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Héja M, Fekete I, Horváth L, Márton S, Fekete KE. Experiences With Intravenous Thrombolysis in Acute Ischemic Stroke by Elderly Patients-A "Real World Scenario". Front Neurol 2021; 12:721337. [PMID: 34589048 PMCID: PMC8473829 DOI: 10.3389/fneur.2021.721337] [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: 06/06/2021] [Accepted: 08/19/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives: This retrospective single-center study aimed to investigate the risk factors, outcomes and complication rates in patients older vs. younger than 80 years treated with intravenous alteplase. Methods: Data of 1,253 thrombolysed patients were analyzed between January 1, 2004 and August 31, 2016. Vascular risk factors, stroke severity based on the NIHSS score, functional outcome using modified Rankin Scale (mRS), mortality and symptomatic intracerebral hemorrhage (SICH) were compared between two subgroups (<80 and ≥80 years). Results: 1,125 patients were included, 199 (17.6%) among them were aged over 80 years, majority (63.3%) were female (p < 0.00001). Mean age was 68.2 ± 12.4 years, i.e., 64.7 ± 10.8 years and 84.3 ± 3.4 years in the younger and the older groups, respectively (p < 0.001). Atrial fibrillation and pre-stroke anticoagulation among patients over 80 years was more likely (p < 0.0005 and p = 0.02, respectively). NIHSS scores on admission and at 24 h were higher in elderly patients (p < 0.0001). ASPECT score at 24 h was less favorable in elderly patients (p = 0.007) and was associated with worse outcome. At 3 months, 59.8% of the patients from the older group had an unfavorable outcome (p < 0.0001), however 34.7% had independent outcome. The one-year- survival was significantly worse in the older group (p < 0.0001). The incidence of SICH was lower among older patients. In a logistic regression model, atrial fibrillation, heart failure, diabetes mellitus and smoking were proven as a significant independent risk factors for worse outcome. Conclusion: Although, the outcomes were less favorable in patients over 80 years of age, our results support the feasibility of using intravenous thrombolysis among patients over 80 years of age.
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Affiliation(s)
- Máté Héja
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Horváth
- Department of Pharmaceutical Surveillance and Economics, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Sándor Márton
- Institute of Political Science and Sociology, Faculty of Arts, University of Debrecen, Debrecen, Hungary
| | - Klára Edit Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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2
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Thommessen B, Næss H, Logallo N, Kvistad CE, Waje-Andreassen U, Ihle-Hansen H, Ihle-Hansen H, Thomassen L, Morten Rønning O. Tenecteplase versus alteplase after acute ischemic stroke at high age. Int J Stroke 2020; 16:295-299. [PMID: 32631157 DOI: 10.1177/1747493020938306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Stroke prevalence is increasing with age. Alteplase is the only agent approved for thrombolytic treatment for patients with ischemic stroke, including patients ≥80 years. In the present study, the aim was to compare efficacy and safety of tenecteplase and alteplase in patients ≥80 years. METHODS Data from the Norwegian Tenecteplase Stroke Trial, a randomized controlled trial comparing alteplase and tenecteplase, were assessed. RESULTS Of the 273 patients ≥80 years included, mean age was 85.5 years.In the intention-to-treat analyses, 43.1% receiving tenecteplase and 39.9% receiving alteplase reached excellent functional outcome (modified Rankin Scale score 0-1) after 3 months (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.70-1.85, p=0.59). No significant differences among patients in the two treatment groups regarding frequency of symptomatic intracranial hemorrhage during the first 48 h were identified (11 (8.5%) in the tenecteplase group, 10 (7.0%) in the alteplase group, OR 1.23, 95% CI 0.50-3.00, p 0.65). Death within 3 months occurred in 18 patients (14.3%) in the tenecteplase group and in 21 (15.3%) in the alteplase group (p 0.84). After excluding stroke mimics, the proportion of patients with excellent functional outcome was 44.1% in the tenecteplase group and 34.4% in the alteplase group (OR 1.50 CI 0.90-2.52, p 0.12). CONCLUSION No differences in the efficacy and safety of tenecteplase versus alteplase in patients ≥80 years were identified. TRIAL REGISTRATION Clinicaltrials.gov (NCT01949948).
