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Miyoshi K, Akamatsu Y, Fujimoto K, Kojima D, Chida K, Kashimura H, Sato M, Itabashi R, Ogasawara K. Endovascular treatment for secondary basilar occlusion caused by spontaneous thrombus migration from the vertebral artery: Two case reports. Radiol Case Rep 2024; 19:5248-5252. [PMID: 39280741 PMCID: PMC11399790 DOI: 10.1016/j.radcr.2024.08.006] [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: 04/04/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/18/2024] Open
Abstract
Thrombus migration is a well-known clinical condition that occurs before mechanical thrombectomy and after intravenous thrombolysis in patients with anterior circulation strokes. Although thrombus migration from the vertebral artery (VA) can result in life-threatening basilar artery (BA) occlusion, its occurrence in the posterior circulation has rarely been discussed. Two patients with secondary BA occlusion caused by spontaneous thrombus migration from the VA are presented. A 60-year-old man with a left cerebellar infarction secondary to ipsilateral VA occlusion was admitted to our hospital 8 hours after onset, with a National Institute of Health Stroke Scale (NIHSS) score of 4. The patient became comatose 3.5 hours after arrival owing to subsequent BA occlusion. He was successfully treated with mechanical thrombectomy. A 74-year-old man with right cerebellar infarction secondary to ipsilateral VA occlusion was admitted to our hospital 26 hours after onset, with an NIHSS score of 3. He became comatose 1 hour after arrival owing to BA occlusion and was treated with thrombectomy, followed by internal and external decompression. Despite the mild symptoms of VA occlusion and consequently delayed admission to the hospital, stroke physicians should be aware that spontaneous thrombus migration from the VA to the BA can result in a life-threatening presentation.
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Affiliation(s)
- Kenya Miyoshi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Iwate, Japan
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Yosuke Akamatsu
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Iwate, Japan
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Kentaro Fujimoto
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Iwate, Japan
| | - Daigo Kojima
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Kohei Chida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Iwate, Japan
| | - Hiroshi Kashimura
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Mitsunobu Sato
- Stroke Center, Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Ryo Itabashi
- Stroke Center, Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Iwate, Japan
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Schaefer JH, Lieschke F, Urban H, Bohmann FO, Gatzke F, Miesbach W. Feasibility and comparability of different platelet function tests in acute stroke with or without prior antiplatelet therapy. Front Neurol 2024; 15:1361751. [PMID: 38410198 PMCID: PMC10894916 DOI: 10.3389/fneur.2024.1361751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/30/2024] [Indexed: 02/28/2024] Open
Abstract
Background The clinical course of ischemic and hemorrhagic strokes can be influenced by the coagulation status of individual patients. The prior use of antiplatelet therapy (APT) such as acetylsalicylic acid (ASA) or P2Y12-antagonists has been inconsistently described as possibly increasing the risk of hemorrhagic transformation or expansion. Since clinical studies describing prior use of antiplatelet medication are overwhelmingly lacking specific functional tests, we aimed to implement testing in routine stroke care. Methods We used fluorescence-activated cell sorting (FACS) with antibodies against CD61 for thrombocyte identification and CD62p or platelet activation complex-1 (PAC-1) to determine platelet activation. Aggregometry and automated platelet functioning analyzer (PFA-200) were employed to test thrombocyte reactivity. FACS and aggregometry samples were stimulated in vitro with arachidonic acid (AA) and adenosine diphosphate (ADP) to measure increase in CD62p-/PAC-1-expression or aggregation, respectively. Results Between February and July 2023, 20 blood samples (n = 11 ischemic strokes; n = 7 hemorrhagic strokes; n = 2 controls) were acquired and analyzed within 24 h of symptom onset. N = 11 patients had taken ASA, n = 8 patients no APT and n = 1 ASA+clopidogrel. ASA intake compared to no APT was associated with lower CD62p expression after stimulation with AA on FACS analysis (median 15.8% [interquartile range {IQR} 12.6-37.2%] vs. 40.1% [IQR 20.3-56.3%]; p = 0.020), lower platelet aggregation (9.0% [IQR 7.0-12.0%] vs. 88.5% [IQR 11.8-92.0%]; p = 0.015) and longer time to plug formation with PFA-200 (248.0 s [IQR 157.0-297] vs. 121.5 s [IQR 99.8-174.3]; p = 0.027). Significant correlations were noted between AA-induced CD62p expression and aggregometry analysis (n = 18; ρ = 0.714; p < 0.001) as well as a negative correlation between CD62p increase and PFA clot formation time (n = 18; ρ = -0.613; p = 0.007). Sensitivity for ASA intake was highest for PFA (81.8% for values ≥155.5 s). The combination of ASA + clopidogrel also affected ADP-induced CD62p and PAC-1 expression. Conclusion In the clinical setting it is feasible to use differentiated platelet analytics to determine alterations caused by antiplatelet therapy. Among the tests under investigation, PFA-200 showed the highest sensitivity for the intake of ASA in stroke patients. FACS analysis on the other hand might be able to provide a more nuanced approach to altered platelet reactivity.
