bivalirudin could offer promise for use in patients with heparin-induced thrombocytopaenia (HIT) after thrombolysis for massive pulmonary embolism.

GPIIb/IIIa Receptor Antagonism Using Small Molecules Provides no Additive Long-Term Protection after Percutaneous Coronary Intervention as Compared to Clopidogrel Plus Aspirin

Background:

There is some controversy as to whether tirofiban or eptifibatide, two small anti-aggregating drugs (AAD), may reduce the incidence of composite ischemic events within one year in patients undergoing percutaneous coronary intervention (PCI) in the real clinical world.

Methods:

We compared consecutive patients on oral double AAD (with clopidogrel and aspirin) who underwent PCI (n=207) and patients who were on single AAD and received a second AAD, just prior to PCI, and either high-dose tirofiban or double-bolus eptifibatide (double AAD plus small molecules group, n=666). The primary end point (incidence of composite ischemic events within one year) included death, acute myocardial infarction, unstable angina, stent thrombosis or repeat PCI or coronary bypass surgery (related to the target vessel PCI failure) and was modelled by Cox’s regression.

Results:

There were 89 composite ischemic events: 24 (11.6%) in double AAD alone and 65 (9.8%) in double AAD plus small molecules groups (log-rank test: p=0.36). Incidences by type of ischemic events were similar between the 2 groups. Based on 21 potential covariates fitted simultaneously, adjusted hazard ratios (HR and 95% confidence intervals) showed that age (HR 1.03, 1.01-1.06, p=0.01), diabetes (HR 1.68, 1.01-2.79, p=0.05) and intra aortic balloon pump (HR 5.12, 2.36-11.10, p=0.0001) were significant risk factors whereas thrombolysis by tenecteplase (HR 0.35, 0.13-0.98, p=0.05) and having had hypertension or anti-hypertensive treatment (HR 0.58, 0.36-0.93, p=0.03) were significant protectors for events. Whether small molecules were present provided a non significant additional benefit as compared to double AAD alone (HR 0.83, 0.51-1.36, p=0.46). Pre-PCI CK-MB were not useful to predict events (HR 1.01, 0.99-1.01, p=0.17).

Conclusions:

In clinical world patients undergoing PCI (rescue plus primary <13%) while on double AAD, based on clopidogrel plus aspirin, small molecules (tirofiban or eptifibatide) provided no additive long-term protection against the occurrence of composite ischemic events whereas thrombolysis by tenecteplase did.

Recanalization of an occluded intrahepatic portosystemic covered stent via the percutaneous transhepatic approach

A 41-year-old woman with liver cirrhosis had recurrent portal hypertension and bleeding from esophageal varices due to complete occlusion of a previously inserted transjugular intrahepatic portosystemic shunt stent. Because recanalization of the stent by the transjugular approach was unsuccessful, ultrasound-guided entry to the splenic vein and portal vein was used. After catheter-directed intrathrombus thrombolysis, successful opening of the stent was achieved and a stent was placed. We herein report a rare case in which thrombolysis and recanalization of a TIPS stent were performed via a percutaneous transhepatic approach.

Intra-arterial thrombolysis for central retinal artery occlusion: two cases report

Central retinal artery occlusion (CRAO) causes severe visual loss in affected eye and vision does not recover in more than 90% of the patients. It is believed that it occurs by occlusion of the central retinal artery with small emboli from atherosclerotic plaque of internal cerebral artery. Retina is a part of the brain, thus basically CRAO is corresponding to acute occlusion of intracerebral artery and retinal ischemia is to cerebral stroke. Therefore, intra-arterial thrombolysis (IAT) has been considered as a treatment method in CRAO. Recently, we treated 2 patients diagnosed as CRAO and could achieve complete recanalization on fundus fluorescein angiogram with IAT. Of them, one recovered visual acuity to 20/25. We report our 2 CRAO cases treated with IAT and discuss technical aspects for IAT and management of patient. To the best of our knowledge, this is the first Korean report of IAT for CRAO.

Catheter-directed thrombolysis with conventional aspiration thrombectomy for lower extremity deep vein thrombosis

PURPOSE

The purpose of this study is to evaluate treatment outcomes in patients with symptomatic deep vein thrombosis (DVT) who had undergone a catheter-directed thrombolysis with conventional aspiration thrombectomy for the treatment of lower extremity deep vein thrombosis.

