Repeated intravenous thrombolysis after recurrent stroke. A case series and review of the literature

Association of Atrial Fibrillation with Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results from a Multicenter Study in China

INTRODUCTION

This study aimed to investigate the association between atrial fibrillation (AF), particularly newly diagnosed AF, and remote intracerebral hemorrhage (rICH) in patients with ischemic stroke who were treated with intravenous thrombolysis (IVT).

METHODS

This observational study was conducted on patients with ischemic stroke who received IVT with recombinant tissue-type plasminogen activator. The data were taken from a multicenter prospective registry of a Chinese population. rICH was defined as any extraischemic hemorrhage detected on computerized tomography (CT) 24 h after intravenous thrombolysis. We collected and compared the demographic data and clinical characteristics of all the patients with rICH to those of patients without any type of hemorrhagic transformation. The association between AF and rICH was analyzed using univariate analysis and binary logistic regression.

RESULTS

A total of 20,697 patients were included in the study, with 1566 (7.6%) experiencing intracerebral hemorrhage (ICH), 586 (2.8%) experiencing rICH, and 19,131 (92.4%) not experiencing any form of hemorrhagic transformation. Univariate analysis revealed significant differences in age, pre-thrombolysis systolic blood pressure, baseline National Institute of Health Stroke Scale score, previously known AF, newly diagnosed AF, coronary heart disease, congestive heart failure, hyperhomocysteinemia, and history of thrombolysis between the rICH and control groups (P < 0.05). Further multivariate logistic regression analysis indicated that total AF (OR 1.821, 95% CI 1.082-3.065, P < 0.05), previously known AF (OR 1.470, 95% CI 1.170-1.847), and newly diagnosed AF (OR 1.920, 95% CI 1.304-2.825) were independently associated with rICH.

CONCLUSIONS

This study suggests that AF, regardless of whether it is newly diagnosed or previously known, may be associated with the occurrence of rICH following intravenous thrombolysis. Interestingly, our findings suggest that newly diagnosed AF may have a stronger impact on rICH than previously known AF, although confirmation from more studies is needed.

Ultraearly repeated systemic thrombolysis in recurrent ischemic stroke - A multicentre case study

OBJECTIVE

We analysed outcomes of patients who received off-label repeated thrombolysis with recombinant tissue plasminogen activator for ischemic stroke recurrence within 10 days (ultraearly repeated thrombolysis, UERT).

METHOD

We identified patients receiving UERT from the prospective telestroke network of South-East Bavaria (TEMPiS) registry and by database search (Pubmed, Google scholar). Corresponding authors were contacted for further details. Baseline demographic data and clinical, laboratory, and imaging findings were analysed in a multicentric case study.

RESULTS

Sixteen patients receiving UERT were identified. The median time between first and second thrombolysis was 3.5 days. In patients with available data, second thrombolysis achieved an early clinical improvement (NIHSS reduction ≥4 points) in 12 of 14 (85.7%) and a favourable outcome (mRS 0-2 after 3 months) in 11 of 16 (68.8%) patients. Intracerebral haemorrhage (ICH) occurred in 4 patients (25.0%) with one fatal large parenchymatous haemorrhage (6.3%). Neither allergic reactions nor other immunoreactive events were observed.

CONCLUSIONS

In our analysis UERT led to early clinical improvement and a favourable clinical outcome in a high percentage of patients with ICH rates comparable to prior publications. UERT might be considered in patients with early recurrent stroke under careful risk-benefit assessment.

Repeated intravenous thrombolysis in early recurrent stroke secondary to carotid web: Case report

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is the first effective approved treatment for reducing ischemic stroke disability, and having a stroke within 3 months is usually a contraindication to thrombolysis. In this paper, we describe the case of a 58-year-old patient who received repeated intravenous thrombolysis at 10 days interval for a recurrent ischemic stroke, with dramatic improvement. The carotid diaphragm was behind this recurrent stroke and it was treated by stenting.

Re-examining the exclusion criterion of early recurrent ischemic stroke in intravenous thrombolysis: A meta-analysis

BACKGROUND

Current guidelines preclude the administration of intravenous tissue plasminogen activator in patients with early recurrent stroke (prior ischemic stroke within three months).

OBJECTIVES

This is a meta-analysis that aimed to determine the safety and efficacy of thrombolysis in patients with early recurrent stroke.