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Affiliation(s)
- Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Hans Urban
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Florian Gatzke
- Department of Internal Medicine II, Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Wolfgang Miesbach
- Department of Internal Medicine II, Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Tsivgoulis G, Palaiodimou L, Stefanou MI, Theodorou A, Kõrv J, Nunes AP, Candelaresi P, Dall'Ora E, Sariaslani P, Provinciali L, Conforto AB, Cidrao AADL, Karapanayiotides T, Ahmed N. Predictors of functional outcome after symptomatic intracranial hemorrhage complicating intravenous thrombolysis: results from the SITS-ISTR. Eur J Neurol 2023; 30:3161-3171. [PMID: 37410547 DOI: 10.1111/ene.15968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND PURPOSE Several risk factors of symptomatic intracerebral hemorrhage (SICH) following intravenous thrombolysis for acute ischaemic stroke have been established. However, potential predictors of good functional outcome post-SICH have been less studied. METHODS Patient data registered in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) from 2005 to 2021 were used. Acute ischaemic stroke patients who developed post intravenous thrombolysis SICH according to the SITS Monitoring Study definition were analyzed to identify predictors of functional outcomes. RESULTS A total of 1679 patients with reported SICH were included, out of which only 2.8% achieved good functional outcome (modified Rankin Scale scores of 0-2), whilst 80.9% died at 3 months. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score and 24-h ΔNIHSS score were independently associated with a lower likelihood of achieving both good and excellent functional outcomes at 3 months. Baseline NIHSS and hematoma location (presence of both SICHs, defined as remote and local SICH concurrently; n = 478) were predictors of early mortality within 24 h. Independent predictors of 3-month mortality were age, baseline NIHSS, 24-h ΔNIHSS, admission serum glucose values and hematoma location (both SICHs). Age, baseline NIHSS score, 24-h ΔNIHSS, hyperlipidemia, prior stroke/transient ischaemic attack, antiplatelet treatment, diastolic blood pressure at admission, glucose values on admission and SICH location (both SICHs) were associated with reduced disability at 3 months (≥1-point reduction across all modified Rankin Scale scores). Patients with remote SICH (n = 219) and local SICH (n = 964) had comparable clinical outcomes, both before and after propensity score matching. CONCLUSIONS Symptomatic intracerebral hemorrhage presents an alarmingly high prevalence of adverse clinical outcomes, with no difference in clinical outcomes between remote and local SICH.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ana Paiva Nunes
- Stroke Unit, Hospital São José, Lisbon Central University Hospital Center, Lisbon, Portugal
| | | | - Elisa Dall'Ora
- Stroke Unit, Department of Neurology, Bolzano Central Hospital, Bolzano, Italy
| | - Payam Sariaslani
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Leandro Provinciali
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Adriana B Conforto
- Divisão de Neurologia Clínica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | - Theodore Karapanayiotides
- Second Department of Neurology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Li W, Xing X, Wen C, Liu H. Risk factors and functional outcome were associated with hemorrhagic transformation after mechanical thrombectomy for acute large vessel occlusion stroke. J Neurosurg Sci 2023; 67:585-590. [PMID: 33320467 DOI: 10.23736/s0390-5616.20.05141-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Risk factors and functional outcome of hemorrhagic transformation (HT) after mechanical thrombectomy (MT) are to be elucidated in patients with acute large vessel occlusion stroke. METHODS We retrospectively analyzed data from 88 patients who underwent MT treatment. Independent risk factors of hemorrhagic infarction (HI), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) were implemented to determine. Association between HI, PH, sICH and mortality at 90 days after treatment were analyzed. RESULTS Of 88 patients, 44.3%had HT (N.=39). 64.1% had HI (N.=25), 35.9% had PH (N.=14) and 12.5% had sICH (N.=11). Independent risk factors for HI were associated with higher NIHSS Score (OR 1.190; 95% CI 1.073~1.319, P=0.001, per 1 score increase), history of coronary heart disease (OR 4.645; 95% CI 1.092~19.758, P=0.038), and use of intravenous thrombolysis (OR 3.438; 95% CI 1.029~11.483, P=0.045). Independent risk factors for PH were associated with higher NIHSS Score (OR 1.227; 95% CI 1.085~1.387, P=0.001, per 1 score increase) and history of oral antiplatelet and/or anticoagulation drugs (OR 6.694; 95% CI 1.245~35.977, P=0.027). Independent risk factors for sICH were associated with higher NIHSS Score (OR 1.393; 95% CI 1.138~1.704, P=0.001, per 1 score increase), increased systolic blood pressure (OR 1.061; 95% CI 1.006~1.120, P=0.030, per 1 mmHg increase) and history of coronary heart disease (OR 13.699; 95% CI 1.019~184.098, P=0.048). Patients who had PH were more likely to cause mortality at 90 days (OR 10.15; 95% CI 1.455~70.914, P=0.019). CONCLUSIONS Higher NIHSS Score was associated with HI, PH, and sICH. History of coronary heart was associated with HI and sICH. Use of intravenous thrombolysis was associated with HI. History of oral antiplatelet and/or anticoagulation drugs was associated with PH. Increased systolic blood pressure was associated with sICH. PHs was remarkably associated with mortality at 90 days.
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Affiliation(s)
- Weirong Li
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China
| | - Xiaolian Xing
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China
| | - Chao Wen
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China
| | - Hongwei Liu
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China -
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Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
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Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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Amaral S, Duloquin G, Béjot Y. Symptomatic Intracranial Hemorrhage after Ischemic Stroke Treated with Bridging Revascularization Therapy. Life (Basel) 2023; 13:1593. [PMID: 37511968 PMCID: PMC10381185 DOI: 10.3390/life13071593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: bridging revascularization therapy is now the standard of care in patients with ischemic stroke due to large vessel occlusion. This study aimed to determine the frequency of symptomatic intracranial hemorrhage (sICH) related to this treatment, and to assess contributing factors and patients' outcomes. (2) Methods: consecutive ischemic stroke patients treated with bridging therapy were prospectively enrolled. sICH (intracranial hemorrhage with an increase in NIHSS score of ≥4 points) was assessed on imaging at 24 h. The functional status of patients was measured at 6 months using the mRS score; (3) Results: 176 patients were included (mean age 68.7 ± 1.2 years, 52.3% women), among whom 15 (8.5%) had sICH. Patients with sICH had more frequent alcohol abuse (30.1% versus 9.7%, p = 0.023), prestroke use of dual antiplatelet therapy (14.3% versus 1.3%, p = 0.002), higher NIHSS scores at admission (median score 20.5 versus 15, p = 0.01), greater systolic blood pressure upon admission, more frequent vascular intracranial calcifications (p = 0.004), leukoaraiosis (p = 0.001), and intracranial atheroma (p = 0.02), and higher neutrophil-to-lymphocyte ratios (p = 0.02) and neutrophil-to-platelet ratios (p = 0.04). At 6-month follow-up, 9 (60%) patients with sICH died, versus 18% of patients without sICH (p < 0.001). Only 1 (7%) patient with sICH had a good functional outcome, defined as an mRS score of 0 to 2, versus 51% of patients without sICH. (4) Conclusions: one in twelve ischemic stroke patients treated with bridging therapy suffered sICH. Given the observed poor outcomes after sICH, further studies are required to better identify patients at risk to help clinicians in guiding therapeutic strategies.