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Affiliation(s)
- Bente Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher E Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Hege Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Håkon Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ole Morten Rønning
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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3
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Epidemiology and Outcomes of Ischemic Stroke and Transient Ischemic Attack in the Adult and Geriatric Population. J Stroke Cerebrovasc Dis 2018; 28:84-89. [PMID: 30297169 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/17/2018] [Accepted: 09/03/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Rate of ischemic strokes and transient ischemic attacks (TIAs) increases with age. There is lack of evidence on how age affects treatment strategies and outcomes. Our aim is to compare epidemiology of ischemic strokes and TIAs in adult and geriatric populations including risk factors, treatment delivered, and outcomes. DESIGN We designed a retrospective cross-sectional review of patients admitted to neurology with diagnosis of stroke or TIA from 2010 to 2015. Obtained variables were: age, sex, risk factors, acute therapy, National Institutes of Health Stroke Scale on admission and discharge, and disposition. Means, confidence intervals, or percentages were calculated as appropriate. RESULTS Around 1,457 patients were divided into two groups: younger than 80 (n = 968) and 80 and older (n = 487). Rates of stroke and TIA were similar across younger and older groups (11% versus 12% TIA and 89% versus 88% stroke, respectively). Younger patients had lower admission National Institutes of Health Stroke Scale (mean 4.64 versus 7.84 in older group) and greater improvement on discharge (mean change -1.51 versus -1.29 accordingly). Older patients received tissue-type plasminogen activator (tPA) more often than younger patients, but no difference in rates of thrombectomy between groups. Older patients were more likely to have hypertension, atrial fibrillation, coronary artery disease, and less likely to be a smoker. On discharge, younger patients with stroke were discharged home or to acute rehab more frequently, regardless of tPA administration. CONCLUSIONS Older patients had more comorbidities, received tPA more often, and had worse outcomes regardless of use of intravenous tPA or thrombectomy, and were more frequently institutionalized after discharge.
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4
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Alanazy MH, Barakeh RB, Asiri A, Edrees MF, Abuzinadah AR, Aljafen BN, Muayqil T. Practice Patterns and Barriers for Intravenous Thrombolysis: A Survey of Neurologists in Saudi Arabia. Neurol Res Int 2018; 2018:1695014. [PMID: 29666704 PMCID: PMC5831958 DOI: 10.1155/2018/1695014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/03/2018] [Accepted: 01/18/2018] [Indexed: 02/04/2023] Open
Abstract
Only a small fraction of patients with acute ischemic stroke receive intravenous thrombolysis (IVT). We sought to assess barriers and practice patterns in using IVT for acute ischemic stroke among neurologists in Saudi Arabia. An electronic survey was sent to all neurologists registered with the Saudi Commission for Health Specialties. A total of 148 (77.5%) neurologists responded. The most common reported barriers for IVT administration were delayed presentation to hospitals (82.4%) and unclear time of symptom onset (50.0%). Only 9.9% of neurologists reported strict adherence to the American Heart Association/American Stroke Association guidelines for IVT administration. The most frequently waived criteria were "minor stroke with National Institutes of Health Stroke Scale [NIHSS] < 5" (49.4%) and "seizure at onset" (45.7%). For the extended 3-4.5-hour window, 18.5% of neurologists reported strict adherence to the four exclusion criteria. The most frequently waived criteria were "age older than 80 years" (53.1%) and "history of both diabetes and prior stroke" (42.0%). In conclusion, most neurologists do not adhere to the IVT exclusion criteria. However, little consensus exists regarding which criteria do not interfere with IVT administration. Barriers to IVT administration were identified and require immediate action by healthcare authorities in Saudi Arabia.
