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van der Steen W, van der Ende NAM, van Kranendonk KR, Chalos V, Brouwer J, van Oostenbrugge RJ, van Zwam WH, van Doormaal PJ, van Es ACGM, Majoie CBLM, van der Lugt A, Dippel DWJ, Roozenbeek B. Timing of symptomatic intracranial hemorrhage after endovascular stroke treatment. Eur Stroke J 2022; 7:393-401. [PMID: 36478761 PMCID: PMC9720857 DOI: 10.1177/23969873221112279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/20/2022] [Indexed: 02/13/2024] Open
Abstract
INTRODUCTION Little is known about the timing of occurrence of symptomatic intracranial hemorrhage (sICH) after endovascular therapy (EVT) for acute ischemic stroke. A better understanding could optimize in-hospital surveillance time points and duration. The aim of this study was to delineate the probability of sICH over time and to identify factors associated with its timing. PATIENTS AND METHODS We retrospectively analyzed data from the Dutch MR CLEAN trial and MR CLEAN Registry. We included adult patients who underwent EVT for an anterior circulation large vessel occlusion within 6.5 h of stroke onset. In patients with sICH (defined as ICH causing an increase of ⩾4 points on the National Institutes of Health Stroke Scale [NIHSS]), univariable and multivariable linear regression analysis was used to identify factors associated with the timing of sICH. This was defined as the time between end of EVT and the time of first CT-scan on which ICH was seen as a proxy. RESULTS SICH occurred in 205 (6%) of 3391 included patients. Median time from end of EVT procedure to sICH detection on NCCT was 9.0 [IQR 2.9-22.5] hours, with a rapidly decreasing incidence after 24 h. None of the analyzed factors, including baseline NIHSS, intravenous alteplase treatment, and poor reperfusion at the end of the procedure were associated with the timing of sICH. CONCLUSION SICHs primarily occur in the first hours after EVT, and less frequently beyond 24 h. Guidelines that recommend to perform frequent neurological assessments for at least 24 h after intravenous alteplase treatment can be applied to ischemic stroke patients treated with EVT.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nadinda AM van der Ende
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear
Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The
Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
| | - Josje Brouwer
- Department of Neurology, Amsterdam
University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht
University Medical Center, Cardiovascular Research Institute Maastricht (CARIM),
Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear
Medicine, Maastricht University Medical Center, Cardiovascular Research Institute
Maastricht (CARIM), Maastricht, The Netherlands
| | - Pieter J van Doormaal
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
| | - Adriaan CGM van Es
- Department of Radiology, Leiden
University Medical Center, Leiden, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear
Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The
Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Moreland S, Mukherjee D, Nickel NP. Contemporary Treatment of Pulmonary Embolism: Medical Treatment and Management. Int J Angiol 2022; 31:155-161. [DOI: 10.1055/s-0042-1750329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractPulmonary embolus (PE) is defined as obstruction of the pulmonary artery or one of its branches by material (e.g., thrombus, tumor, air, or fat) but most commonly due to thrombus originating from the lower extremity deep veins.We reviewed the current literature describing the optimal medical treatment and management of PE.Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched for relevant studies and guidelines for management of patients with PE.The initial approach to patients with suspected PE should focus upon stabilizing the patient while further workup for risk stratification is in progress. In most cases, anticoagulation should ideally be started even prior to confirming PE, if risk–benefit regarding suspicion of PE and bleeding risk is favorable.Once the diagnosis is confirmed, risk stratification will guide further therapies consisting of anticoagulation, thrombolysis, or catheter-directed interventions. Data for initial, long-term, and indefinite anticoagulation, and factors that determine whether or not a patient can be treated in the outpatient setting, are reviewed and discussed.