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Affiliation(s)
- Simon Amaral
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
| | - Gauthier Duloquin
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
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Noseda R, Rea F, Pagnamenta A, Agazzi P, Bianco G, Sihabdeen S, Seiffge D, Michel P, Nedeltchev K, Bonati L, Kägi G, Niederhauser J, Nyffeler T, Luft A, Wegener S, Schelosky L, Medlin F, Rodic B, Peters N, Renaud S, Mono ML, Carrera E, Fischer U, Ceschi A, Cereda CW. Sex Differences in Outcomes of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Preadmission Use of Antiplatelets. CNS Drugs 2023; 37:351-361. [PMID: 36976463 PMCID: PMC10126038 DOI: 10.1007/s40263-023-00997-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
AIM To compare safety and functional outcomes of intravenous thrombolysis (IVT) between females and males with acute ischaemic stroke (AIS) in relation to preadmission use of antiplatelets. METHODS Multicentre cohort study of patients admitted from 1 January 2014 to 31 January 2020 to hospitals participating in the Swiss Stroke Registry, presenting with AIS and receiving IVT. Primary safety outcome was in-hospital symptomatic intracerebral haemorrhage (sICH). Primary functional outcome was functional independence at 3 months after discharge. Multivariable logistic regression models were fitted to assess the association between sex and each outcome according to preadmission use of antiplatelets. RESULTS The study included 4996 patients (42.51 % females, older than males, median age 79 vs 71 years, p < 0.0001). Comparable proportions of females (39.92 %) and males (40.39 %) used antiplatelets before admission (p = 0.74). In total, 3.06 % females and 2.47 % males developed in-hospital sICH (p = 0.19), with similar odds (adjusted odds ratio, [AOR] 0.93, 95 % confidence interval, [CI] 0.63-1.39). No interaction was found between sex and preadmission use of either single or dual antiplatelets in relation to in-hospital sICH (p = 0.94 and p = 0.23). Males had higher odds of functional independence at 3 months (AOR 1.34, 95 % CI 1.09-1.65), regardless of preadmission use of antiplatelets (interaction between sex and preadmission use of either single or dual antiplatelets p = 0.41 and p = 0.58). CONCLUSION No sex differences were observed in the safety of IVT regarding preadmission use of antiplatelets. Males showed more favourable 3-month functional independence than females; however, this sex difference was apparently not explained by a sex-specific mechanism related to preadmission use of antiplatelets.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Federico Rea
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Pamela Agazzi
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Giovanni Bianco
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Shairin Sihabdeen
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Thomas Nyffeler
- Center of Neurology and Neurorehabilitation, Luzerner Kantonsspital, Luzern, Switzerland
| | - Andreas Luft
- Universitätsspital Zürich, Neurology, Zürich, Switzerland
| | | | - Ludwig Schelosky
- Division of Neurology, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Friedrich Medlin
- Division of Neurology, HFR Fribourg, Stroke Unit, Fribourg, Switzerland
| | - Biljana Rodic
- Kantonsspital Winterthur, Neurology, Winterthur, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, Hirslanden Hospital, Zurich, Switzerland
| | - Susanne Renaud
- Division of Neurology, Pourtalès Hospital, Neuchatel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Walter Cereda
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland.
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Vertebral to Basilar Thrombus Migration Post Intravenous Thrombolysis. Can J Neurol Sci 2023; 50:119-122. [PMID: 34666862 DOI: 10.1017/cjn.2021.237] [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: 11/06/2022]
Abstract
Recombinant tissue plasminogen activator improves outcomes in acute ischemic stroke. Alteplase may result in thrombus migration (TM) distally to a critical arterial supply that can worsen perfusion to eloquent brain tissue. Alteplase-related stroke recanalization and clot migration in vertebral artery (VA) occlusion whereby the clot migrates to the basilar artery (BA) may be harmful. We identified seven subjects with isolated symptomatic vertebral occlusion. Two cases suffered early neurologic deterioration due to TM from VA to BA following alteplase. Precautionary transfer to thrombectomy centers may be warranted in alteplase-treated symptomatic VA occlusions in case of migration to basilar occlusion.
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Palaiodimou L, Kargiotis O, Katsanos AH, Kiamili A, Bakola E, Komnos A, Zisimopoulou V, Natsis K, Papagiannopoulou G, Theodorou A, Zompola C, Safouris A, Psychogios K, Ntais E, Plomaritis P, Karamatzianni G, Mavriki A, Koutsokera M, Lykou C, Koutroulou I, Gourbali V, Skafida A, Roussopoulou A, Kourtesi G, Papamichalis P, Papagiannopoulos S, Gryllia M, Tavernarakis A, Kazis D, Karapanayiotides T, Magoufis G, Giannopoulos S, Tsivgoulis G. Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation. Eur Stroke J 2023; 8:5-15. [PMID: 36793743 PMCID: PMC9923128 DOI: 10.1177/23969873221103474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/09/2022] [Indexed: 02/12/2023] Open
Abstract
Introduction Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset. Methods Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented. Results A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001). Conclusions Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Lina Palaiodimou, Second Department of
Neurology, “Attikon” University Hospital, School of Medicine, National and
Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece.
| | | | - Aristeidis H Katsanos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Argyro Kiamili
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Apostolos Komnos
- Intensive Care Unit, General Hospital
of Larissa, Larissa, Greece
| | - Vaso Zisimopoulou
- Stroke Unit, Athens Euroclinic, Athens,
Greece
- Department of Neurology, 251 Hellenic
Air Force & VA General Hospital, Athens, Greece
| | | | - Georgia Papagiannopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Christina Zompola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | | | | | - Evangelos Ntais
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Panagiotis Plomaritis
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Georgia Karamatzianni
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Andriana Mavriki
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Maria Koutsokera
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Christina Lykou
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Ioanna Koutroulou
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | | | - Andromachi Roussopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, Tzaneio
General Hospital, Pireaus, Greece
| | - Georgia Kourtesi
- Department of Neurology, General
Hospital of Serres, Serres, Greece
| | | | - Sotirios Papagiannopoulos
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Maria Gryllia
- Department of Neurology, Athens
General Hospital G. Gennimatas, Athens, Greece
| | | | - Dimitrios Kazis
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | - Sotirios Giannopoulos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
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10
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Tsivgoulis G, Katsanos AH, Christogiannis C, Faouzi B, Mavridis D, Dixit AK, Palaiodimou L, Khurana D, Petruzzellis M, Psychogios K, Macleod MJ, Ahmed N. IV thrombolysis with tenecteplase for the treatment of acute ischemic stroke. Ann Neurol 2022; 92:349-357. [PMID: 35713213 DOI: 10.1002/ana.26445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Intravenous thrombolysis (IVT) with tenecteplase has been associated with better clinical outcomes in acute ischemic stroke (AIS) patients with confirmed large vessel occlusions compared to IVT with alteplase. However, the utility of tenecteplase for the treatment of all AIS patients eligible for IVT has not been established. METHODS We compared the safety and efficacy of tenecteplase vs. alteplase in AIS patients by analysing propensity score matched data from 20 centres participating in the SITS-ISTR registry. Patients receiving IVT with tenecteplase were matched with up to three patients receiving alteplase from the same centre. The primary outcome of interest was the distribution of 3-month functional outcomes. Secondary outcomes included the rates of patients with symptomatic intracranial hemorrhage (SICH) in the first 24 hours, excellent (mRS-scores of 0-1) or good (mRS-scores of 0-2) functional outcome, and all-cause mortality at 3 months. RESULTS A total of 331 tenecteplase-treated AIS patients were matched to 797 patients treated with alteplase [median age of 70 years; 43.9% women; median NIHSS-score: 11 (IQR: 6-17)]. Patients treated with tenecteplase had better three-month functional outcomes (common OR=1.54,95%CI:1.18-2.00) with higher odds of good functional outcome (OR=2.00,95%CI:1.45-2.77) and a lower likelihood of all-cause mortality (OR=0.43,95%CI:0.27-0.67) at three months, compared to alteplase-treated patients. No difference was found in the likelihood of the three-month excellent functional outcomes (OR=1.31,95%CI:0.96-1.78) and 24-hour SICH (1.0% vs. 1.3%; OR=0.72,95%CI:.20-2.64). INTERPRETATION IVT with tenecteplase was associated with better three-month clinical outcomes compared to IVT with alteplase in AIS patients, with no increased risk of symptomatic intracranial bleeding. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | | | - Belahsen Faouzi
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Anand K Dixit
- Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Newcastle-Upon-Tyne, UK
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Marco Petruzzellis
- Neurology Unit and Stroke Center, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Klearchos Psychogios
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Mary Joan Macleod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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11
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Abstract
PURPOSE OF REVIEW The aim of this study was to summarize available evidence regarding the safety and efficacy of intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with specific comorbidities and potential contraindications to systemic reperfusion therapy. Recent advances in IVT implementation in wake-up stroke and in extended time window using advanced neuroimaging will also be highlighted. RECENT FINDINGS Despite theoretical concerns of a higher bleeding risk with IVT, there are no data showing increased risk of symptomatic intracerebral haemorrhage (sICH) in patients with stroke mimics, including seizures, increasing age and dual antiplatelet pretreatment. In addition, recent randomized evidence allows us to expand the time window of IVT for AIS using advanced neuroimaging both in wake-up stroke patients and in patients presenting within 4.5-9 h from symptom onset fulfilling certain neuroimaging criteria (based on DWI/FLAIR mismatch or perfusion mismatch). SUMMARY IVT is a highly effective systemic reperfusion therapy that counts 25 years of everyday clinical experience but still presents several challenges in its application. Appropriate patient selection and adherence to rt-PA protocol is paramount in terms of safety. The effort to simplify the indications, expand the therapeutic time window and eliminate specific initial contraindications is continuously evolving.