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Affiliation(s)
- Mohammed H. Alanazy
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rima B. Barakeh
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alanood Asiri
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maha F. Edrees
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad R. Abuzinadah
- Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bandar N. Aljafen
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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5
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Zhu W, Xiao L, Lin M, Liu X, Yan B. Large-Vessel Occlusion Is Associated with Poor Outcome in Stroke Patients Aged 80 Years or Older Who Underwent Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2016; 25:2712-2716. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/14/2016] [Accepted: 07/10/2016] [Indexed: 11/30/2022] Open
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6
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Fredwall M, Sternberg S, Blackhurst D, Lee A, Leacock R, Nathaniel TI. Gender Differences in Exclusion Criteria for Recombinant Tissue-Type Plasminogen Activator. J Stroke Cerebrovasc Dis 2016; 25:2569-2574. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 04/06/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022] Open
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7
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Sagnier S, Galli P, Poli M, Debruxelles S, Renou P, Olindo S, Rouanet F, Sibon I. The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after 90 years old. BMC Geriatr 2016; 16:156. [PMID: 27562122 PMCID: PMC5000473 DOI: 10.1186/s12877-016-0331-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/20/2016] [Indexed: 12/24/2022] Open
Abstract
Background Age increases the risk of mortality and poor prognosis following stroke. The benefit of intravenous thrombolysis in very old patients remains uncertain. The purpose of the study was to evaluate the efficacy and safety of thrombolysis in very old patients considering their perfusion-imaging profile. Methods We conducted a retrospective study including patients older than 90 y.o. admitted for an acute ischemic stroke. A computed tomography perfusion-imaging (CTP) was performed in patients who received thrombolysis. Primary outcome was the functional status at 3 months, assessed by the modified Rankin scale (mRS). Secondary outcomes were the rate of hemorrhagic transformations, duration of hospitalization and the rate of death in the first 7 days. Patients receiving thrombolysis were compared with an age-matched group of non-thrombolysed patients. Results 78 patients were included (31 % male, aged 92 ± 1.7 y.o). 37 patients received thrombolysis and among them, 30 had CTP with a mismatch. The three months mRS was not significantly different in the two groups (mRS 0–2: 5 % and 7 % in the thrombolysed and non-thrombolysed group, respectively). Hemorrhagic transformations were more frequent in the thrombolysed group (54 % versus 12 %, p = 0.002) and symptomatic intracranial hemorrhage tended to be associated with mRS at three months and death in the first 7 days. Duration of hospitalization was longer in the thrombolysed group (10 days ± 12 versus 7 days ± 9, p = 0.046). Conclusions Patients who received thrombolysis did not have a better functional prognosis than non-thrombolysed patients. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0331-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Sagnier
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - P Galli
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - M Poli
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - S Debruxelles
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - P Renou
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - S Olindo
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - F Rouanet
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - I Sibon
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
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8
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Pego PM, Nunes AP, Ferreira P, Sousa C, Amaral-Silva A. Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe. J Stroke Cerebrovasc Dis 2016; 25:1532-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/23/2016] [Accepted: 03/03/2016] [Indexed: 11/24/2022] Open
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9
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Perren F, Eriksson A, Jönsson AC, Kremer C. Older Women Benefit from Thrombolysis as Much as Older Men. J Stroke Cerebrovasc Dis 2016; 25:1882-6. [PMID: 27158000 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/17/2016] [Accepted: 03/02/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Although the incidence of stroke among older people increases, the use of intravenous thrombolysis has initially been restricted in the elderly. However, more people aged more than 80 years, a majority of them women, may benefit from thrombolysis. Therefore characteristics, outcome, and complications in older women (aged more than 80 years) undergoing thrombolysis are studied and compared to older men and to younger women (aged less than 80 years) to detect any gender and age differences. METHODS Retrospective study of stroke patients treated with thrombolysis based on data collected from medical records. Outcome and complications were analyzed in 3 groups in relation to age and gender. RESULTS From a total of 108 patients treated with thrombolysis, 94 could be included in the study (36 women ≥80 years, 23 men ≥80 years, and 35 women <80 years). Improvement over the first 24 hours and at 3 months, and mortality were comparable between older women and men. Older women had more major strokes, a higher mortality, and 3-month morbidity than younger women. There was no significant difference in intracranial hemorrhage between the groups. CONCLUSIONS We found no significant difference between older women and men in outcome and mortality after thrombolysis. Older women suffered from more severe strokes, and had a higher mortality and worse outcome than younger women. The frequency of intracranial hemorrhage was comparable. Given the higher percentage of older women suffering from more severe strokes, our results emphasize that thrombolysis should not be withheld exclusively based on age.
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Affiliation(s)
- Fabienne Perren
- Department of Clinical Neurosciences, Division of Neurology, Neurovascular and Neurosonology Unit, HUG, University Hospital and Medical Faculty of Geneva, Geneva, Switzerland
| | | | | | - Christine Kremer
- Department of Neurology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden.
