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Bücke P, Jung S, Kaesmacher J, Goeldlin MB, Horvath T, Prange U, Beyeler M, Fischer U, Arnold M, Seiffge DJ, Meinel TR. Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: A target trial analysis after the liberalization of institutional guidelines. Eur Stroke J 2024:23969873241252751. [PMID: 38738861 DOI: 10.1177/23969873241252751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy. PATIENTS AND METHODS We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT. RESULTS Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes. DISCUSSION AND CONCLUSION After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.
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Affiliation(s)
- Philipp Bücke
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martina B Goeldlin
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas Horvath
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Ulrike Prange
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Morin Beyeler
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David J Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas R Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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Mac Grory B, Holmes DN, Matsouaka RA, Shah S, Chang CWJ, Rison R, Jindal J, Holmstedt C, Logan WR, Corral C, Mackey JS, Gee JR, Bonovich D, Walker J, Gropen T, Benesch C, Dissin J, Pandey H, Wang D, Unverdorben M, Hernandez AF, Reeves M, Smith EE, Schwamm LH, Bhatt DL, Saver JL, Fonarow GC, Peterson ED, Xian Y. Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke. JAMA 2023; 329:2038-2049. [PMID: 37338878 PMCID: PMC10282891 DOI: 10.1001/jama.2023.8073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/25/2023] [Indexed: 06/21/2023]
Abstract
Importance Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications. Objective To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice. Design, Setting, and Participants Retrospective, observational cohort study based on the American Heart Association's Get With the Guidelines-Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32 715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included. Exposure VKA use within the 7 days prior to hospital arrival. Main Outcome and Measures The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice. Results Of 32 715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29 628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29 628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, -0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, -0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups. Conclusions and Relevance Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Roland A. Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Cherylee W. J. Chang
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Richard Rison
- Department of Neurology, USC Keck School of Medicine, Los Angeles, California
| | - Jenelle Jindal
- Department of Neurology, Peter C. Fung, MD, Stroke Center, El Camino Hospital, Mountain View, California
| | | | - William R. Logan
- Department of Neurology, Mercy Hospital of St Louis, St Louis, Missouri
| | - Candy Corral
- Department of Neurology, Huntington Memorial Hospital, Pasadena, California
| | - Jason S. Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Joey R. Gee
- Department of Neurology, St Joseph’s Heritage Medical Group, Irvine, California
| | - David Bonovich
- Department of Neurology, Sutter Health, Castro Valley, California
| | - James Walker
- Department of Anesthesiology, Critical Care, and Neurocritical Care, Ascension Via Christi Hospital and University of Kansas School of Medicine, Wichita
| | - Toby Gropen
- Department of Neurology, University of Alabama School of Medicine, Birmingham
| | - Curtis Benesch
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Jonathan Dissin
- Department of Neurology, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Hemant Pandey
- Department of Neurology, Banner Baywood Medical Center, Chandler, Arizona
| | - David Wang
- Department of Neurology, OSF Healthcare, Peoria, Illinois
| | - Martin Unverdorben
- Global Specialty Medical Affairs, Daiichi Sankyo Inc, Basking Ridge, New Jersey
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Eric E. Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
- Yale School of Medicine, New Haven, Connecticut
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New Nork, New York
| | | | - Gregg C. Fonarow
- Department of Medicine, University of California, Los Angeles
- Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California
| | - Eric D. Peterson
- Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Population and Data Science, UT Southwestern Medical Center, Dallas, Texas
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Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
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Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Fan ZX, Liu RX, Liu GZ. Development and refinement of diagnostic and therapeutic strategies for managing patients with cardiogenic stroke: An arduous journey. World J Clin Cases 2023; 11:719-724. [PMID: 36818629 PMCID: PMC9928701 DOI: 10.12998/wjcc.v11.i4.719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
Cardioembolic stroke, referred to as cardiogenic stroke, is a clinical syndrome in which emboli from the heart pass through the circulatory system and cause cerebral artery embolism and corresponding brain dysfunction. Compared to other subtypes of ischemic stroke, cardiogenic stroke presents with more etiologies, greater severity, worse prognosis, and a higher recurrence rate. In this minireview, we provide new insights into the etiological classification, diagnostic methods, and interventions of cardiogenic stroke.
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Affiliation(s)
- Ze-Xin Fan
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
| | - Ri-Xia Liu
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
| | - Guang-Zhi Liu
- Department of Neurology, Beijing Anzhen Hospital, Beijing 100029, China
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Siller T, Chandratheva A, Bücke P, Werring DJ, Seiffge D. Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option? Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients.
Recent Findings
Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients.
Summary
IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.
