Predictors of Postthrombolysis Outcome and Symptomatic Postthrombolysis Hemorrhage following Intravenous Thrombolysis with Alteplase for Acute Ischemic Stroke

Repeated intravenous thrombolysis in recurrent ischemic stroke within 3 months: a systematic review

BACKGROUND

Repeated intravenous thrombolysis (RIVT) within 3 months is an off-guideline therapy, however, may be an effective and safe way to treat early recurrent ischemic stroke. This study was conducted to assess the potential influencing factors on the efficacy and safety of RIVT in recurrent ischemic stroke within 3 months and to explore the strategy of RIVT within 3 months.

METHODS

PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, and Wanfang Database were searched for cases of RIVT in recurrent ischemic stroke within 3 months up to February 1, 2023. Clinical characteristics were compared and analyzed between the good-outcome and poor-outcome groups and between the symptomatic intracranial hemorrhage (sICH) and non-sICH groups respectively.

RESULTS

A total of 16 studies including 24 cases of RIVT within 3 months were retrospectively analyzed in the present study. The patients' ages ranged from 42 to 87 years (median 73.5 years) and the intervals between thrombolysis were from 0.25 to 90 days (median 9.5 days). Comparing the clinical characteristics between the good-outcome group and the poor-outcome group, no statistically significant differences were found (P > 0.05), but the differences in baseline National Institutes of Health stroke scale (NIHSS) score of the recurrent stroke (P = 0.056) and good outcome after the previous IVT (P = 0.054) nearly reached statistical significance. Comparing the data between the non-sICH group and the sICH group, statistically significant differences were found in terms of the proportion of cardiogenic embolism (P = 0.036), baseline NIHSS score in the recurrent stroke (P = 0.007) and the interval between thrombolysis (P = 0.041), but no significant difference was found by regression analysis.

CONCLUSION

In patients with recurrent ischemic stroke within 3 months, those with a good outcome after the previous IVT and a low baseline NIHSS score in the recurrent stroke may be considered for RIVT, whereas those with a high baseline NIHSS score, a short interval between thrombolysis, and cardiogenic embolism may suffer a higher risk of sICH. Due to sample size and publication bias, more studies with larger sample sizes and more rigorous designs are needed to confirm this conclusion.

Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis

Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.

Safety outcomes of early initiation of antithrombotic agents within 24 h after intravenous alteplase at 0.6 mg/kg

BACKGROUND

We examined outcome of acute ischemic stroke (AIS) with administration of antithrombotics within 24 h after intravenous low-dose alteplase.

METHODS

Consecutive AIS patients who were treated with intravenous alteplase at 0.6 mg/kg from 2005 to 2021 were retrospectively included in our single-center registry. Patients were classified into two groups: those who received antithrombotics within 24 h after intravenous alteplase (early initiation group) and those who did not (control group). Safety outcomes were any intracranial hemorrhage (ICH), symptomatic ICH (sICH) within 36 h after onset, and death within 3 months. sICH was defined as any ICH with a ≥ 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score or death within 36 h.

RESULTS

Of 1111 patients (women, 426; median age, 76 [interquartile range, 69-83] years; median NIHSS score, 11 [6-19]; cardioembolism, 580 [52.2%]), early initiation group comprised 58 patients (22; 72 [65-80] years; 7 [4-12]; 11 [19.0%]) and control group comprised 1053 patients (404; 77 [69-84] years; 11 [6-19]; 569 [54.1%]). No significant between-group differences were observed in the incidence of any ICH (17.2% vs. 21.6%; adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 0.57-2.44), sICH (0% vs. 0.9%, P = 1.00), or death within 3 months (5.2% vs. 6.7%; aOR, 1.23; 95% CI, 0.36-4.23).

CONCLUSIONS

Early initiation of antithrombotics after intravenous alteplase at 0.6 mg/kg did not increase the rate of sICH or death within 3 months and may be used with caution in patients with advanced neurological deterioration.

Predictors and long-term outcome of intracranial hemorrhage after thrombolytic therapy for acute ischemic stroke-A prospective single-center study

Introduction

Acute ischemic stroke (AIS) is a potentially devastating disease with high disability and mortality. Recombinant tissue plasminogen activator (rt-PA) is an effective treatment with a 2-8% possible risk for symptomatic intracranial hemorrhage (sICH). Our aim was to investigate the risk factors and long-term clinical outcomes of ICH in patients after rt-PA treatment.