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Affiliation(s)
- Klearchos Psychogios
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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12
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Lee JS, Lee SJ, Hong JM, Alverne FJAM, Lima FO, Nogueira RG. Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease. J Stroke 2022; 24:3-20. [PMID: 35135056 PMCID: PMC8829471 DOI: 10.5853/jos.2021.01375] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
Mechanical thrombectomy (MT) has become the gold-standard for patients with acute large vessel occlusion strokes (LVOS). MT is highly effective in the treatment of embolic occlusions; however, underlying intracranial atherosclerotic disease (ICAD) represents a therapeutic challenge, often requiring pharmacological and/or mechanical rescue treatment. Glycoprotein IIb/IIIa inhibitors have been suggested as the best initial approach, if reperfusion can be achieved after thrombectomy, with angioplasty and/or stenting being reserved for the more refractory cases. In this review, we focus on the therapeutic considerations surrounding the endovascular treatment of ICAD-related acute LVOS.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | | | | | - Raul G. Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
- Correspondence: Raul G. Nogueira Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, C-400 PUH, 200 Lothrop Street, Pittsburgh, PA 15213, USA Tel: +1-412-647-8080 Fax: +1-412-647-8445 E-mail:
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13
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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14
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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] [MESH Headings] [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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15
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Lin SF, Hu HH, Ho BL, Chen CH, Chan L, Lin HJ, Sun Y, Lin YY, Chen PL, Lin SK, Wei CY, Lin YT, Lee JT, Chao AC. Pre-treatment of Single and Double Antiplatelet and Anticoagulant With Intravenous Thrombolysis for Older Adults With Acute Ischemic Stroke: The TTT-AIS Experience. Front Neurol 2021; 12:628077. [PMID: 33692743 PMCID: PMC7937707 DOI: 10.3389/fneur.2021.628077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study aimed to investigate the safety and efficacy of single antiplatelet, anticoagulant and Dual Antiplatelet pre-treatment (DAPP) in older, moderate to high severity acute ischemic stroke patients treated with intravenous thrombolysis (IVT). Methods: A prospective cohort study was conducted to monitor the development of symptomatic intracranial hemorrhage (SICH) and functional outcomes at 90 days. Two different dosages of alteplase were used for IVT. Logistic regression models were used for analysis of the safety and efficacy outcomes. Results: A total of 1,156 patients were enrolled and categorized into six groups based on their pre-treatment medications: (1) aspirin (n = 213), (2) clopidogrel (n = 37), (3) DAPP of aspirin + clopidogrel (n= 27), (4) warfarin (n = 44), (5) any of the above pre-medications (n = 331), and (6) none of these medications as controls (n = 825). The DAPP group showed significantly increased SICH by the NINDS (adjusted OR: 4.90, 95% CI 1.28-18.69) and the ECASS II (adjusted OR: 5.09, 95% CI: 1.01-25.68) standards. The aspirin group was found to significantly improve the favorable functional outcome of the modified Rankin Scale (mRS) of 0-1 (adjusted OR: 1.91, 95% CI, 1.31.2.78), but no significance for mRS of 0-2 (adjusted OR: 1.39, 95% CI, 0.97-1.99). The DAPP group also significantly increased mortality (adjusted OR: 4.75, 95% CI: 1.77-12.72). A significant interaction between different dosages for IVT and the functional status was noted. Compared to standard dose, the DAPP group showed higher proportions of disability and mortality with low dose of IVT. Conclusion: For older adults with higher baseline severity of acute ischemic stroke, DAPP may increase the risk of SICH and mortality post IVT. However, DAPP is still not an indication to withdraw IVT and to prescribe low-dose IVT for older adults.