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Affiliation(s)
- Stephen Moreland
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Nils P. Nickel
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
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Javed K, Boyke A, Naidu I, Ryvlin J, Fluss R, Fortunel AN, Dardick J, Kadaba D, Altschul DJ, Haranhalli N. Predictors of Radiographic and Symptomatic Hemorrhagic Conversion Following Endovascular Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion. Cureus 2022; 14:e24449. [PMID: 35637796 PMCID: PMC9129917 DOI: 10.7759/cureus.24449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 11/05/2022] Open
Abstract
Background Endovascular therapy is known to achieve a high rate of recanalization in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and is currently the standard of care. Hemorrhagic conversion is a severe complication that may occur following AIS in patients undergoing endovascular thrombectomy (EVT). There is a scarcity of data on the risk factors related to HV in post-EVT patients, especially those who develop symptomatic hemorrhagic conversion. The main objective of our study is to identify independent predictors of radiographic and symptomatic hemorrhagic conversion in our diverse patient population with multiple baseline comorbidities that presented with AIS and were treated with EVT as per the most updated guidelines and practices. Methodology This is a retrospective chart review in which we enrolled adult patients treated with EVT for AIS at a comprehensive stroke center in the Bronx, NY, over a four-year period. Bivariate analyses followed by multiple logistic regression modeling were performed to determine the independent predictors of all and symptomatic hemorrhagic conversion. Results A total of 326 patients who underwent EVT for AIS were enrolled. Of these, 74 (22.7%) had an HC, while 252 (77.3%) did not. In total, 25 out of the 74 (33.7%) patients were symptomatic. In the logistic regression model, a history of prior ischemic stroke (odds ratio (OR) = 2.197; 95% confidence interval (CI) = 1.062-4.545; p-value = 0.034), Alberta Stroke Program Early CT Score (ASPECTS) of <6 (OR = 2.207; 95% CI = 1.477-7.194; p-value = 0.019), and Thrombolysis in Cerebral Infarction (TICI) 2B-3 recanalization (OR = 2.551; 95% CI = 1.998-6.520; p-value=0.045) were found to be independent predictors of all types of hemorrhagic conversion. The only independent predictor of symptomatic hemorrhagic conversion on multiple logistic regression modeling was an elevated international normalized ratio (INR) (OR = 11.051; 95% CI = 1.866-65.440; p-value = 0.008). Conclusions History of prior ischemic stroke, low ASPECTS score, and TICI 2B-3 recanalization are independent predictors of hemorrhagic conversion while an elevated INR is the only independent predictor of symptomatic hemorrhagic conversion in post-thrombectomy patients.
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Lillyblad MP, Qadri GA, Weise BE, Smith CS, St Hill C, Tierney DM, Melamed RR. Post-thrombolytic coagulopathy and complications in patients with pulmonary embolism treated with fixed-dose systemic alteplase. J Thromb Thrombolysis 2022; 54:605-615. [PMID: 35320471 DOI: 10.1007/s11239-022-02640-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Alteplase treatment can cause a systemic coagulopathy although the incidence and contributory factors are unknown in pulmonary embolism (PE). Fixed-dosing of alteplase for PE may lead to interpatient variability in drug exposure and influence post-thrombolytic coagulopathy (PTC). While changes in fibrinogen and INR have been used to describe PTC, no universal PTC definition is available. OBJECTIVES Evaluate the incidence of PTC after alteplase treatment for PE, the effect of patient weight and blood/plasma volume and the association with bleeding complications. METHODS We conducted a retrospective cohort study of patients treated with alteplase for massive or high-risk submassive PE. Demographics, alteplase dosing, laboratory assessment of coagulopathy, and bleeding events were collected. The primary endpoint was incidence of PTC defined as an international normalized ratio (INR) > 1.5 or fibrinogen < 170 mg/dL. Secondary outcomes included correlation between coagulopathies and alteplase dose normalized to actual body weight (ABW), ideal body weight (IBW), plasma volume (PV), and estimated blood volume (EBV). Bleeding events in patients with and without PTC were compared. RESULTS 125 patients met criteria for inclusion in the study. PTC occurred in 35.3% of patients, with INR >1.5 in 21.8% and fibrinogen <170 mg/dL in 26%. Alteplase dose >50 mg was associated with increased odds of PTC (OR 6.5, CI 2.1-19.9). Dose normalized to ABW and EBV correlated weakly with absolute increase in post-alteplase INR (r =0.20, p =0.06 and r =0.21, p =0.057 respectively) and to percent change in INR (r =0.20, p = 0.058 and r =0.21, p =0.048 respectively). Dose/ABW, dose/PV, and dose/EBV each correlated moderately with absolute decrease in fibrinogen (r =-0.53, -0.49, and -0.47 respectively, p <0.001 for each) and percent change in fibrinogen (r = -0.55, -0.49, and -0.49 respectively, p < 0.001 for each). Dose/IBW correlated weakly with absolute and percent decrease in fibrinogen (r = -0.32, p =0.013 and r =-0.33, p =0.011). Patients with bleeding were more likely to have PTC (58.3% vs. 28.6%, p= 0.05) and a bleeding event was predictive of PTC (OR 5.33, 1.32-23.99). CONCLUSIONS PTC is prevalent in patients with PE. PTC is influenced by alteplase dose and exposure parameters (ABW, IBW, PV, EBV) and may contribute to the bleeding risk.