MATERIALS AND METHODS

The authors retrospectively reviewed the records of 74 patients (mean age 61 +/- 15) that underwent a catheter-directed thrombolysis with conventional aspiration thrombectomy. A retrieval inferior vena cava (IVC) filter was placed to protect against a pulmonary embolism in 60 patients (81%). Stenting and balloon angioplasty were performed in 37 patients (50%) under the left common iliac vein compression.

RESULTS

Sixty-seven patients (91%) showed a clinical improvement within 48 hours, but seven patients (9%) showed no improvement. Multi detector computerized tomographic venography (MDCT venography) at discharge showed no thrombus in 15 patients (20%) and partial thrombus in 52 (70%). Twenty-eight patients (38%) developed post-thrombotic syndrome at 3.0 +/- 4.2 months postoperatively. Six patients (8%) were admitted due to DVT recurrence at a mean of 5.6 +/- 7.4 months postoperatively. Sixty-nine patients underwent follow up MDCT venography at 5.7 +/- 5.6 months. fifty (72%) of these showed no thrombus, 15 (22%) partial thrombus, and 4 (6%) showed obstruction. Twenty-eight of 61 (46%) were asymptomatic, twenty-eight (46%) had moderate improvement, and four (6%) were mildly improved by a telephone interview (81%) at 22.8 +/- 10.7 months postoperatively.

CONCLUSION

Catheter-directed thrombolysis with conventional aspiration thrombectomy is an effective treatment for lower extremity deep vein thrombosis and produces satisfactory clinical results.

Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis

AIM: To summarize our methods and experience with interventional treatment for symptomatic acute-subacute portal vein and superior mesenteric vein thrombosis (PV-SMV) thrombosis.

METHODS: Forty-six patients (30 males, 16 females, aged 17-68 years) with symptomatic acute-subacute portal and superior mesenteric vein thrombosis were accurately diagnosed with Doppler ultrasound scans, computed tomography and magnetic resonance imaging. They were treated with interventional therapy, including direct thrombolysis (26 cases through a transjugular intrahepatic portosystemic shunt; 6 through percutaneous transhepatic portal vein cannulation) and indirect thrombolysis (10 through the femoral artery to superior mesenteric artery catheterization; 4 through the radial artery to superior mesenteric artery catheterization).

RESULTS: The blood reperfusion of PV-SMV was achieved completely or partially in 34 patients 3-13 d after thrombolysis. In 11 patients there was no PV-SMV blood reperfusion but the number of collateral vessels increased significantly. Symptoms in these 45 patients were improved dramatically without severe operational complications. In 1 patient, the thrombi did not respond to the interventional treatment and resulted in intestinal necrosis, which required surgical treatment. In 3 patients with interventional treatment, thrombi re-formed 1, 3 and 4 mo after treatment. In these 3 patients, indirect PV-SMV thrombolysis was performed again and was successful.

CONCLUSION: Interventional treatment, including direct or indirect PV-SMV thrombolysis, is a safe and effective method for patients with symptomatic acute-subacute PV-SMV thrombosis.

Acute extensive portal and mesenteric venous thrombosis after splenectomy: Treated by interventional thrombolysis with transjugular approach

AIM: To present a series of cases with symptomatic acute extensive portal vein (PV) and superior mesenteric vein (SMV) thrombosis after splenectomy treated by transjugular intrahepatic approach catheter-directed thrombolysis.

METHODS: A total of 6 patients with acute extensive PV-SMV thrombosis after splenectomy were treated by transjugular approach catheter-directed thrombolysis. The mean age of the patients was 41.2 years. After access to the portal system via the transjugular approach, pigtail catheter fragmentation of clots, local urokinase injection, and manual aspiration thrombectomy were used for the initial treatment of PV-SMV thrombosis, followed by continuous thrombolytic therapy via an indwelling infusion catheter in the SMV, which was performed for three to six days. Adequate anticoagulation was given during treatment, throughout hospitalization, and after discharge.

RESULTS: Technical success was achieved in all 6 patients. Clinical improvement was seen in these patients within 12-24 h of the procedure. No complications were observed. The 6 patients were discharged 6-14 d (8 ± 2.5 d) after admission. The mean duration of follow-up after hospital discharge was 40 ± 16.5 mo. Ultrasound and contrast-enhanced computed tomography confirmed patency of the PV and SMV, and no recurrent episodes of PV-SMV thrombosis developed during the follow-up period.

CONCLUSION: Catheter-directed thrombolysis via transjugular intrahepatic access is a safe and effective therapy for the management of patients with symptomatic acute extensive PV-SMV thrombosis.