Methods

Consecutive patients with AIS, thrombolysed at the Department of Neurology, University of Debrecen, between 1 January 2004 and 31 August 2016 were enrolled prospectively. Risk factors, stroke severity based on the National Institute of Health Stroke Scale (NIHSS), functional outcome using the modified Rankin scale, and mortality at 1 year were compared in patients with and without ICH following rt-PA treatment. We evaluated clinical characteristics and prognosis by hemorrhage type based on the Heidelberg Bleeding Classification. Descriptive statistics, the chi-square test, the Mann-Whitney U-test, ANOVA, the Kruskal-Wallis test, a survival analysis, and logistic regression were performed as appropriate.

Results

Out of 1,252 patients with thrombolysis, ICH developed in 138 patients, with 37 (2.95%) being symptomatic. Mean ages in the ICH and non-ICH groups differed significantly (p = 0.041). On admission, the 24-h NIHSS after thrombolysis was higher in patients with ICH (p < 0.0001). Large vessel occlusion was more prevalent in patients with ICH (p = 0.0095). The ICH risk was lower after intravenous thrombolysis than intra-arterial or combined thrombolysis (p < 0.0001). Both at 3 months and 1 year, the outcome was worse in patients with ICH compared to patients without ICH group (p < 0.0001). Mortality and poor outcome were more prevalent in all hemorrhage types with a tendency for massive bleeding associated with unfavorable prognosis. At 3 months with the logistic regression model, the worse outcome was detected in patients with ICH after thrombolysis, at 1 year in patients with ICH after thrombolysis and smoking.

Discussion

Older age, higher NIHSS, large vessel occlusion, and intra-arterial thrombolysis may correlate with ICH. The unfavorable outcome is more common in patients with ICH. Precise scoring of post-thrombolysis bleeding might be a useful tool in the evaluation of the patient's prognosis. Our findings may help to identify predictors and estimate the prognosis of ICH in patients with AIS treated with rt-PA.

Outcome predictors in anterior and posterior ischemic strokes: a study based on the Iranian SITS registry

Ischemic stroke is the major form of stroke with two separate vascular territories. Many risk factors are related to stroke outcomes in both territories. The present descriptive research was carried out on the basis of data obtained from the Safe Implementation of Treatments in Stroke (SITS) registry on Iranian intravenous thrombolysis ischemic stroke cases. Vascular territory involved in each case and three-month excellent outcome, functional independence, mortality rate, and brain hemorrhage occurrence were determined. Univariable and multivariable logistics regression analyses were utilized in order to investigate association of ischemic stroke outcomes with the vascular territory involved and other related factors. Among 1566 patients 95.4% was anterior circulation stroke patients and 4.6% was posterior circulation stroke cases. There is no significant association between vascular territory with mortality (OR of PCS vs ACS: 0.74, 95% CI 0.37-1.46), excellent functional outcome (OR 0.72, 95% CI 0.44-1.19), functional outcome (OR 0.86, 95% CI 0.52-1.42) and local hemorrhage (OR 0.98, 95% CI 0.30-3.21). Among major risk factors, age, diabetes, NIHSS score and admission duration, increased significantly odds of three-month mortality, excellent outcome, and functional independence in the multivariate analysis. The highest of odds was in NIHSS score with a dose-response association. The vascular territory was not an outcome predictor in ischemic strokes. The most important predictor was baseline NIHSS.

Effect of admission serum glucose on the clinical prognosis of patients with acute ischemic stroke receiving alteplase intravenous thrombolysis