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Affiliation(s)
- Matthew P Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, 800 East 28th Street - MR 11321, 55407, Minneapolis, MN, USA.
| | - Ghaziuddin A Qadri
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Brynn E Weise
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Claire S Smith
- Care Delivery Research, Allina Health, Minneapolis, MN, USA
| | | | - David M Tierney
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Roman R Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, MN, USA
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Sanders CB, Knisely K, Rathfoot C, Edrissi C, Nathaniel T. Acute Ischemic Stroke and Heart Failure: Stroke Risk Factors Associated with Exclusion from Thrombolytic Therapy. Clin Appl Thromb Hemost 2022; 28:10760296221116347. [PMID: 36278505 PMCID: PMC9596934 DOI: 10.1177/10760296221116347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/22/2022] [Accepted: 07/11/2022] [Indexed: 11/05/2022] Open
Abstract
Objective: Acute ischemic stroke (AIS) patients with congestive heart failure (HF) that present with various risk factors are less likely to receive recombinant tissue plasminogen activator (rtPA). The risk factors associated with excluding AIS patients with congestive heart failure (AIS-HF) from rtPA therapy have not been fully established. Methods: Retrospective data for 5469 AIS patients comprised of 590 AIS patients with HF and 4879 AIS patients without HF were collected from a regional stroke registry between January 2010 and June 2016. Baseline risk factors were analyzed using logistic regression analysis to determine the risk factors associated with rtPA exclusion in AIS-HF patients. Results: In the adjusted analysis, AIS-HF patients that that did not receive rtPA were more likely to be older (OR = 0.982, 95% CI, 0.966-1, P = .020), presented with coronary artery disease (OR = 0.618, 95% CI, 0.391-0.98, P = .040), and with an elevated INR (OR = 0.326, 95% CI, 0.129-0.82, P = .018). AIS-HF patients that were included for rtPA therapy were more likely to show improvement in ambulatory status (OR = 1.69, 95% CI, 1.058-2.7, P = .028). The discriminating power of the model was strong with an area under the curve (AUROC) = 0.668 (95% CI, 0.611-0.724, P < .001). Conclusion: Our study establishes the associations between stroke risk factors and exclusion from rtPA therapy. This finding suggests the need to develop management strategies for older HF patients with carotid artery disease and an elevated INR to improve their eligibility for rtPA treatment following an acute ischemic stroke.
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Affiliation(s)
| | - Krista Knisely
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
| | - Chase Rathfoot
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
| | - Camron Edrissi
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
| | - Thomas Nathaniel
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
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Romoli M, Giannandrea D, Zini A. Fibrinogen depletion and intracerebral hemorrhage after thrombolysis for ischemic stroke: a meta-analysis. Neurol Sci 2021; 43:1127-1134. [PMID: 34212264 DOI: 10.1007/s10072-021-05441-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/24/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Intracerebral hemorrhage (ICH) can be a fatal complication of intravenous thrombolysis (IVT) for acute ischemic stroke. An early coagulopathy can develop after IVT, in relation to a significant fibrinogen depletion, increasing the risk of ICH. This systematic review and meta-analysis aimed at defining the role of fibrinogen depletion after IVT on the risk of ICH after IVT. METHODS Protocol was registered with PROSPERO (CRD42020124241) and followed PRISMA and MOOSE guidelines. We systematically searched English studies reporting rates of post-IVT ICH depending on fibrinogen depletion until 7/1/2021. Primary outcome was symptomatic ICH (sICH). Meta-analysis followed random-effects model to account for heterogeneity in design and timing of ascertainments. Biases were assessed via the Newcastle-Ottawa Scale. RESULTS Overall, among 352 records identified, 5 observational studies were eligible for quantitative synthesis (n = 2142), all of fair quality. Considering sICH within 24-36 h post-IVT, pooling data from 4 studies (n = 1753), fibrinogen depletion consistently increased the risk of sICH (OR 3.67, 95%CI 2.28-5.90, pheterogeneity = 0.55). Pooling adjusted estimated for age, gender, and NIHSS from 3 studies (n = 723), fibrinogen depletion was confirmed to significantly increase the risk of ICH after IVT (OR 5.41, 95%CI 2.96-9.89). CONCLUSIONS Fibrinogen depletion significantly increases the risk of ICH after IVT for acute ischemic stroke. Routine fibrinogen assessment might be considered to identify people at higher risk of ICH. As fibrinogen repletion is feasible, trials should investigate its efficacy in preventing ICH, potentially increasing the net benefit profile of IVT in acute ischemic stroke.