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Affiliation(s)
- Sheng-Feng Lin
- School of Public Health, College of Public Health, Taipei, Taiwan.,Division of Hospitalist, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan.,Department of Neurology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Han-Hwa Hu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Department of Neurology, Taipei Medical University-Shaung Ho Hospital, Taipei, Taiwan
| | - Bo-Lin Ho
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Neurology, National Cheng Kung University, Tainan, Taiwan
| | - Lung Chan
- Department of Neurology, Taipei Medical University-Shaung Ho Hospital, Taipei, Taiwan
| | - Huey-Juan Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Yung-Yang Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shinn-Kuang Lin
- Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
| | - Cheng-Yu Wei
- Department of Neurology, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Yu-Te Lin
- Division of Neurology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - A-Ching Chao
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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16
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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: 506] [Impact Index Per Article: 168.7] [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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17
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Kargiotis O, Tsivgoulis G. The 2020 breakthroughs in early secondary prevention: dual antiplatelet therapy versus single antiplatelet therapy. Curr Opin Neurol 2021; 34:45-54. [PMID: 33196579 DOI: 10.1097/wco.0000000000000878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA. RECENT FINDINGS Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed. SUMMARY DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Xu W, Hu X. Reader Response: Safety and Efficacy of Dual Antiplatelet Pretreatment in Patients With Ischemic Stroke Treated With IV Thrombolysis: A Systematic Review and Meta-analysis. Neurology 2021; 96:134-135. [PMID: 33462129 DOI: 10.1212/wnl.0000000000011290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Katsanos AH, Tsivgoulis G. Author Response: Safety and Efficacy of Dual Antiplatelet Pretreatment in Patients With Ischemic Stroke Treated With IV Thrombolysis: A Systematic Review and Meta-analysis. Neurology 2021; 96:135. [PMID: 33462130 DOI: 10.1212/wnl.0000000000011291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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20
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Zhang H, Zheng L. Statistical analysis for efficacy of tirofiban combined with ozagrel in the treatment of progressive cerebral infarction patients out of thrombolytic therapy time window. Clinics (Sao Paulo) 2021; 76:e2728. [PMID: 34133479 PMCID: PMC8183337 DOI: 10.6061/clinics/2021/e2728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/13/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To investigate the safety and efficacy of combined tirofiban-ozagrel therapy for treating progressive stroke patients out of thrombolytic therapy time window. METHODS This prospective, double-blind, randomized controlled study included 337 patients who had experienced an acute ischemic stroke between November 2017 and December 2018. All patients were randomized into three groups: 1) the tirofiban/ozagrel group (n=113), 2) the tirofiban group (n=110), and 3) the ozagrel group (n=114). The platelet aggregation (PAG), thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen (FIB) levels in the patients from these groups were evaluated before starting treatment and then, at 24h, 7 days, and 14 days after treatment. The National Institutes of Health Stroke Scale (NIHSS) scores were evaluated before treatment and then, 24h, 1 week, 2 weeks, and 4 weeks after treatment. The Barthel Index (BI) score was used to measure safety, and the modified Rankin scale (mRS) was used to evaluate disability following 3 months of treatment. The risk factors affecting clinical outcomes were analyzed using logistic multivariate regression. RESULTS The mean NIHSS score for all the patients was 13.17±3.13 before treatment, and no significant difference between the basic clinical parameters of the three patient groups was found. Following treatment, both PAG and FIB were significantly reduced compared with the baseline (p<0.05). The levels of PAG and FIB in the tirofiban/ozagrel group were significantly lower than those in the tirofiban and ozagrel groups at 24h and 7 days after treatment (p<0.05). The NIHSS score decreased significantly in all treatment groups (p<0.05). The tirofiban/ozagrel NIHSS scores were significantly lower than that of the tirofiban and ozagrel groups at 24h, 1 week, and 2 weeks post initiation (p<0.05 for all). There were no significant differences in the BI and mRS scores or the intracranial hemorrhage rates; further, age, sex, Trial of ORG 10172 in acute stroke treatment (TOAST) type, baseline NIHSS and 24-h NIHSS scores, baseline thrombus-related factors, and treatment methods were shown to not be independent risk factors for clinical outcomes. CONCLUSION The combination of tirofiban and ozagrel, as well as monotherapy with either tirofiban or ozagrel, transiently improves the neural function of patients and reduces platelet aggregation and fibrinogen formation in the first 4 weeks following a stroke event; additionally, none of these treatments increased the risk for hemorrhage in these progressive stroke patients over a 3-month period.
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Affiliation(s)
- Huiying Zhang
- School of Statistics, ShanXi University of Finance & Economics, Taiyuan, Shanxi Province, 030006, China
| | - Lei Zheng
- Department of Cardiovascular Medicine, ShanXi Bethune Hospital, Taiyuan, Shanxi Province, 030032, China
- Corresponding author. E-mail:
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21
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Lieschke F, Zheng Y, Foerch C, van Leyen K. Thrombolysis in acute stroke under dual antiplatelet therapy: perspectives arising from translational studies. Neural Regen Res 2021; 16:113-114. [PMID: 32788459 PMCID: PMC7818874 DOI: 10.4103/1673-5374.284906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Franziska Lieschke
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Yi Zheng
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Christian Foerch
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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22
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Li KHC, Jesuthasan A, Kui C, Davies R, Tse G, Lip GYH. Acute ischemic stroke management: concepts and controversies.A narrative review. Expert Rev Neurother 2020; 21:65-79. [PMID: 33047640 DOI: 10.1080/14737175.2021.1836963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amongst the 25.7 million survivors and 6.5 million deaths from stroke between 1990 and 2013, ischemic strokes accounted for approximately 70% and 50% of the cases, respectively. With patients still suffering from complications and stroke recurrence, more questions have been raised as to how we can better improve patient management. AREAS COVERED The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Newcastle-Ottawa Scale (NOS) were adopted to ensure a comprehensive inclusion of quality literature from various sources. PubMed and Embase were searched for evidence on thrombolysis, mechanical thrombectomy, artificial intelligence (AI), antiplatelet therapy, anticoagulation and hypertension management. EXPERT OPINION The directions of future research in these areas are dependent on the current level of validation. Endovascular therapy and applications of AI are relatively new compared to the other areas discussed in this review. As such, future studies need to focus on validating their efficacy. As for thrombolysis, antiplatelet and anticoagulation therapy, their efficacy has been well-established and future research efforts should be directed toward adjusting its use according to patient-specific factors, starting with factors with the most clinical relevance and prevalence.
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Affiliation(s)
- Ka Hou Christien Li
- Medicine, Newcastle University , Newcastle, UK.,Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | | | | | - Ruth Davies
- Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University , Tianjin, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
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Nogueira RG, Tsivgoulis G. Large Vessel Occlusion Strokes After the DIRECT-MT and SKIP Trials. Stroke 2020; 51:3182-3186. [DOI: 10.1161/strokeaha.120.030796] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Greece (G.T.)
- Department of Neurology, University of Tennessee HealthCare Center, Memphis (G.T.)
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Iodinated Contrast Agents Reduce the Efficacy of Intravenous Recombinant Tissue-Type Plasminogen Activator in Acute Ischemic Stroke Patients: a Multicenter Cohort Study. Transl Stroke Res 2020; 12:530-539. [PMID: 32895894 DOI: 10.1007/s12975-020-00846-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/23/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
This study aimed to investigate whether the application of iodinated contrast agents before intravenous (IV) recombinant tissue plasminogen activator (rt-PA) reduces the efficacy in acute ischemic stroke (AIS) patients. To determine whether the application of iodinated contrast agents before intravenous rt-PA reduces the efficacy in AIS patients. We analyzed our prospectively collected data of consecutive AIS patients receiving IV rt-PA treatment in the MISSION CHINA study. Clinical outcome at 3 months was assessed with modified Rankin Scale (mRS) score and dichotomized into good outcome (0-2) and poor outcome (3-6). Symptomatic intracerebral hemorrhage (sICH) was defined as cerebral hemorrhagic transformation in combination with clinical deterioration of National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points at 24-h. We performed logistic regression analysis and propensity score matching analysis to investigate the impact of iodinated contrast agents before IV rt-PA on poor outcome and sICH, respectively. A total of 3593 patients were finally included, and iodinated contrast agents were used before IV rt-PA among 859 (23.9%) patients. Patients in the iodinated contrast group were more likely to result in poor outcome (39.9% vs 33.4%, P = 0.001) and sICH (3.4% vs 1.5%, P < 0.001), compared with non-contrast group. Binary logistic regression analysis revealed that the application of iodinated contrast agents was independently associated with poor outcome (OR 1.342; 95% CI 1.103-1.631; P = 0.003) and sICH (OR 1.929; 95% CI 1.153-3.230; P = 0.012), respectively. After propensity score matching, the application of iodinated contrast agents was still independently associated with poor outcome (OR 1.246; 95% CI 1.016-1.531; P = 0.034) and sICH (OR 1.965; 95% CI 1.118-3.456; P = 0.019). Applying iodinated contrast agents before IV rt-PA may reduce the thrombolytic efficacy in AIS patients. Further benefit-risk analysis might be needed when iodinated contrast-used imaging is considered before intravenous thrombolysis.