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Cao L, Tong X, Lu H. Successful intravenous thrombolysis in an acute ischemic stroke patient with contraindicating values of the international standardized ratio and prothrombin time. Acta Neurol Belg 2021; 121:1069-1072. [PMID: 33034829 PMCID: PMC8349323 DOI: 10.1007/s13760-020-01512-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Liming Cao
- Department of Neurology, The Third Affiliated Hospital of Shenzhen University, 47 Friendship Road, Luohu District, Shenzhen, 518000, China.
| | - Xibao Tong
- Department of Internal Medicine, People's Hospital of Xilin County, Baise, 533500, Guangxi, China
| | - Hua Lu
- Department of Internal Medicine, People's Hospital of Xilin County, Baise, 533500, Guangxi, China
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Seiffge DJ, Meinel T, Purrucker JC, Kaesmacher J, Fischer U, Wilson D, Wu TY. Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants. J Neurol Neurosurg Psychiatry 2021; 92:534-541. [PMID: 33542084 PMCID: PMC8053326 DOI: 10.1136/jnnp-2020-325456] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake-as a surrogate for anticoagulant activity-is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.
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Affiliation(s)
- David J Seiffge
- Stroke Research Center, Queen Square Institute of Neurology, London, UK .,Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | | | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric RadiologyUniversity Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Duncan Wilson
- Stroke Research Center, Queen Square Institute of Neurology, London, UK.,Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Teddy Y Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 444] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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9
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Meinel TR, Branca M, De Marchis GM, Nedeltchev K, Kahles T, Bonati L, Arnold M, Heldner MR, Jung S, Carrera E, Dirren E, Michel P, Strambo D, Cereda CW, Bianco G, Kägi G, Vehoff J, Katan M, Bolognese M, Backhaus R, Salmen S, Albert S, Medlin F, Berger C, Schelosky L, Renaud S, Niederhauser J, Bonvin C, Schaerer M, Mono ML, Rodic B, Tarnutzer AA, Mordasini P, Gralla J, Kaesmacher J, Engelter S, Fischer U, Seiffge DJ. Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation. Ann Neurol 2020; 89:42-53. [PMID: 32996627 PMCID: PMC7756294 DOI: 10.1002/ana.25917] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes. METHODS This was a cohort study of consecutive patients (2014-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0-2) at 3 months. RESULTS Of 8,179 patients (mean [SD] age, 79.8 [9.6] years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, [interquartile range 2-11]) compared with VKA (6, [2-14]) and controls (7, [3-15], p < 0.001; quantile regression: β -2.1, 95% confidence interval [CI] -2.6 to -1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 [63%]; adjusted odds ratio [aOR] 0.67; 95% CI 0.50-0.90) and particularly in patients on DOACs (69 of 464 [15%]; aOR 0.06; 95% CI 0.05-0.08) compared with controls (1,544 of 2,504 [74%]). sICH after IVT occurred in 3.6% (2.6-4.7%) of controls, 9 of 195 (4.6%; 1.9-9.2%; aOR 0.93; 95% CI 0.46-1.90) patients on VKA and 2 of 65 (3.1%; 0.4-10.8%, aOR 0.56; 95% CI 0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3-month outcome (aOR 1.24; 1.01-1.51). INTERPRETATION Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42-53.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mattia Branca
- Clinicial Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabeth Dirren
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital Zurich, Basel, Switzerland
| | | | | | | | | | | | | | - Ludwig Schelosky
- Neurology, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Susanne Renaud
- Neurology, Cantonal Hospital Neuchatel, Neuchâtel, Switzerland
| | | | | | | | | | - Biljana Rodic
- Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatic Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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10
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Huseynov A, Haselmann V, Kittel M, Bertsch T, Alonso A, Neumaier M, Borggrefe M, Hoffmann U. Lupus Antibody Mimicking Reduced Plasmatic Coagulation in a Patient With Atrial Fibrillation and Ischemic Stroke. Front Neurol 2020; 11:896. [PMID: 32973661 PMCID: PMC7472954 DOI: 10.3389/fneur.2020.00896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/13/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Lupus anticoagulant (LA) owns procoagulant properties in vivo and prolongs phospholipid-dependent clotting times in vitro. The prolonged in vitro clotting time can be misinterpreted as a bleeding disorder. In some cases, it is necessary to differentiate LA-associated in vitro changes from in vivo coagulation factor deficiency. In this case, we used different laboratory testing in a patient with ischemic stroke and reduced prothrombin time (PT) to identify an in-vitro effect of LA excluding an in-vivo bleeding disorder. Methods: The activity of various coagulation factors was evaluated both with recombinant thromboplastin Innovin (Siemens Healthcare) and reagent tissue extracted thromboplastin Thromborel® (Siemens Healthcare). Moreover, a 1:1 plasma mixing test with standard plasma was performed. In order to exclude the interaction of tromboplastin and LA thromboplastin, an independent global coagulation test, thromboelastography, was used. Diluted-Russel-Viper-Venom (dRVVT) assay was applied to detect the presence of LA detection. Results: The activity of several coagulation factors measured with recombinant thromboplastin Innovin (Siemens Healthcare) showed a reduced activity of the following coagulation factors: Factor V (20.9%), Factor VII (23.8%), Factor X (19.7%) and international normalized ratio (INR) of 2.33. Re-assessment of the factor's activity with another reagent tissue extracted thromboplastin Thromborel® (Siemens Healthcare) showed a normalization of INR and factor's activity in comparison to thromboplastin reagent Innovin®: Factor V (77%), Factor VII (45.4%), Factor X (64.2%), and INR of 1.28. A plasma mixing study with 1:1 standard plasma revealed reduced (<50%) normalization of INR as well as coagulation factor's activity confirming a LA-inhibitor in the patient plasma. Diagnostic LA testing was also performed with dRVVT assay showing a significantly prolonged (112.8 s) test time. Thromboelastography revealed no abnormalities. Conclusions: Different thromboplastin reagents and plasma mixing tests as well as thromboplastin independent coagulation tests may be helpful to differentiate LA and in vitro changes from in vivo factor deficiency in patients with LA.