SUMMARY OF REVIEW

Pubmed, Cochrane, Scopus, Embase and Clinicaltrials.gov were searched for studies comparing the outcomes of acute ischemic stroke patients undergoing intravenous thrombolysis between those with early recurrent stroke and those without. Random-effects meta-analysis was used to evaluate the outcomes in terms of symptomatic intracranial hemorrhage, mortality and good functional outcomes at 3 months (modified Rankin Score ≤ 2). Three retrospective cohort studies with a total of 48,459 thrombolysed patients (824 with early recurrent stroke and 47,635 without early recurrent stroke) were included in the meta-analysis. There was no significant difference between thrombolysed patients with early recurrent stroke and those without in terms of symptomatic intracranial hemorrhage (Odds Ratio [OR] 1.39, 95% Confidence Interval [CI] 0.75-2.58), mortality (OR 1.36, 95% CI 0.60-3.09) and good functional outcomes at 3 months (OR 0.74, 95% CI 0.47-1.16).

CONCLUSIONS

Patients who received thrombolysis despite early recurrent stroke were not found to be at an increased risk of adverse outcomes compared to patients without early recurrent stroke. Our meta-analysis suggests that there is insufficient evidence to substantiate excluding patients with early recurrent stroke from receiving thrombolysis. Further studies to re-examine early recurrent stroke as an exclusion criterion for receiving thrombolysis are warranted.

Why not Intravenous Thrombolysis in Patients with Recurrent Stroke within 3 Months?

Acute ischemic stroke continues to be a very severe disorder that has significant impact on human health. Its treatment options are limited and alteplase remains the only American Food and Drug Administration-approved drug for patients with acute ischemic stroke. Furthermore, intravenous thrombolysis remains substantially underutilized, because it has rigorous indications and contraindications. Most patients simply do not meet these criteria and cannot receive thrombolytic treatment. Guidelines in many countries currently include a history of stroke within months as one of the exclusion criteria for intravenous thrombolysis. Although this is based on previous data, it lacks strong evidentiary support. Several recent studies suggested that intravenous thrombolysis may be beneficial for this patient population. We reviewed relevant publications of intravenous thrombolysis or repeated intravenous thrombolysis in patients with a history of stroke in the past 3 months. We found that intravenous thrombolysis in these patients is not as hazardous as previously believed. Among patients with relatively small infarctions and a good prognosis, intravenous thrombolysis may be a good treatment option. We hope that more research will be carried out on this topic to reexamine the criteria for intravenous thrombolysis to allow more patients to benefit from treatment.

Knowledge of Stroke Risk Factors and Warning Signs in Patients with Recurrent Stroke or Recurrent Transient Ischaemic Attack in Thailand

Stroke is a global burden. It is not known whether patients who are most at risk of stroke (recurrent stroke or recurrent transient ischaemic attack) have enough knowledge of stroke risk factors and warning signs. The aim of this study was to assess the knowledge of stroke risk factors and warning signs in this high-risk population. We performed a cross-sectional questionnaire-based study of patients with recurrent stroke or recurrent TIA admitted to Srinagarind Hospital and Khon Kaen Hospital, Thailand. A total of 140 patients were included in the study (age 65.6 ± 11.3 years [mean ± SD], 62 females). Using an open-ended questionnaire, nearly one-third of patients (31.4%) could not name any risk factors for stroke. The most commonly recognized risk factors were hypertension (35%), dyslipidemia (28.6%), and diabetes (22.9%). Regarding stroke warning signs, the most commonly recognized warning signs were sudden unilateral weakness (61.4%), sudden trouble with speaking (25.7%), and sudden trouble with walking, loss of balance, or dizziness (21.4%). Nineteen patients (13.6%) could not identify any warning signs. The results showed that knowledge of stroke obtained from open-ended questionnaires is still unsatisfactory. The healthcare provider should provide structured interventions to increase knowledge and awareness of stroke in these patients.

Outcome of Repeated Thrombolysis in Debrecen Thrombolysis Database

INTRODUCTION

Recombinant tissue plasminogen activator (rtPA) is an efficient therapy of acute ischemic stroke. The risk of a recurrent ischemic stroke is high. This prospective single center study aimed to assess whether or not the repeated rtPA treatment is beneficial for acute stroke patients.