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25
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Altersberger VL, Sturzenegger R, Räty S, Hametner C, Scheitz JF, Moulin S, Berg SA, Zini A, Nannoni S, Heldner MR, Jovanovic DR, Martinez‐Majander N, Tiainen M, Valkonen K, Berberich A, Erdur H, Cordonnier C, Peters N, Gopisingh KM, Bigliardi G, Strambo D, De Marchis GM, Ntaios G, Cereda CW, Wegener S, Kägi G, Pezzini A, Padjen V, Arnold M, Michel P, Vandelli L, Nederkoorn PJ, Leys D, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Prior Dual Antiplatelet Therapy and Thrombolysis in Acute Stroke. Ann Neurol 2020; 88:857-859. [DOI: 10.1002/ana.25850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Valerian L. Altersberger
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | | | - Silja Räty
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Christian Hametner
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Jan F. Scheitz
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | - Solène Moulin
- Department of Neurology Centre Hospitalier Universitaire de Reims Reims France
| | - Sophie A. Berg
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | - Andrea Zini
- Department of Neurology and Stroke Center IRCCS Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital Bologna Italy
| | - Stefania Nannoni
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital Bern University Hospital and University of Bern Bern Switzerland
| | - Dejana R. Jovanovic
- Neurology Clinic, Clinical Centre of Serbia Belgrade Serbia
- Medical Faculty University of Belgrade Belgrade Serbia
| | | | - Marjaana Tiainen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kati Valkonen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anne Berberich
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Hebun Erdur
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | | | - Nils Peters
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
| | - Kiran M. Gopisingh
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | - Guido Bigliardi
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile “S. Agostino‐Estense,” Modena University Hospital Modena Italy
| | - Davide Strambo
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Gian M. De Marchis
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine School of Health Sciences, University of Thessaly Larissa Greece
| | - Carlo W. Cereda
- Stroke Center and Department of Neurology Neurocenter of Southern Switzerland Lugano Switzerland
| | - Susanne Wegener
- Department of Neurology University Hospital Zurich and University of Zurich Zurich Switzerland
| | - Georg Kägi
- Department of Neurology Kantonsspital St. Gallen St. Gallen Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences Neurology Clinic, University of Brescia Brescia Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia Belgrade Serbia
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern University Hospital and University of Bern Bern Switzerland
| | - Patrik Michel
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Laura Vandelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile “S. Agostino‐Estense,” Modena University Hospital Modena Italy
| | - Paul J. Nederkoorn
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | | | - Christian H. Nolte
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | - Peter A. Ringleb
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Sami Curtze
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Stefan T. Engelter
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
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Tsivgoulis G, Katsanos AH, Ahmed N. Reply to "Prior Dual Antiplatelet Therapy and Thrombolysis in Acute Stroke". Ann Neurol 2020; 88:859-860. [PMID: 32683728 DOI: 10.1002/ana.25851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/16/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/ Population Health Research Institute, Hamilton, Canada
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Solna, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Lieschke F, Zheng Y, Schaefer JH, van Leyen K, Foerch C. Measurement of Platelet Function in an Experimental Stroke Model With Aspirin and Clopidogrel Treatment. Front Neurol 2020; 11:85. [PMID: 32117036 PMCID: PMC7026492 DOI: 10.3389/fneur.2020.00085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/23/2020] [Indexed: 01/19/2023] Open
Abstract
Dual antiplatelet treatment (DAPT) increases the risk of tPA-associated hemorrhagic transformation (HT) in ischemic stroke. To investigate the effects of DAPT in rodents, reliable indicators of platelet function utilizing a minimally invasive procedure are required. We here established a fluorescence-based assay to monitor DAPT efficiency in a mouse model of ischemic stroke with HT. Male C57/BL6 mice were fed with aspirin and clopidogrel (ASA+CPG). Venous blood was collected, stimulated with thrombin, labeled with anti-CD41-FITC and anti-CD62P-PE, and analyzed by flow cytometry. Subsequently, animals were subjected to experimental stroke and tail bleeding tests. HT was quantified using NIH ImageJ software. In ASA+CPG mice, the platelet activation marker CD62P was reduced by 40.6 ± 4.2% (p < 0.0001) compared to controls. In vitro platelet function correlated inversely with tail bleeding tests (r = −0.8, p = 0.0033, n = 12). Twenty-four hours after drug withdrawal, platelet activation rates in ASA+CPG mice were still reduced by 20.2 ± 4.1% (p = 0.0026) compared to controls, while tail bleeding volumes were increased by 4.0 ± 1.4 μl (p = 0.004). Conventional tests using light transmission aggregometry require large amounts of blood and thus cannot be used in experimental stroke studies. In contrast, flow cytometry is a highly sensitive method that utilizes small volumes and can easily be incorporated into the experimental stroke workflow. Our test can be used to monitor the inhibitory effects of DAPT in mice. Reduced platelet activation is indicative of an increased risk for tPA-associated cerebral hemorrhage following experimental stroke. The test can be applied to individual animals and implemented flexibly prior and subsequent to experimental stroke.