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Affiliation(s)
- Aydin Huseynov
- First Department of Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.,DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung - German Centre for Cardiovascular Research), Mannheim, Germany
| | - Verena Haselmann
- Medical Faculty Mannheim, Institute for Clinical Chemistry, University of Heidelberg, Mannheim, Germany
| | - Maximillian Kittel
- Medical Faculty Mannheim, Institute for Clinical Chemistry, University of Heidelberg, Mannheim, Germany
| | - Thomas Bertsch
- Laboratory Medicine and Transfusion Medicine, Institute of Clinical Chemistry, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Neumaier
- Medical Faculty Mannheim, Institute for Clinical Chemistry, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.,DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung - German Centre for Cardiovascular Research), Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.,DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung - German Centre for Cardiovascular Research), Mannheim, Germany
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11
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Li Z, Su J, Zhang S, Du H, Tang Y, Duan J, Chen Z. Is intravenous thrombolysis safe for acute ischemic stroke patients taking warfarin with INR 1.9?: A case report. Medicine (Baltimore) 2020; 99:e19358. [PMID: 32150076 PMCID: PMC7478538 DOI: 10.1097/md.0000000000019358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR > 1.7 or PT > 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9. PATIENT CONCERNS A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92. DIAGNOSIS Acute ischemic stroke. INTERVENTIONS The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered. OUTCOME The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life. CONCLUSION The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients.
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Affiliation(s)
| | - Jing Su
- Department of Hematology, Mianyang Central Hospital, Mianyang, China
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12
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Best JG, Bell R, Haque M, Chandratheva A, Werring DJ. Atrial fibrillation and stroke: a practical guide. Pract Neurol 2019; 19:208-224. [PMID: 30826740 DOI: 10.1136/practneurol-2018-002089] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neurologists and stroke physicians will be familiar with atrial fibrillation as a major cause of ischaemic stroke, and the role of anticoagulation in preventing cardioembolic stroke. However, making decisions about anticoagulation for individual patients remains a difficult area of clinical practice, balancing the serious risk of ischaemic stroke against that of major bleeding, particularly intracranial haemorrhage. Atrial fibrillation management requires interdisciplinary collaboration with colleagues in cardiology and haematology. Recent advances, especially the now-widespread availability of direct oral anticoagulants, have brought opportunities to improve stroke care while posing new challenges. This article gives an overview of the contemporary diagnosis and management of atrial fibrillation, and the associated evidence base. Where there is uncertainty, we describe our own approach to these areas, while highlighting ongoing research that will likely guide future practice.
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Affiliation(s)
- Jonathan Gordon Best
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK
| | - Robert Bell
- Institute of Cardiovascular Science, University College London, London, UK
| | - Mohammed Haque
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arvind Chandratheva
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - David John Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK .,Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
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13
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Diener HC, Aisenberg J, Ansell J, Atar D, Breithardt G, Eikelboom J, Ezekowitz MD, Granger CB, Halperin JL, Hohnloser SH, Hylek EM, Kirchhof P, Lane DA, Verheugt FWA, Veltkamp R, Lip GYH. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 2. Eur Heart J 2018; 38:860-868. [PMID: 26848150 DOI: 10.1093/eurheartj/ehw069] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/09/2015] [Indexed: 12/11/2022] Open
Abstract
The choice of oral anticoagulant (OAC) for patients with atrial fibrillation (AF) may be influenced by individual clinical features or by patterns of risk factors and comorbidities. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. non-vitamin K oral anticoagulants (NOACs) for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In addition, we discuss the timing of initiation of anticoagulation. In the second of a two-part review, we discuss the use of NOAC for stroke prevention in the following subgroups of patients with AF: (vii) secondary stroke prevention in patients after stroke or transient ischaemic attack (TIA), (viii) patients with acute stroke requiring thrombolysis or thrombectomy, (ix) those initiating or restarting OAC treatment after stroke or TIA, (x) those with renal impairment on dialysis, (xi) the elderly, (xii) those at high risk of gastrointestinal bleeding, and (xiii) those with hypertension. In addition, we discuss adherence and compliance. Finally, we present a summary of treatment suggestions. In specific subgroups of patients with AF, evidence supports the use of particular NOACs and/or particular doses of anticoagulant. The appropriate choice of treatment for these subgroups will help to promote optimal clinical outcomes.