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10
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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11
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Stroke. Support for IV tPA in ischaemic stroke in elderly people. Nat Rev Neurol 2015; 12:8-9. [PMID: 26670296 DOI: 10.1038/nrneurol.2015.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In Europe, use of intravenous tissue plasminogen activator (tPA) in patients older than 80 years is discouraged because these patients have been excluded from certain past clinical trials. A new retrospective, observational study shows that tPA can substantially improve functional outcome after ischaemic stroke in patients aged 80–89 years.
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12
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Reuter B, Gumbinger C, Sauer T, Wiethölter H, Bruder I, Rode S, Ringleb PA, Kern R, Hacke W, Hennerici MG. Intravenous thrombolysis for acute ischaemic stroke in the elderly: data from the Baden-Wuerttemberg stroke registry. Eur J Neurol 2015; 23:13-20. [DOI: 10.1111/ene.12829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Affiliation(s)
- B. Reuter
- Department of Neurology; Universitätsmedizin Mannheim; University of Heidelberg; Mannheim Germany
- Department of Neurology; University Hospital Freiburg; University of Freiburg; Freiburg Germany
| | - C. Gumbinger
- Department of Neurology; University of Heidelberg; Heidelberg Germany
| | - T. Sauer
- Department of Neurology; Universitätsmedizin Mannheim; University of Heidelberg; Mannheim Germany
| | - H. Wiethölter
- (formerly) Department of Neurology; Bürgerhospital; Stuttgart Germany
| | - I. Bruder
- Office for Quality Assurance in Hospitals (GeQiK); Baden-Wuerttembergische Hospital Association; Stuttgart Germany
| | - S. Rode
- Office for Quality Assurance in Hospitals (GeQiK); Baden-Wuerttembergische Hospital Association; Stuttgart Germany
| | - P. A. Ringleb
- Department of Neurology; University of Heidelberg; Heidelberg Germany
| | - R. Kern
- Department of Neurology; Universitätsmedizin Mannheim; University of Heidelberg; Mannheim Germany
| | - W. Hacke
- Department of Neurology; University of Heidelberg; Heidelberg Germany
| | - M. G. Hennerici
- Department of Neurology; Universitätsmedizin Mannheim; University of Heidelberg; Mannheim Germany
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13
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Quality of Life After Off-Label Thrombolysis for Ischemic Stroke in Elderly Patients. Drugs Aging 2015; 32:917-26. [DOI: 10.1007/s40266-015-0307-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Sobolewski P, Kozera G, Kaźmierski R, Michalak S, Szczuchniak W, Nyka W. Efficacy of cerebral thrombolysis in an extended 'time window'. J Clin Pharm Ther 2015; 40:472-6. [PMID: 26059848 DOI: 10.1111/jcpt.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/29/2015] [Indexed: 01/23/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Cerebral systemic thrombolysis (i.v. thrombolysis) with tissue-type plasminogen activator (rt-PA) is the only proven medical therapy for ischaemic stroke. The use of i.v. thrombolysis up to 4·5 h from stroke onset was approved in certain countries in 2008, but its safety and efficacy have not been fully determined to date. OBJECTIVE To assess the long-term outcome and complication rate of i.v. thrombolysis performed in the extended 'time window'. METHODS The study included 403 ischaemic stroke patients consecutively treated with i.v. thrombolysis from 2006 to 2012 at three comprehensive stroke centres in Poland. The long-term outcome and the haemorrhagic complications' (HC) rate were compared between subgroups of patients treated within 3 vs. 3-4·5 h from stroke onset. RESULTS AND DISCUSSION About 132 (32·75%) patients were treated between 3 and 4·5 h from stroke onset. Neurological deficits tended to be more severe in patients treated ≤3 than in those treated 3-4·5 h (National Institutes of Health Stroke Scale, NIHSS 12 vs.10 points; P = 0·053); however, the ratio of patients with a favourable outcome (mRS 0-2 points) and mortality did not differ between the two groups (53·9 vs. 58·3, P = 0·39 and 17·7 vs. 21·2, P = 0·39, respectively). The rate of HC also did not differ between the two groups (18·8% vs. 15·1%, P = 0·46). WHAT IS NEW AND CONCLUSION The efficacy of i.v. thrombolysis routinely performed in an extended 'time window' is not reduced when compared to procedures performed within 3 h from symptom onset.