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Affiliation(s)
- Michele Romoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurology and Stroke Center, Ospedale Maggiore, Bologna, Italy. .,Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy. .,Neurology and Stroke Unit, "Maurizio Bufalini" Hospital, Cesena, Italy.
| | - David Giannandrea
- Neurology and Stroke Unit, Gubbio-Gualdo Tadino Hospital, Gubbio, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurology and Stroke Center, Ospedale Maggiore, Bologna, Italy
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Response to the Letter to the Editor: Consideration Needed for Early Anticoagulation Following Intravenous tPA in Patients with COVID-19. J Stroke Cerebrovasc Dis 2021; 30:105789. [PMID: 33840594 PMCID: PMC8006190 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cheng Z, Huang X, Muse FM, Xia L, Zhan Z, Lin X, Cao Y, Han Z. Low Serum Magnesium Levels Are Associated With Hemorrhagic Transformation After Thrombolysis in Acute Ischemic Stroke. Front Neurol 2020; 11:962. [PMID: 32982953 PMCID: PMC7492199 DOI: 10.3389/fneur.2020.00962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background: In patients with acute ischemic stroke, hemorrhagic transformation is a major complication after intravenous thrombolysis. This study aimed to investigate the relationship between serum magnesium levels and hemorrhagic transformation (HT) after thrombolytic therapy. Methods: We retrospectively analyzed data from 242 patients who received thrombolytic therapy at the Second Affiliated Hospital of the Wenzhou Medical University in China. Baseline serum magnesium levels were measured before intravenous thrombolysis, and the occurrence of HT was evaluated using computed tomography images reviewed within 24–36 h after therapy. The relationship between serum magnesium levels and HT was examined using multivariate logistic regression, subgroup analysis, and restricted cubic spline models. Results: Of the 242 included patients, 43 (17.8%) developed HT. Patients with HT had significant lower serum magnesium levels than those without HT (0.81 ± 0.08 vs. 0.85 ± 0.08 mmol/L, p = 0.007). Multivariable logistic regression analysis indicated that patients with higher serum magnesium levels had lower risk of HT (OR per 0.1-mmol/L increase 0.43, 95% CI 0.27–0.73, p = 0.002). However, this association did not persist when baseline levels of serum magnesium were higher than the median value (0.85 mmol/L) in subgroup analysis (OR per 0.1-mmol/L increase 0.58, 95% CI 0.14–2.51, p = 0.47). This threshold effect was also observed in the restricted cubic spline model when serum magnesium levels were above 0.88 mmol/L. No association between symptomatic HT and serum magnesium levels was observed in our study (OR per 0.1-mmol/L increase 0.52, 95% CI 0.25–1.11, p = 0.092). Conclusions: Lower serum magnesium levels in patients with ischemic stroke are associated with an increased risk of HT after intravenous thrombolysis, but perhaps only when serum magnesium is below a certain minimal concentration.