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Affiliation(s)
| | | | - Jack Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, USA
| | - Dan Atar
- Division of Medicine, Oslo University Hospital, Ullevål and University of Oslo, Norway
| | - Günter Breithardt
- Division of Rhythmology, Department of Cardiovascular Medicine, Hospital of the University Münster, Münster, Germany
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael D Ezekowitz
- Cardiovascular Research Foundation, New York, NY, USA.,Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.,Lankenau Medical Center, Wynnewood, PA, USA
| | | | - Jonathan L Halperin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK.,Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | - Deirdre A Lane
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Gregory Y H Lip
- University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Lee JM, Joung B, Cha MJ, Lee JH, Lim WH, Kim TH, Shin SY, Uhm JS, Lim HE, Kim JB, Kim JS. 2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial Fibrillation. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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15
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Lyden PD. When less is more (brain)-comment on "Rivaroxaban plasma levels in acute ischemic stroke and intracerebral hemorrhage". Ann Neurol 2018; 83:446-448. [PMID: 29394506 DOI: 10.1002/ana.25163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/30/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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16
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Alanazy MH, Barakeh RB, Asiri A, Edrees MF, Abuzinadah AR, Aljafen BN, Muayqil T. Practice Patterns and Barriers for Intravenous Thrombolysis: A Survey of Neurologists in Saudi Arabia. Neurol Res Int 2018; 2018:1695014. [PMID: 29666704 PMCID: PMC5831958 DOI: 10.1155/2018/1695014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/03/2018] [Accepted: 01/18/2018] [Indexed: 02/04/2023] Open
Abstract
Only a small fraction of patients with acute ischemic stroke receive intravenous thrombolysis (IVT). We sought to assess barriers and practice patterns in using IVT for acute ischemic stroke among neurologists in Saudi Arabia. An electronic survey was sent to all neurologists registered with the Saudi Commission for Health Specialties. A total of 148 (77.5%) neurologists responded. The most common reported barriers for IVT administration were delayed presentation to hospitals (82.4%) and unclear time of symptom onset (50.0%). Only 9.9% of neurologists reported strict adherence to the American Heart Association/American Stroke Association guidelines for IVT administration. The most frequently waived criteria were "minor stroke with National Institutes of Health Stroke Scale [NIHSS] < 5" (49.4%) and "seizure at onset" (45.7%). For the extended 3-4.5-hour window, 18.5% of neurologists reported strict adherence to the four exclusion criteria. The most frequently waived criteria were "age older than 80 years" (53.1%) and "history of both diabetes and prior stroke" (42.0%). In conclusion, most neurologists do not adhere to the IVT exclusion criteria. However, little consensus exists regarding which criteria do not interfere with IVT administration. Barriers to IVT administration were identified and require immediate action by healthcare authorities in Saudi Arabia.
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Affiliation(s)
- Mohammed H. Alanazy
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rima B. Barakeh
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alanood Asiri
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maha F. Edrees
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad R. Abuzinadah
- Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bandar N. Aljafen
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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17
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Dolscheid-Pommerich RC, Dolscheid S, Eichhorn L, Stoffel-Wagner B, Graeff I. Thrombolysis in stroke patients: Comparability of point-of-care versus central laboratory international normalized ratio. PLoS One 2018; 13:e0190867. [PMID: 29320558 PMCID: PMC5761884 DOI: 10.1371/journal.pone.0190867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 12/21/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In acute stroke patients, thrombolysis is one gold standard therapy option within the first four hours after the ischemic event. A contraindication for thrombolysis is an International Normalized Ratio (INR) value >1.7. Since time is brain, rapid and reliable INR results are fundamental. Aim was to compare INR values determined by central laboratory (CL) analyzer and Point-of-Care Testing(POCT)-device and to evaluate the quality of POCT performance in cases of potential therapeutic thrombolysis at a certified stroke unit. METHODS In 153 patients INR measurements using POCT-devices (HEMOCHRON Signature Elite®) were compared to INR measurements (BCS®XP) performed at the central laboratory. Outlier evaluation was performed regarding the critical thrombolysis cut-off. RESULTS Overall, we demonstrated a significant correlation (r = 0.809, p<0.0001) between both measurement methods. Mean value of the absolute difference between CL-INR and POCT-INR measurements was 0.23. In 95.4% of these cases, no differences regarding the critical cut-off (INR 1.7) were observed. POCT-INR values tended to be higher than the CL-INR values (p = 0.01). In 4.6% cases, a different value regarding thrombolysis cut-off was found. All patients were >75 years. CONCLUSIONS POCT-INR measurements based on our POCT concept are suitable to determine INR values in critical stroke patients. Nevertheless, outlier evaluation is mandatory.
