Efficacy and safety of low dose alteplase for intravenous thrombolysis in Asian stroke patients: a meta-analysis

Comparison of Effectiveness and Safety of Low-Dose Versus Standard-Dose Intravenous Recombinant Tissue Plasminogen Activator in Patients With Acute Ischemic Stroke: A Meta-Analysis

The aim of the present meta-analysis is to compare the efficacy and safety of low-dose and standard-dose recombinant tissue plasminogen activators (r-tPA) in patients with acute ischemic stroke. The present meta-analysis was conducted according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted a systematic search in PubMed, Embase, and the Cochrane Library to identify studies published between January 1, 2010, and January 31, 2023, using the following terms: "stroke," "alteplase," "doses," "efficacy," "tissue plasminogen activator," "r-tPA," and "safety." Primary efficacy outcomes included favorable outcomes (Modified Rankin Scale scores of 0-2), while secondary efficacy outcome was all-cause mortality at 90 days. Safety outcomes included asymptomatic intracerebral hemorrhage (ICH) and symptomatic ICH assessed using the National Institute of Neurological Disorders and Stroke (NINDS) study and the Safe Implementation of Thrombolysis in Stroke-Monitoring (SITS-MOST) study. We also compared parenchymal hematomas as safety outcome between the two groups defined by the authors themselves in their research. A total of 16 studies were included in the present meta-analysis. The meta-analysis did not report any significant difference between low-dose and standard-dose r-tPA in terms of mortality, symptomatic intracranial hemorrhage (SICH), asymptomatic ICH, and parenchymal hematomas. However, the favorable outcome was significantly greater in patients receiving a standard dose of r-tPA.

Outcomes of stroke patients undergoing thrombolysis in Sri Lanka; an observational prospective study from a low-middle income country

Background

Stroke related deaths are relatively higher in low- and middle-income countries where only a fraction of eligible patients undergo thrombolysis. There is also limited evidence on post-thrombolysis outcomes of patients from Asian countries in these income bands.

Methods

This is a single center prospective observational study of a patient cohort with acute ischaemic stroke, undergoing thrombolysis with alteplase (low and standard dose), over a 24-month period in 2019/2020. Modified Rankin scale (mRS) for dependency at 3 months (primary outcome), duration of hospital stay, incidence of symptomatic intracranial haemorrhages and all-cause mortality at 3 months (secondary outcomes) were recorded. Demographic, clinical and treatment related factors associated with these outcomes were explored.

Results

Eighty-nine patients (males – 61, 69%, mean age: 60 years ±12.18) were recruited. Time from symptom onset to reperfusion was 174 min ± 56.50. Fifty-one patients were independent according to mRS, 11 (12.4%) patients died, and 11 (12.5%) developed symptomatic intracranial haemorrhages by 3 months. Functional independence at 3 months was independently associated with National Institutes of Health Stroke Scale (NIHSS) on admission (p < 0.05). Thrombolysis with low dose alteplase did not lead to better or worse outcomes compared to standard dose.

Conclusions

On admission NIHSS is predictive of functional independence at 3 months post-thrombolysis. Low dose alteplase may be as efficacious as standard dose alteplase with associated cost savings, but this needs to be confirmed by a prospective clinical trial for the Sri Lankan population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02475-3.

The Efficacy and Safety of Intravenous Thrombolysis in Older Chinese Patients with Acute Ischemic Stroke

To study the efficacy and safety of intravenous thrombolysis for the older acute ischemic stroke patients, clinical data were prospectively analyzed from 168 patients with acute ischemic stroke including 42 older adult patients (ET group), 66 younger patients (NET group) treated with rt-PA, and 60 older adult patients treated without rt-PA (ENT group). Stroke severity was assessed with an NIHSS score at baseline, 1-day and 14-day after treatment. Functional outcomes were evaluated by the modified Rankin scale and a Barthel index. Adverse effects were observed during the treatment. The rate of "good" prognosis was higher in the ET group than that in the ENT group at 90 days post-stroke. In older patients with stroke, thrombolytic therapy was found to be of greater benefit to patients with lower NIHSS scores at baseline, or patients classified as posterior circulation infarction, than for patients with higher NIHSS scores or infarctions located in other brain regions. Thrombolytic therapy may exhibit long-term efficacy by improving the future quality of life for older stroke patients with fewer bleeding risk factors and lower baseline NIHSS scores.