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Affiliation(s)
- Zicheng Cheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoyan Huang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Farah Mohamed Muse
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lingfan Xia
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenxiang Zhan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianda Lin
- Department of Neurology, The Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Yungang Cao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhao Han
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Ling XW, Lin K, Jiang XQ, Wu Q, Liu ZJ, Li S, Zhao S, Lin C. International normalised ratio as an independent predictor of mortality in limb necrotising fasciitis with sepsis. Ann R Coll Surg Engl 2020; 103:35-40. [PMID: 32829649 DOI: 10.1308/rcsann.2020.0189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Necrotising fasciitis with sepsis is a life threatening disease. The aim of this study was to analyse the association between international normalised ratio (INR) and mortality in sepsis patients with necrotising fasciitis. METHODS A retrospective review was undertaken of 106 patients suffering from necrotising fasciitis with sepsis between November 2007 and December 2016. Data on comorbidities, clinical manifestations, laboratory findings, causative microbiological organisms, APACHE II (Acute Physiology and Chronic Health Evaluation II) score and outcomes were extracted. Logistic regression was carried out to examine the factors affecting mortality. RESULTS Forty patients (37.7%) died. There was no significant difference in the white blood count (WBC) for the survivor and non-survivor groups. Non-survivors had a lower mean oxygenation index (OI) (288.7mmHg vs 329.4mmHg, p=0.032) and platelet count (PC) (139.5 vs 214.8 x 109/l, p=0.028), and a higher mean INR (1.9 vs 1.3, p=0.000), activated partial thromboplastin time (APTT) (54.6 vs 44.2 seconds, p=0.005) and serum creatinine (2.3mg/dl vs 1.4mg/dl, p=0.007). Mortality in patients with INR >1.5 was significantly higher than in those with INR <1.5 when all risk factors (WBC, PC, OI, INR, APTT, creatinine) were considered (odds ratio: 4.414, 95% confidence interval: 1.263-15.428, p=0.020). Even after adjusting for age, sex, bacteraemia, diabetes and hepatic disorders, the data still exhibited elevated mortality for patients with INR >1.5 (odds ratio: 5.600, 95% confidence interval: 1.415-22.166, p=0.014). CONCLUSIONS INR is a significant independent predictor of mortality in sepsis patients diagnosed with necrotising fasciitis.
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Affiliation(s)
- X W Ling
- First Affiliated Hospital of Wenzhou Medical University, China
| | - K Lin
- First Affiliated Hospital of Wenzhou Medical University, China
| | - X Q Jiang
- First Affiliated Hospital of Wenzhou Medical University, China
| | - Q Wu
- First Affiliated Hospital of Wenzhou Medical University, China
| | - Z J Liu
- First Affiliated Hospital of Wenzhou Medical University, China
| | - S Li
- First Affiliated Hospital of Wenzhou Medical University, China
| | - S Zhao
- First Affiliated Hospital of Wenzhou Medical University, China
| | - C Lin
- First Affiliated Hospital of Wenzhou Medical University, China
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Erdman MJ, Davidson KE, Haller JT, Shah S, Gross W, Andrews J, Patel A, Jones GM. Effect of Alteplase Administration on International Normalized Ratio in Patients With Acute Ischemic Stroke. Neurohospitalist 2020; 10:176-180. [PMID: 32549940 DOI: 10.1177/1941874419879813] [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] [Indexed: 01/01/2023] Open
Abstract
Background/Objective Alteplase may elevate international normalized ratio (INR) results, although the exact rate of elevation occurrence is not firmly established in the literature. The purpose of this study is to determine the occurrence rate of INR elevation following alteplase administration. We also aimed to determine what factors are independently associated with the development of elevated INR following alteplase administration for ischemic stroke. Methods We conducted a multicenter, retrospective, cohort study of patients who received alteplase for acute ischemic stroke. Patients were screened for baseline INR measurement and a repeat value within 24 hours of alteplase administration. The primary outcome was the percent of patients who experienced ≥0.4-point increase in INR. Secondary outcomes included the rate of adverse bleeding events and identification of factors independently associated with elevated INR following alteplase administration. Results and Conclusions Two hundred and sixty-one patients were included, with 44 (16.9%) patients having an INR increase of 0.4 or more. Patients with an INR increase ≥0.4 experienced a nonstatistically significant increase in bleeding episodes (8.8% vs 18.2%; P = .10). We identified African American race (odds ratio, 3.48, 95% confidence interval, 1.5-7.6; P = .002) as an independent predictor of INR increase ≥0.04. An INR elevation is common following receipt of alteplase for ischemic stroke. Those of African American race were at increased risk of INR elevation; however, more studies are needed to determine whether these patients are at a higher bleeding risk as a result of INR elevation.