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Affiliation(s)
| | - Sarah Dolscheid
- Department of Rehabilitation and Special Education, University of Cologne, Köln, Germany
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Birgit Stoffel-Wagner
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Ingo Graeff
- Center Clinician Scientist, Emergency Department, University Hospital Bonn, Bonn, Germany
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18
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Mundiyanapurath S, Hees K, Ahmed N, Wahlgren N, Uhlmann L, Kieser M, Ringleb PA, Hacke W, Nagel S. Predictors of symptomatic intracranial haemorrhage in off-label thrombolysis: an analysis of the Safe Implementation of Treatments in Stroke registry. Eur J Neurol 2017; 25:340-e11. [PMID: 29105904 DOI: 10.1111/ene.13507] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) is the only approved pharmacological treatment for acute ischemic stroke. Off-label IVT for ischemic stroke is common. We aimed to analyse its safety in a large database. METHODS This was a retrospective analysis of the safe implementation of treatments in stroke (SITS) thrombolysis registry with regard to 11 off-label criteria according to the European licence for alteplase. Symptomatic intracranial haemorrhage (SICH) according to SITS was defined as primary safety endpoint and SICH according to the European Cooperative Acute Stroke Study (ECASS II) definition and the National Institute of Neurological Disorders and Stroke definition as secondary safety endpoints. Multivariable logistic regression analyses after replacing missing values using multiple imputations were performed. RESULTS Patients from 793 centres in 44 countries were included, mainly (95%) in Europe. A total of 56 258 patients who were treated with intravenous alteplase were included. Median age was 71 (IQR 61-78) years and median National Institutes of Health Stroke Scale score was 12 (IQR 7-17). A total of 16 740 (30%) patients received off-label IVT and 1037 (1.8%) patients suffered from SICH according to the SITS definition (SICH SITS). Median percentage of missing values per variable was 0.4%. The only two off-label criteria constituting independent positive and negative predictors for SICH SITS were high blood pressure (odds ratio, 1.39; 95% confidence interval, 1.08-1.80; P = 0.012) and minor stroke (odds ratio, 0.51; 95% confidence interval, 0.33-0.78; P = 0.002). Very severe stroke, previous stroke and diabetes, age and high glucose levels were additional independent predictors of SICH according to the ECASS II and National Institute of Neurological Disorders and Stroke definitions. CONCLUSIONS Thrombolysis appears to be safe with regard to SICH for most of the off-label criteria, especially for minor stroke, but is risky in patients with high blood pressure. Individual risk-benefit evaluation should be performed.
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Affiliation(s)
| | - K Hees
- Institute of Medical Biometry and Informatics, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - N Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm.,Department of Neurology, Karolinska University Hospital-Solna, Stockholm, Sweden
| | - N Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm.,Department of Neurology, Karolinska University Hospital-Solna, Stockholm, Sweden
| | - L Uhlmann
- Institute of Medical Biometry and Informatics, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - M Kieser
- Institute of Medical Biometry and Informatics, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg
| | - W Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg
| | - S Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg
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Hankey GJ. Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants. Thromb Haemost 2017; 111:808-16. [DOI: 10.1160/th13-09-0741] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 10/15/2013] [Indexed: 11/05/2022]
Abstract
SummaryThis review article discusses the following, as yet unanswered, questions and research priorities to optimise patient management and stroke prevention in atrial fibrillation with the new direct oral anticoagulants (NOACs): 1. In patients prescribed a NOAC, can the anticoagulant effects or plasma concentrations of the NOACs be measured rapidly and reliably and, if so, can “cut-off points” between which anticoagulation is therapeutic (i.e. the “therapeutic range”) be defined? 2. In patients who are taking a NOAC and bleeding (e.g. intracerebral haemorrhage), can the anticoagulant effects of the direct NOACs be reversed rapidly and, if so, can NOAC-associated bleeding and complications be minimised and patient outcome improved? 3. In patients taking a NOAC who experience an acute ischaemic stroke, to what degree of anticoagulation or plasma concentration of NOAC, if any, can thrombolysis be administered safely and effectively? 4. In patients with a recent cardioembolic ischaemic stroke, what is the optimal time to start (or re-start) anticoagulation with a NOAC (or warfarin)? 5. In anticoagulated patients who experience an intracranial haemorrhage, can anticoagulation with a NOAC be re-started safely and effectively, and if so when? 6. Are the NOACs effective and safe in multimorbid geriatric people (who commonly have atrial fibrillation and are at high risk of stroke but also bleeding)? 7. Can dose-adjusted NOAC therapy augment the established safety and efficacy of fixed-dose unmonitored NOAC therapy? 8. Is there a dose or dosing regimen for each NOAC that is as effective and safe as adjusted-dose warfarin for patients with atrial fibrillation who have mechanical prosthetic heart valves? 9. What is the long-term safety of the NOACs?
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Seiffge DJ, Traenka C, Polymeris AA, Thilemann S, Wagner B, Hert L, Müller MD, Gensicke H, Peters N, Nickel CH, Stippich C, Sutter R, Marsch S, Fisch U, Guzman R, De Marchis GM, Lyrer PA, Bonati LH, Tsakiris DA, Engelter ST. Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice. J Stroke 2017; 19:347-355. [PMID: 28877563 PMCID: PMC5647628 DOI: 10.5853/jos.2017.00395] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/25/2017] [Accepted: 05/22/2017] [Indexed: 12/29/2022] Open
Abstract
Background and Purpose Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) or endovascular treatment (EVT). Methods This was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were <20 ng/mL, 20‒100 ng/mL, and >100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage. Results Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range [IQR] 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment. Conclusions Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.