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Affiliation(s)
- Franziska Lieschke
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Yi Zheng
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Malhotra K, Katsanos AH, Goyal N, Ahmed N, Strbian D, Palaiodimou L, Karapanayiotides T, Alexandrov AW, Grotta JC, Alexandrov AV, Tsivgoulis G. Safety and efficacy of dual antiplatelet pretreatment in patients with ischemic stroke treated with IV thrombolysis: A systematic review and meta-analysis. Neurology 2020; 94:e657-e666. [PMID: 31959709 DOI: 10.1212/wnl.0000000000008961] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/29/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Conflicting data exist on the safety and efficacy of IV thrombolysis (IVT) in patients with acute ischemic stroke (AIS) receiving dual antiplatelet pretreatment (DAPP). The aim of the present systematic review and meta-analysis is to assess the safety and outcome of DAPP history among patients with AIS treated with IVT. METHODS We performed a comprehensive literature review to identify studies that investigated the safety and efficacy of DAPP among patients with AIS treated with IVT. RESULTS We identified 9 studies comprising 66,675 patients. In unadjusted analyses, DAPP was associated with a higher likelihood of pooled symptomatic intracranial hemorrhage (sICH; odds ratio [OR] 2.26; 95% confidence interval [CI] 1.39-3.67) and 3-month mortality (OR 1.47; 95% CI 1.25-1.73). DAPP was also related to higher odds of sICH according to Safe Implementation of Treatments in Stroke Monitoring Study (OR 2.71; 95% CI 2.05-3.59), European Cooperative Acute Stroke Study II (OR 2.23; 95% CI 1.46-3.40), and National Institute of Neurological Disorders and Stroke (OR 1.59, 95% CI 1.38-1.83) definitions. There was no association between DAPP and 3-month favorable functional outcome (FFO, modified Rankin Scale [mRS] score 0-1) and 3-month functional independence (FI; mRS score 0-2). In adjusted analyses, history of DAPP was not associated with pooled sICH (OR 2.03; 95% CI 0.75-5.52), 3-month mortality (OR 1.11; 95% CI 0.87-1.40), 3-month FFO (OR 0.92; 95% CI 0.77-1.09), and 3-month FI (OR 1.01; 95% CI 0.89-1.15). CONCLUSIONS After adjustment for potential confounders, DAPP appears not to be associated with higher risk of adverse outcomes in patients with AIS treated with IVT.
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Affiliation(s)
- Konark Malhotra
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Aristeidis H Katsanos
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Nitin Goyal
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Niaz Ahmed
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Daniel Strbian
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Lina Palaiodimou
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Theodore Karapanayiotides
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Anne W Alexandrov
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - James C Grotta
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Andrei V Alexandrov
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Georgios Tsivgoulis
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston.
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29
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Chhabra M, Gudi SK, Rashid M, Sharma P, Sharma S, Khan H. Assessment of Knowledge on Risk Factors, Warning Signs, and Early Treatment Approaches of Stroke among Community Adults in North India: A Telephone Interview Survey. J Neurosci Rural Pract 2019; 10:417-422. [PMID: 31595113 PMCID: PMC6779547 DOI: 10.1055/s-0039-1697561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background
As stroke is a catastrophic illness, knowing its risk factors, early signs and symptoms, and management strategies could potentially prevent morbidity and mortality among the people.
Objectives
The aim of this study is to determine the public cognizance of risk factors, signs and symptoms, and early treatment options available for stroke with particular emphases on thrombolysis, and its window period.
Materials and Methods
A cross-sectional telephonic interview-based survey was conducted in the states of Punjab, Haryana, and Himachal Pradesh of North India from August 2017 to December 2017.
Results
Of 350 respondents those participated in the survey with a mean age ± standard deviation of 39.93 ± 13.41 years, hypertension was found to be the most common risk factor among the study participants (
n
= 205, 58.57%) and 28.85% of the study participants were not aware of the risk factors, whereas 46% of the participants were not aware of warning signs of stroke. The window period of thrombolysis was compared with gender, and it was found that the higher number of male participants (
n
= 49) adduced the right window of thrombolysis (0–4.5 hours) as compared with the female participants (
n
= 26).
Conclusions
Survey results suggested that there exists scant information about risk factors, alarming signs, and early treatment approaches among community adults toward stroke. In this regard, there is an immense need to conduct awareness camps related to stroke to educate the vulnerable public.
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Affiliation(s)
- Manik Chhabra
- Department of Pharmacy Practice, Indo-Soviet Friendship College of Pharmacy, Moga, Punjab, India
| | - Sai Krishna Gudi
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Manitoba, Canada
| | - Muhammed Rashid
- Department of Pharmacy Practice, Sri Adichunchanagiri College of Pharmacy, Adichunchanagiri University, Mandya, Karnataka, India
| | | | - Puneet Sharma
- Department of Pharmacy Practice, Indo-Soviet Friendship College of Pharmacy, Moga, Punjab, India
| | - Shubham Sharma
- Department of Pharmacy Practice, Indo-Soviet Friendship College of Pharmacy, Moga, Punjab, India
| | - Hashim Khan
- Department of Pharmacy Practice, College of Pharmacy, Teerthanker Mahaveer University (TMU), Moradabad, Uttar Pradesh, India
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30
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Tsivgoulis G, Katsanos AH, Mavridis D, Lambadiari V, Roffe C, Macleod MJ, Sevcik P, Cappellari M, Nevšímalová M, Toni D, Ahmed N. Association of Baseline Hyperglycemia With Outcomes of Patients With and Without Diabetes With Acute Ischemic Stroke Treated With Intravenous Thrombolysis: A Propensity Score-Matched Analysis From the SITS-ISTR Registry. Diabetes 2019; 68:1861-1869. [PMID: 31217175 DOI: 10.2337/db19-0440] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/17/2019] [Indexed: 11/13/2022]
Abstract
Available data from observational studies on the association of admission hyperglycemia (aHG) with outcomes of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) are contradictory, especially when stratified by diabetes mellitus (DM) history. We assessed the association of aHG (≥144 mg/dL) with outcomes stratified by DM history using propensity score-matched (PSM) data from the SITS-ISTR. The primary safety outcome was symptomatic intracranial hemorrhage (SICH); 3-month functional independence (FI) (modified Rankin Scale [mRS] scores 0-2) represented the primary efficacy outcome. Patients with and without aHG did not differ in baseline characteristics both in the non-DM (n = 12,318) and DM (n = 6,572) PSM subgroups. In the non-DM group, patients with aHG had lower 3-month FI rates (53.3% vs. 57.9%, P < 0.001), higher 3-month mortality rates (19.2% vs. 16.0%, P < 0.001), and similar symptomatic intracerebral hemorrhage (SICH) rates (1.7% vs. 1.8%, P = 0.563) compared with patients without aHG. Similarly, in the DM group, patients with aHG had lower rates of 3-month favorable functional outcome (mRS scores 0-1, 34.1% vs. 39.3%, P < 0.001) and FI (48.2% vs. 52.5%, P < 0.001), higher 3-month mortality rates (23.7% vs. 19.9%, P < 0.001), and similar SICH rates (2.2% vs. 2.7%, P = 0.224) compared with patients without aHG. In conclusion, aHG was associated with unfavorable 3-month clinical outcomes in patients with and without DM and AIS treated with IVT.