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Affiliation(s)
- P Sobolewski
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - G Kozera
- Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - R Kaźmierski
- Department of Neurology and Cerebrovascular Disorders, Poznań University of Medical Sciences, Poznań, Poland
| | - S Michalak
- Department of Neurochemistry and Neuropathology, Poznań University of Medical Sciences, Poznań, Poland
| | - W Szczuchniak
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - W Nyka
- Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland
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15
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Influence of neurologists' experience on the outcome of patients treated by intravenous thrombolysis for cerebral ischaemia. J Neurol 2015; 262:1209-15. [PMID: 25740665 DOI: 10.1007/s00415-015-7693-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
Abstract
Intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) should be available on a 24/7 basis in hospitals admitting patients with stroke. We aimed at evaluating the influence of the number of patients previously treated with i.v. rt-PA by neurologists on patients' outcome. For each patient consecutively treated with i.v. rt-PA for cerebral ischaemia at the Lille University Hospital, we determined the number of previous treatments with rt-PA administered by the neurologist. We performed logistic regression analyses to determine the influence of the experience on the outcome evaluated by the modified Rankin scale (mRS) after 3 months, 0-1 meaning independence, and 0-2 meaning absence of handicap. We compared outcomes of patients treated by the 25% less experienced neurologists with those of trials. Forty-four neurologists treated 800 patients. The experience of the treating neurologist was independently associated with independence (adjusted odds ratio [(adj)OR] 1.062 for 10 patients more; 95% confidence interval [CI] 1.008-1.120), and absence of handicap ((adj)OR 1.076 for 10 patients more; 95%CI 1.016-1.140) at 3 months, but not with symptomatic intracerebral haemorrhage and death. The proportions of patients from the 1st quartile who were independent and without handicap at 3 months were 37.9 and 51.1%. Patients treated by less experienced neurologists, have similar outcomes than expected from trials, suggesting they benefit from thrombolysis. However, the outcome of patients treated by more experienced neurologists was slightly better. Less experienced neurologists should not be excluded from rt-PA programmes, but their practices should be evaluated and educational programmes organised.
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Zhu W, Churilov L, Campbell BC, Lin M, Liu X, Davis SM, Yan B. Does Large Vessel Occlusion Affect Clinical Outcome in Stroke with Mild Neurologic Deficits after Intravenous Thrombolysis? J Stroke Cerebrovasc Dis 2014; 23:2888-2893. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/28/2014] [Accepted: 07/11/2014] [Indexed: 11/29/2022] Open
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Chausson N, Olindo S, Joux J, Saint-Vil M, Aveillan M, Smadja D. Safety of Standard-dose (.9-mg/kg) Alteplase Intravenous Thrombolysis for Acute Ischemic Stroke in Afro–Caribbeans, French West Indies. J Stroke Cerebrovasc Dis 2014; 23:1776-80. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/16/2014] [Accepted: 05/05/2014] [Indexed: 10/25/2022] Open
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Abstract
Alteplase has traditionally been the only pharmacologic agent available for treating acute ischemic stroke worldwide, and is considered an effective and safe therapeutic drug for acute cerebral ischemia. However, the drug is usually indicated for use in patients aged <81 years due to insufficient literature regarding the drug’s safety in older individuals. Nevertheless, the elderly can benefit from alteplase after they experience an acute ischemic stroke. Age differences have been observed in the clinical presentation of acute ischemic stroke; however, the safety and efficacy of alteplase for patients with acute ischemic stroke do not depend on age or sex. Evidence of an increasing rate of intracerebral hemorrhage among the elderly with acute ischemic stroke, following alteplase treatment, has not been reported. Severe intracranial hemorrhage is a known side effect of alteplase but is not associated with age in patients with acute ischemic stroke. Alteplase can be used safely and effectively to treat elderly patients who suffer an acute ischemic stroke, including those over the age of 80 years.
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Affiliation(s)
- Josef Yayan
- Department of Internal Medicine, University Hospital of Saarland, Homburg/Saar, Germany.
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Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and "inpatient" management models for geriatric emergencies. Clin Geriatr Med 2013; 29:31-47. [PMID: 23177599 PMCID: PMC3875836 DOI: 10.1016/j.cger.2012.09.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care.
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Sarikaya H. Safety and Efficacy of Thrombolysis with Intravenous Alteplase in Older Stroke Patients. Drugs Aging 2013; 30:227-34. [DOI: 10.1007/s40266-013-0052-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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