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Affiliation(s)
- David J Seiffge
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandros A Polymeris
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lisa Hert
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mandy D Müller
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nils Peters
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Christoph Stippich
- Neuroradiology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Urs Fisch
- Neurosurgery and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Raphael Guzman
- Neurosurgery and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dimitrios A Tsakiris
- Department of Diagnostic Hematology, University Hospital Basel, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, University of Basel, Basel, Switzerland
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21
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Liu Y, Zheng Y, Karatas H, Wang X, Foerch C, Lo EH, van Leyen K. 12/15-Lipoxygenase Inhibition or Knockout Reduces Warfarin-Associated Hemorrhagic Transformation After Experimental Stroke. Stroke 2017; 48:445-451. [PMID: 28057806 DOI: 10.1161/strokeaha.116.014790] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/17/2016] [Accepted: 11/16/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE For stroke prevention, patients with atrial fibrillation typically receive oral anticoagulation. The commonly used anticoagulant warfarin increases the risk of hemorrhagic transformation (HT) when a stroke occurs; tissue-type plasminogen activator treatment is therefore restricted in these patients. This study was designed to test the hypothesis that 12/15-lipoxygenase (12/15-LOX) inhibition would reduce HT in warfarin-treated mice subjected to experimental stroke. METHODS Warfarin was dosed orally in drinking water, and international normalized ratio values were determined using a Coaguchek device. C57BL6J mice or 12/15-LOX knockout mice were subjected to transient middle cerebral artery occlusion with 3 hours severe ischemia (model A) or 2 hours ischemia and tissue-type plasminogen activator infusion (model B), with or without the 12/15-LOX inhibitor ML351. Hemoglobin was determined in brain homogenates, and hemorrhage areas on the brain surface and in brain sections were measured. 12/15-LOX expression was detected by immunohistochemistry. RESULTS Warfarin treatment resulted in reproducible increased international normalized ratio values and significant HT in both models. 12/15-LOX knockout mice suffered less HT after severe ischemia, and ML351 reduced HT in wild-type mice. When normalized to infarct size, ML351 still independently reduced hemorrhage. HT after tissue-type plasminogen activator was similarly reduced by ML351. CONCLUSIONS In addition to its benefits in infarct size reduction, 12/15-LOX inhibition also may independently reduce HT in warfarin-treated mice. ML351 should be further evaluated as stroke treatment in anticoagulated patients suffering a stroke, either alone or in conjunction with tissue-type plasminogen activator.
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Affiliation(s)
- Yu Liu
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.).,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Yi Zheng
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.).,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Hulya Karatas
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.).,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Xiaoying Wang
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.).,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Christian Foerch
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.).,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Eng H Lo
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.).,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Klaus van Leyen
- From the Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.L., Y.Z., H.K., X.W., E.H.L., K.v.L.); Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, China (Y.L.); and Department of Neurology, Goethe University, Frankfurt am Main, Germany (C.F.). .,Dr Karatas: Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey.
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22
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Thomson RG, De Brún A, Flynn D, Ternent L, Price CI, Rodgers H, Ford GA, Rudd M, Lancsar E, Simpson S, Teah J. Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BackgroundIntravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.ObjectivesTo identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.MethodsA discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.ResultsA total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).LimitationsWe anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.ConclusionsThere was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.Future workThe nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Aoife De Brún
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Matthew Rudd
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Emily Lancsar
- Centre for Health Economics, Monash University, Melbourne, VIC, Australia
| | | | - John Teah
- The Stroke Association, Gateshead, UK
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23
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Kepplinger J, Prakapenia A, Barlinn K, Siegert G, Gehrisch S, Zerna C, Beyer-Westendorf J, Puetz V, Reichmann H, Siepmann T, Bodechtel U. Standardized use of novel oral anticoagulants plasma level thresholds in a new thrombolysis decision making protocol. J Thromb Thrombolysis 2016; 41:293-300. [PMID: 26001908 DOI: 10.1007/s11239-015-1229-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) patients receiving non-vitamin-K antagonist oral anticoagulants (NOAC) are commonly excluded from thrombolytic therapy, as interpretation of coagulation tests remains unclear. We aimed to investigate the applicability of a novel institutional protocol for thrombolysis based on current expert recommendations and NOAC specific coagulation assessment. We included hospitalized AIS patients receiving NOAC for at least 24 h and consecutive AIS patients not receiving NOAC into a prospective study. We performed standard coagulation tests and specific tests for dabigatran, rivaroxaban and apixaban plasma levels. We studied 65 patients: mean age 72 ± 13 years, 30 (46 %) male, median NIHSS score 3 (IQR 6). Fifteen (23 %) were on NOAC treatment (5 dabigatran, 5 rivaroxaban, and 5 apixaban, respectively) and 50 (77 %) were not. In patients without NOAC, dabigatran was not detectable (0 ng/ml), and plasma levels of rivaroxaban (median: 10.0 ng/ml, IQR 7.0) and apixaban (7.2 ng/ml, IQR 6.7) were below our lower thresholds that allow thrombolysis. In patients with dabigatran pre-treatment, trough levels (58.0 ng/ml, IQR 143.0) were below our upper threshold that would allow thrombolysis in 3/5 patients. In patients receiving rivaroxaban, trough level (68.0 ng/ml, IQR 64.0) was below our predefined upper thresholds that would allow thrombolysis in 4/5 patients. In all patients on apixaban, trough level was above our predefined threshold of 40 ng/ml that precludes thrombolysis (98.2 ng/ml, IQR 84.3). Predefined thresholds of NOAC plasma levels in the decision of thrombolysis in NOAC treated AIS patients might supplement routine coagulation tests and should be validated in a larger study population.