METHODS

All thrombolysed patients' data at the Department of Neurology, University of Debrecen have been recorded in the Debrecen Thrombolysis Database (DTD) since 2004. We identified 21 patients with repeated thrombolysis. Stroke severity by the NIH stroke scale score (NIHSSS) and imaging findings by the Alberta Stroke Programme Early CT Score were evaluated on admission and 1 day later. The modified Rankin Scale score at 3 months and case fatality at 1 year were evaluated. We compared the first and second thrombolyses, and we screened for bleeding and allergic reactions to determine safety.

RESULTS

Within the 27-month median time, 18 patients were thrombolysed twice, with complete follow-up. In recurrent stroke patients, diabetes mellitus, congestive heart failure, and anticoagulation were more common. Admission cholesterol levels were decreased. After the first and second treatments, 24-hour NIHSSS were 3 (1;6) and 7 (1;10), respectively. At 3 months, good outcome was significantly higher after the first treatment than those of DTD, with no differences between the 2 attempts. There was little difference in 3-month and 1-year outcomes, regardless of laterality-ipsilateral or contralateral hemisphere-in recurrent strokes. One patient had nonsymptomatic intracranial bleeding after repeated rtPA treatment.

DISCUSSION

Recurrent rtPA treatment may be safe and effective in patients who have mild or moderate residual symptoms after the index stroke.

Repeated Intravenous Thrombolysis for Early Recurrent Stroke: Challenging the Exclusion Criterion

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) within 4.5 hours from symptom onset improves functional outcome in patients with acute ischemic stroke. Its use in patients with previous stroke within the preceding 3 months is contraindicated because of the assumed higher risk of intracranial hemorrhage. In addition, tissue-type plasminogen activator may itself promote neurotoxicity and blood-brain barrier disruption. However, safety and effectiveness of repeated IVT is essentially unknown in patients with early (<3 months) recurrent stroke (ERS), because they were excluded from thrombolysis trials. This article reports the largest case series of repeated IVT in ERS.

METHODS

We reviewed databases of prospectively collected patient data of 8 European stroke centers for the presence of patients with ERS, who received IVT for both the index stroke and ERS. Demographics, clinical and radiological data, bleeding complications, and functional outcome were analyzed.

RESULTS

We identified 19 subjects with repeated IVT in ERS. Mean age was 68±12 years, and 37% of them were female. Median interthrombolysis interval was 30 days (interquartile range, 13-50). Functional independence (modified Rankin scale score ≤2) was achieved in 79% of patients after the first and in 47.4% after repeated IV tissue-type plasminogen activator, respectively. There was no symptomatic intracranial hemorrhage. Median final infarct volume after the first IVT was 1.5 cm(3) (interquartile range, 0.5-3.1).

CONCLUSIONS

Patients with small infarct volumes and robust clinical improvement might be considered for repeated IVT within 3 months. Studies following strict protocols and larger registries incorporating these patients might serve to identify selection criteria for the safe use of repeated IVT in ERS.

Intravenous Thrombolysis for Stroke Recurring Within 3 Months From the Previous Event

Background and Purpose—

According to the European license, alteplase can be given no sooner than 3 months after previous stroke. However, it is not known whether past history of stroke influences the effect of treatment. Our aim was to evaluate safety and functional outcome after intravenous thrombolysis administered in everyday practice to patients with previous stroke ≤3 months compared with those with first-ever stroke.

Methods—

We analyzed consecutive cases treated with alteplase between October 2003 and July 2014 contributed to the Safe Implementation of Thrombolysis for Stroke–Eastern Europe registry from 12 countries. Odds ratios were calculated using unadjusted and adjusted logistic regression.

Results—

Of 13 007 patients, 11 221 (86%) had no history of stroke and 249 (2%) experienced previous stroke ≤3 months before admission. Patients with previous stroke ≤3 months had a higher proportion of hypertension and hyperlipidemia. There were no significant differences in outcome, including symptomatic intracerebral hemorrhage according to European Cooperative Acute Stroke Study (unadjusted odds ratio 1.27, 95% confidence interval: 0.74–2.15), and being alive and independent at 3 months (odds ratio 0.81, 95% confidence interval: 0.61–1.09).

Conclusions—

Patients currently treated with alteplase, despite a history of previous stroke ≤3 months, do not seem to achieve worse outcome than those with first-ever stroke. Although careful patient selection was probably of major importance, our findings provide reassurance that this group of patients may safely benefit from thrombolysis and should not be arbitrarily excluded as a whole. Further studies are needed to identify the shortest safe time lapse from the previous event to treatment with alteplase.