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Affiliation(s)
| | | | | | | | - Whitney Gross
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | - G Morgan Jones
- Methodist University Hospital, Memphis, TN, USA.,University of Tennessee Health Sciences Center, Memphis, TN, USA
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Variability in international normalized ratio and activated partial thromboplastin time after injury are not explained by coagulation factor deficits. J Trauma Acute Care Surg 2020; 87:582-589. [PMID: 31136528 DOI: 10.1097/ta.0000000000002385] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Conventional coagulation assays (CCAs), prothrombin time (PT)/international normalized ratio (INR) and activated partial thromboplastin time (aPTT), detect clotting factor (CF) deficiencies in hematologic disorders. However, there is controversy about how these CCAs should be used to diagnose, treat, and monitor trauma-induced coagulopathy. Study objectives were to determine whether CCA abnormalities are reflective of deficiencies of coagulation factor activity in the setting of severe injury. METHODS Patients without previous CF deficiency within a prospective database at an ACS-verified Level I trauma center had CF activity levels, PT/INR, aPTT, and fibrinogen levels measured upon emergency department arrival from 2014 to 2017. Linear regression assessed how CF activity explained the aPTT and PT/INR variation. Prolonged CCA values were set as INR greater than 1.3 and aPTT greater than 34 seconds. CF deficiency was defined as less than 30% activity, except for fibrinogen, defined as less than 150 mg/dL. RESULTS Sixty patients with a mean age of 35.8 (SD, 13.6) years and median New Injury Severity Score of 32 (interquartile range, 12-43) were included; 53.3% sustained blunt injuries, 23.3% required massive transfusion, and mortality was 11.67%. Overall, 44.6% of the PT/INR variance and 49.5% of the aPTT variance remained unexplained by CF activity. Deficiencies of CFs were: common pathway, 25%; extrinsic pathway, 1.7%; and intrinsic pathway, 6.7%. The positive predictive value for CF deficiencies were: (1) PT/INR greater than 1.3:4.4% for extrinsic pathway, 56.5% for the common pathway; (2) aPTT greater than 34 seconds:16.7% for the intrinsic pathway, 73.7% for the common pathway. CONCLUSION Almost half of the variances of PT/INR and aPTT were unexplained by CF activity. Prolonged PT/INR and aPTT were poor predictors of deficiencies in the intrinsic or extrinsic pathways; however, they were indicators of common pathway deficiencies. LEVEL OF EVIDENCE Prognostic, level III.
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Citrated kaolin thrombelastography (TEG) thresholds for goal-directed therapy in injured patients receiving massive transfusion. J Trauma Acute Care Surg 2019; 85:734-740. [PMID: 30059456 DOI: 10.1097/ta.0000000000002037] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Goal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared with conventional coagulation assays such as international normalized ratio, activated partial thromboplastin time, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG, cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT. METHODS CK-TEG was assessed in trauma activation patients at two Level 1 trauma centers admitted between 2010 and 2017. Receiver operating characteristic (ROC) curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of red blood cells or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation. RESULTS Of the 825 trauma activations, 671 (81.3%) were men, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-time was longer (4.9 vs. 4.4 min, p = 0.0084), angle was lower (66.2 vs. 70.3 degrees, p < 0.0001), maximum amplitude was lower in MT (57 vs. 65.5 mm, p < 0.0001), and LY30 was greater (1.8% vs. 1.2%, p = 0.0012) in patients with MT compared with non-MT. To predict MT, R-time yielded an area under the ROC curve (AUROC) = 0.6002 and a cut point of >4.45 min. Angle had an AUROC = 0.6931 and a cut point of <67 degrees. CMA had an AUROC = 0.7425, and a cut point of <60 mm. LY30 had an AUROC = 0.623 with a cut point of >4.55%. CONCLUSION We have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time >4.45 min, fibrinogen products for an angle <67 degrees, platelet transfusion for MA <60 mm, and antifibrinolytics for LY30 >4.55%. LEVEL OF EVIDENCE Therapeutic study, level V.