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Affiliation(s)
- 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
| | - Aristeidis H Katsanos
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Vaia Lambadiari
- Research Unit and Diabetes Center, Second Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christine Roffe
- University Hospital of North Midlands, Stoke-on-Trent, U.K., and Keele University, Keele, U.K
| | - Mary Joan Macleod
- Division of Applied Medicine, University of Aberdeen, Foresterhill, U.K
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | - Danilo Toni
- Neurovascular Unit, Policlinico Umberto I, Department of Human Neurosciences, University of Rome, "La Sapienza," Rome, Italy
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital Solna, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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31
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Marto JP, Kauppila LA, Jorge C, Calado S, Viana-Baptista M, Pinho-E-Melo T, Fonseca AC. Intravenous Thrombolysis for Acute Ischemic Stroke After Recent Myocardial Infarction: Case Series and Systematic Review. Stroke 2019; 50:2813-2818. [PMID: 31436141 DOI: 10.1161/strokeaha.119.025630] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background and Purpose- The safety of IV r-tPA (intravenous tissue-type plasminogen activator) for acute ischemic stroke (AIS) treatment after recent myocardial infarction (MI) is still a matter of debate. We studied the safety of delivering IV r-tPA to AIS patients with a MI within the preceding 3 months. Methods- Retrospective review of consecutive AIS admitted to 2 tertiary university hospitals' and systematic literature review for AIS patients with history of MI in the previous 3 months. Patients were divided into 2 groups: treated or not treated with standard IV r-tPA dose for AIS. Cardiac complications (cardiac rupture/tamponade, intracardiac thrombus embolization, or life-threatening arrhythmias) were compared between groups and assessed by type of MI (non-ST-segment-elevation myocardial infarction [STEMI], or STEMI) and time elapsed between vascular events. Results- One hundred and two patients were included; 46 (45.1%) were derived from literature review. Median age (interquartile range) was 64 (53-75) years old, and 69 (67.6%) were men. Forty-seven (46.1%) received IV r-tPA. In the treated group, 25 (53.2%) and 23 (48.9%) patients had, respectively, concurrent AIS and MI and STEMI, in comparison with 12 (21.8%; P=0.002) and 36 (65.5%; P=0.110) patients in the nontreated. Four (8.5%) IV r-tPA-treated patients died from confirmed or presumed cardiac rupture/ tamponade, all with a STEMI in the week preceding stroke. This complication occurred in 1 (1.8%) patients in the nontreated group (P=0.178). There were no differences in thrombus embolization (1 [2.1%) versus 2 [3.6]; P=1.000) and life-threatening arrhythmias (3 [6.4%) versus 7 [12.7]; P=0.335). No non-STEMI patients receiving IV r-tPA had cardiac complications. Conclusions- In patients with AIS and recent or concurrent MI, MI type and the time elapsed between the 2 events should be taken into consideration when deciding to deliver IV r-tPA. Although recent non-STEMI or concurrent events seem safe, STEMI in the week preceding stroke should prompt caution. The low number of events and publication bias may have influenced our conclusions.
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Affiliation(s)
- João Pedro Marto
- From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.)
- CEDOC - Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.)
| | - Linda Azevedo Kauppila
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.)
| | - Cláudia Jorge
- Department of Cardiology, Hospital de Santa Maria, University of Lisboa, Portugal (C.J.)
| | - Sofia Calado
- From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.)
- CEDOC - Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.)
| | - Miguel Viana-Baptista
- From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.)
- CEDOC - Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.)
| | - Teresa Pinho-E-Melo
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.)
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal (T.P.-e.-M., C.F.)
| | - Ana Catarina Fonseca
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.)
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal (T.P.-e.-M., C.F.)
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32
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Inohara T, Liang L, Kosinski AS, Smith EE, Schwamm LH, Hernandez AF, Bhatt DL, Fonarow GC, Peterson ED, Xian Y. Recent Myocardial Infarction is Associated With Increased Risk in Older Adults With Acute Ischemic Stroke Receiving Thrombolytic Therapy. J Am Heart Assoc 2019; 8:e012450. [PMID: 31327296 PMCID: PMC6761665 DOI: 10.1161/jaha.119.012450] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Intravenous recombinant tissue‐type plasminogen activator (rtPA) remains the only medical therapy to improve outcomes for acute ischemic stroke (AIS), but the safety of rtPA in AIS patients with a history of recent myocardial infarction (MI) remains controversial. Methods and Results We sought to determine whether the presence of recent MI would alter the risk of mortality and rtPA‐related complications. Multivariate logistic regression models were used to compare in‐hospital outcomes between rtPA‐treated AIS patients with recent MI within 3 months and those with no history of MI from the Get With The Guidelines‐Stroke hospitals between February 2009 and December 2015. Among 40 396 AIS patients aged ≥65 years treated with rtPA, 241 (0.6%) had recent MI, of which 19.5% were ST‐segment–elevation myocardial infarction. Patients with recent MI had more severe stroke than those without (median National Institutes of Health Stroke Scale [interquartile range]: 13.0 [7.0–20.0] versus 11.0 [6.0–18.0]). Recent MI was associated with an increased risk of mortality compared with no history of MI (17.4% versus 9.0%; adjusted odds ratio 1.60 [95% CI, 1.10–2.33]; P=0.014), but no statistically significant differences in rtPA‐related complications (13.5% versus 9.4%; adjusted odds ratio 1.28 [0.88–1.86]; P=0.19). Recent ST‐segment–elevation myocardial infarction was associated with higher risk of death and rtPA‐related complications, but non–ST‐segment–elevation myocardial infarction was not. Conclusions Among older AIS patients treated with rtPA, recent MI was associated with an increased risk of in‐hospital mortality. Further investigations are necessary to determine whether the benefit of rtPA outweighs its risk among AIS patients with recent MI.
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Affiliation(s)
- Taku Inohara
- Duke Clinical Research Institute Duke University Medical Center Durham NC
| | - Li Liang
- Duke Clinical Research Institute Duke University Medical Center Durham NC
| | - Andrzej S Kosinski
- Duke Clinical Research Institute Duke University Medical Center Durham NC
| | - Eric E Smith
- Department of Clinical Neurosciences Hotchkiss Brian Institute University of Calgary Canada
| | - Lee H Schwamm
- Department of Neurology Massachusetts General Hospital Boston MA
| | - Adrian F Hernandez
- Duke Clinical Research Institute Duke University Medical Center Durham NC
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School Boston MA
| | - Gregg C Fonarow
- Division of Cardiology Ronald Reagan University of California Los Angeles Medical Center Los Angeles CA
| | - Eric D Peterson
- Duke Clinical Research Institute Duke University Medical Center Durham NC
| | - Ying Xian
- Duke Clinical Research Institute Duke University Medical Center Durham NC.,Department of Neurology Duke University Medical Center Durham NC
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33
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Sun C, Song B, Jiang C, Zou JJ. Effect of antiplatelet pretreatment on safety and efficacy outcomes in acute ischemic stroke patients after intravenous thrombolysis: a systematic review and meta-analysis. Expert Rev Neurother 2019; 19:349-358. [PMID: 30807235 DOI: 10.1080/14737175.2019.1587295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Chao Sun
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Baili Song
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chunlian Jiang
- Department of Pathology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jian-Jun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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