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Affiliation(s)
- Jessica Kepplinger
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Alexandra Prakapenia
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Gabriele Siegert
- Institute of Clinical Chemistry and Laboratory Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Siegmund Gehrisch
- Institute of Clinical Chemistry and Laboratory Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Charlotte Zerna
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jan Beyer-Westendorf
- Department of Internal Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ulf Bodechtel
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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24
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Diener HC, Kleinschnitz C. Non-Vitamin K Oral Anticoagulants in Stroke Patients: Practical Issues. J Stroke 2016; 18:138-45. [PMID: 27165264 PMCID: PMC4901954 DOI: 10.5853/jos.2016.00157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/08/2016] [Accepted: 03/20/2016] [Indexed: 01/17/2023] Open
Abstract
Non-vitamin-K oral anticoagulants (NOACs) represent a major advance in the prevention of stroke in patients with atrial fibrillation (AF), offering a similar, if not superior, efficacy and safety profile and several practical advantages over oral vitamin K antagonists (VKAs). The rapid onset of action of the NOACs, their relatively short half-live, and the availability of specific reversal agents may be advantageous when managing acute ischemic strokes, and in the post-stroke, post-transient ischemic attack, and post-intracranial hemorrhage settings. In this review article, we offer practical guidance on the use of NOACs in these settings, focusing on managing the acute event and on initiating or resuming anticoagulation for secondary prevention. We also assess the use of NOACs to prevent stroke and bleeding in patients with AF who have chronic kidney disease, are elderly, or cognitively impaired, and we offer guidance on optimizing the use of NOACs and VKAs in these patient groups in the absence of evidence-based guidelines.
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25
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Mazya MV, Lees KR, Collas D, Rand VM, Mikulik R, Toni D, Wahlgren N, Ahmed N. IV thrombolysis in very severe and severe ischemic stroke: Results from the SITS-ISTR Registry. Neurology 2015; 85:2098-106. [PMID: 26546630 DOI: 10.1212/wnl.0000000000002199] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 08/03/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To study the safety of off-label IV thrombolysis in patients with very severe stroke (NIH Stroke Scale [NIHSS] scores >25) compared with severe stroke (NIHSS scores 15-25), where treatment is within European regulations. METHODS Data were analyzed from 57,247 patients with acute ischemic stroke receiving IV tissue plasminogen activator in 793 hospitals participating in the Safe Implementation of Thrombolysis in Stroke (SITS) International Stroke Thrombolysis Registry (2002-2013). Eight hundred sixty-eight patients (1.5%) had NIHSS scores >25 and 19,995 (34.9%) had NIHSS scores 15-25. Outcome measures were parenchymal hemorrhage, symptomatic intracerebral hemorrhage, mortality, and functional outcome. RESULTS Parenchymal hemorrhage occurred in 10.7% vs 11.0% (p = 0.79), symptomatic intracerebral hemorrhage per SITS-MOST (SITS-Monitoring Study) in 1.4% vs 2.5% (p = 0.052), death at 3 months in 50.4% vs 26.9% (p < 0.001), and functional independence at 3 months in 14.0% vs 29.0% (p < 0.001) of patients with NIHSS scores >25 and NIHSS scores 15-25, respectively. Multivariate adjustment did not change findings from univariate comparisons. Posterior circulation stroke was more common in patients with NIHSS scores >25 (36.2% vs 7.4%, p < 0.001), who were also more often obtunded or comatose on presentation (58.4% vs 7.1%, p < 0.001). Of patients with NIHSS scores >25, 26.2% were treated >3 hours from symptom onset vs 14.5% with NIHSS scores of 15-25. CONCLUSIONS Our data show no excess risk of cerebral hemorrhage in patients with NIHSS score >25 compared to score 15-25, suggesting that the European contraindication to IV tissue plasminogen activator treatment at NIHSS levels >25 may be unwarranted. Increased mortality and lower rates of functional independence in patients with NIHSS score >25 are explained by higher stroke severity, impaired consciousness on presentation due to posterior circulation ischemia, and longer treatment delays.