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Heinrichs A, Nikoubashman O, Schürmann K, Tauber SC, Wiesmann M, Schulz JB, Reich A. Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center. Acta Neurol Belg 2018; 118:105-111. [PMID: 29435828 DOI: 10.1007/s13760-018-0892-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.
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Affiliation(s)
- Annette Heinrichs
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Kolja Schürmann
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Simone C Tauber
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
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Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, Kim LJ, Mayer SA, Sheth KN, Schwamm LH. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017; 48:e343-e361. [DOI: 10.1161/str.0000000000000152] [Citation(s) in RCA: 249] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
Symptomatic intracranial hemorrhage (sICH) is the most feared complication of intravenous thrombolytic therapy in acute ischemic stroke. Treatment of sICH is based on expert opinion and small case series, with the efficacy of such treatments not well established. This document aims to provide an overview of sICH with a focus on pathophysiology and treatment.
Methods—
A literature review was performed for randomized trials, prospective and retrospective studies, opinion papers, case series, and case reports on the definitions, epidemiology, risk factors, pathophysiology, treatment, and outcome of sICH. The document sections were divided among writing group members who performed the literature review, summarized the literature, and provided suggestions on the diagnosis and treatment of patients with sICH caused by systemic thrombolysis with alteplase. Several drafts were circulated among writing group members until a consensus was achieved.
Results—
sICH is an uncommon but severe complication of systemic thrombolysis in acute ischemic stroke. Prompt diagnosis and early correction of the coagulopathy after alteplase have remained the mainstay of treatment. Further research is required to establish treatments aimed at maintaining integrity of the blood-brain barrier in acute ischemic stroke based on inhibition of the underlying biochemical processes.
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Mistry EA, Mistry AM, Nakawah MO, Chitale RV, James RF, Volpi JJ, Fusco MR. Mechanical Thrombectomy Outcomes With and Without Intravenous Thrombolysis in Stroke Patients. Stroke 2017; 48:2450-2456. [DOI: 10.1161/strokeaha.117.017320] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/27/2017] [Accepted: 06/30/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Eva A. Mistry
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
| | - Akshitkumar M. Mistry
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
| | - Mohammad Obadah Nakawah
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
| | - Rohan V. Chitale
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
| | - Robert F. James
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
| | - John J. Volpi
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
| | - Matthew R. Fusco
- From the Department of Neurology, University of Cincinnati, OH (E.A.M); Department of Neurology, Houston Methodist Neurological Institute, TX (M.O.N., J.J.V.); Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN (A.M.M., R.V.C., M.R.F.); and Department of Neurosurgery, University of Louisville School of Medicine, KY (R.F.J.)
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Chandra RV, Leslie-Mazwi TM, Mehta BP, Derdeyn CP, Demchuk AM, Menon BK, Goyal M, González RG, Hirsch JA. Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value? J Neurointerv Surg 2016; 8:443-6. [PMID: 26758911 DOI: 10.1136/neurintsurg-2015-012231] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 11/03/2022]
Abstract
As healthcare delivery in the USA transforms into a model that at its core requires value-based considerations, ischemic stroke is confronted by intersecting forces. Modern techniques allow rapid revascularization in the majority of patients with large vessel occlusions. Dramatic advances in the evidentiary basis for mechanical embolectomy are increasing the number of patients treated with this therapy. A key part of the therapeutic arsenal in many patients treated with interventional techniques has been concurrent intravenous thrombolysis. We consider whether this paradigm warrants change.
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Affiliation(s)
- Ronil V Chandra
- Department of Imaging, Monash Imaging, Monash Health, Melbourne, Victoria, Australia Stroke and Ageing Research Centre, Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thabele M Leslie-Mazwi
- NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Colin P Derdeyn
- Departments of Radiology, Neurology and Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - R Gilberto González
- Neuroradiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Tsivgoulis G, Safouris A, Alexandrov AV. Safety of intravenous thrombolysis for acute ischemic stroke in specific conditions. Expert Opin Drug Saf 2015; 14:845-64. [DOI: 10.1517/14740338.2015.1032242] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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