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Affiliation(s)
- Michael V Mazya
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy.
| | - Kennedy R Lees
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
| | - David Collas
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
| | - Viiu-Marika Rand
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
| | - Robert Mikulik
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
| | - Danilo Toni
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
| | - Nils Wahlgren
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
| | - Niaz Ahmed
- From the Department of Neurology (M.V.M., N.W., N.A.), Karolinska University Hospital, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Acute Stroke Unit & Cerebrovascular Clinic (K.R.L.), Institute of Cardiovascular & Medical Sciences, University of Glasgow; Stroke Unit (D.C.), Watford General Hospital, UK; Department of Neurology (V.-M.R.), North Estonia Medical Centre, Tallinn, Estonia; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital, Brno, Czech Republic; and Department of Neurology and Psychiatry (D.T.), Sapienza University of Rome, Italy
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Fluri F, Fleischer M, Kleinschnitz C. Accidental Thrombolysis in a Stroke Patient Receiving Apixaban. Cerebrovasc Dis Extra 2015; 5:55-6. [PMID: 26120321 PMCID: PMC4464016 DOI: 10.1159/000375181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 01/09/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
- Felix Fluri
- Department of Neurology, University Clinic Würzburg, Würzburg, Germany
| | - Michael Fleischer
- Department of Neurology, University Clinic Würzburg, Würzburg, Germany
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Bornkamm K, Harloff A. Safe intravenous thrombolysis in acute stroke despite treatment with rivaroxaban. J Clin Neurosci 2014; 21:2012-3. [DOI: 10.1016/j.jocn.2014.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/01/2014] [Accepted: 03/08/2014] [Indexed: 01/28/2023]
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Hankey GJ, Norrving B, Hacke W, Steiner T. Management of acute stroke in patients taking novel oral anticoagulants. Int J Stroke 2014; 9:627-32. [PMID: 24891030 PMCID: PMC4149783 DOI: 10.1111/ijs.12295] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/07/2014] [Indexed: 12/18/2022]
Abstract
Each year, 1·0–2·0% of individuals with atrial fibrillation and 0·1–0·2% of those with venous thromboembolism who are receiving one of the novel oral anticoagulants (dabigatran, rivaroxaban, or apixaban) can be expected to experience an acute ischemic stroke. Additionally, 0·2–0·5% of individuals with atrial fibrillation who are receiving one of the novel oral anticoagulants can be expected to experience an intracranial hemorrhage. This opinion piece addresses the current literature and offers practical approaches to the management of patients receiving novel oral anticoagulants who present with an ischemic or hemorrhagic stroke. Specifically, we discuss the role of thrombolysis in anticoagulated patients with acute ischemic stroke and factors to consider concerning restarting anticoagulation after acute ischemic and hemorrhagic stroke.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia
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Mechanical thrombectomy in acute ischemic stroke-experience from 6 years of practice. Neuroradiology 2014; 56:477-86. [PMID: 24687568 PMCID: PMC4070491 DOI: 10.1007/s00234-014-1353-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 03/11/2014] [Indexed: 11/30/2022]
Abstract
Introduction We present our results from the first 6 years with mechanical thrombectomy in the treatment of ischemic stroke. Methods Every patient treated with mechanical thrombectomy for acute ischemic stroke from September 2005 to December 2011 was consecutively included in this retrospective analysis. Baseline and outcome data were retrieved from computerized records at the hospital. National Institute of Health Stroke Scale (NIHSS) score and the modified Rankin Scale (mRS) score were used as outcome parameters. Favorable outcome was defined as a mRS score of 0–2, corresponding to independence in activities of daily living. We also evaluated revascularization and severe adverse events, with focus on symptomatic intracranial hemorrhage. Results Good functional outcome (mRS 0–2) was achieved in 50 % (120/240) of all patients. For patients with no neurological deficit prior to stroke onset (i.e., mRS = 0 before stroke), the proportion with good functional outcome was 54 %. Symptomatic hemorrhages occurred in 4.6 % of the cases (5.7 % in the anterior circulation). Conclusion In summary, our results supports that mechanical thrombectomy is a safe and effective method to restore blood flow in selected patients suffering from an acute ischemic stroke.
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Seiffge DJ, Traenka C, Gensicke H, Tsakiris DA, Bonati LH, Peters N, Lyrer P, Engelter ST. Intravenous thrombolysis in stroke patients receiving rivaroxaban. Eur J Neurol 2013; 21:e3-4. [DOI: 10.1111/ene.12285] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- D. J. Seiffge
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
| | - C. Traenka
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
| | - H. Gensicke
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
| | - D. A. Tsakiris
- Diagnostic Haematology; University Hospital Basel; Basel Switzerland
| | - L. H. Bonati
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
| | - N. Peters
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
| | - P. Lyrer
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
| | - S. T. Engelter
- Neurology and Stroke Center; University Hospital Basel; Basel Switzerland
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