Objective: To investigate the effect of admission serum glucose on the clinical prognosis of patients with acute ischemic stroke receiving intravenous alteplase thrombolysis. Methods: Patients with acute ischemic stroke who received intravenous alteplase thrombolysis between January 2016 and December 2017 were enrolled. The clinical prognosis was assessed using the modified Rankin Scale (mRs) at 90 days after onset. Univariate and multivariate logistic regression analyses were conducted to investigate whether admission serum glucose was an independent factor in the 90-day prognosis. The predictive value of admission serum glucose for a 90-day poor prognosis was evaluated using receiver operating characteristic (ROC) curves. All patients were divided into two groups based on admission serum glucose levels: high admission serum glucose (above the cut-off value) and low admission serum glucose (below the cut-off value). The 90-day prognosis of patients with different admission serum glucose was analyzed. Results: A total of 138 patients were enrolled, including 79 males (57.24%), with a mean age of (68 ± 12) years and a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 9 (6 to 13.75). There were 74 cases (53.62%) in the good prognosis group and 64 cases (46.37%) in the poor prognosis group. The results of the univariate analysis indicated that admission serum glucose in the good prognosis group was significantly lower than that in the poor prognosis group [(7.45 ± 2.31) versus (8.80 ± 3.65), p < .05]. Logistic regression analysis revealed that the admission serum glucose level was an independent risk factor for clinical prognosis at 90 days after onset (OR = 1.24, 95% CI:1.01-1.52). ROC curve analysis showed that the cutoff value of admission serum glucose for predicting poor prognosis 90 days after intravenous thrombolytic therapy with alteplase was 6.77 mmol/l AUC (area under curve) 0.623, 95%CI: 0.53-0.72, sensitivity 68.80%, specificity 52.70%. When compared with the admission serum glucose ≥6.77 mmol/l group (83 cases), the 90-day mRS scores in the admission serum glucose <6.77 mmol/l group (55 cases) were lower [3 (1 to 5) scores versus 1 (0 to 3) scores, Z = 2.89, p < .05]. Conclusions: In patients with acute ischemic stroke receiving intravenous alteplase thrombolytic therapy, a higher admission serum glucose level is an independent predictor of adverse neurological outcomes at 90 days postoperatively.

Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants

Background

We elucidated the safety of treatment with alteplase at 0.6 mg/kg within 24 hours for patients on direct oral anticoagulants (DOACs) before ischemic stroke onset.

Methods and Results

Consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis using alteplase at 0.6 mg/kg from 2011 to 2021 were enrolled from our single‐center prospective stroke registry. We compared outcomes between patients taking DOACs and those not taking oral anticoagulants within 48 hours of stroke onset. The primary safety outcome was the rate of symptomatic intracranial hemorrhage with a ≥4‐point increase on the National Institutes of Health Stroke Scale score from baseline. The efficacy outcome was defined as 3‐month modified Rankin Scale score of 0 to 2 after stroke onset. Of 915 patients with acute ischemic stroke who received intravenous thrombolysis (358 women; median age, 76 years; median National Institutes of Health Stroke Scale score, 10), 40 patients took DOACs (6 took dabigatran, 8 took rivaroxaban, 16 took apixaban, and 10 took edoxaban) within 24 hours of onset and 753 patients did not take any oral anticoagulants. The rate of symptomatic intracranial hemorrhage was comparable between patients on DOACs and those not on oral anticoagulants (2.5% versus 2.4%, P=0.95). The rate of favorable outcomes was comparable between the 2 groups (59.4% versus 58.2%, P=0.46), although the admission National Institutes of Health Stroke Scale score was higher in patients on DOACs. No significant differences showed in any intracranial hemorrhage within 36 hours or mortality at 3 months.

Conclusions

Intravenous thrombolysis would be safely performed for patients on DOACs following the recommendations of the Japanese guidelines.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02251665.

Benefit of Intravenous Alteplase Before Thrombectomy Depends on ASPECTS

PURPOSE

Baseline variables could be used to guide the administration of additional intravenous alteplase (IVT) before mechanical thrombectomy (MT). The aim of this study was to determine how baseline imaging and demographic parameters modify the effect of IVT on clinical outcomes in patients with ischemic stroke due to large vessel occlusion.

METHODS

Multicenter retrospective cohort study of ischemic stroke patients triaged by multimodal-CT undergoing MT treatment after direct admission to an MT-eligible center. Inverse-probability weighting analysis (IPW) was used to assess the treatment effect of IVT adjusted for baseline variables. Multivariable logistic regression analysis with IPW-weighting and interaction terms for IVT was performed to predict functional independence (mRS 0-2 at 90-days).

RESULTS

720 patients were included, of which 366 (51%) received IVT. In IPW, the treatment effect of IVT on outcome (mRS 0-2) distinctively varied according to the ASPECTS subgroup (ASPECTS 9-10: +15%, ASPECTS 6-8: +7%, ASPECTS <6: -11%). In multivariable logistic regression analysis, IVT was independently associated with functional independence (aOR: 1.57, 95%CI: 1.16-2.14, p=0.003) and the interaction term was significant for ASPECTS and IVT revealing that IVT was only significantly associated with better outcomes in patients with higher ASPECTS. No other significant baseline variable interaction terms were identified.

INTERPRETATION

ASPECTS was the only baseline variable that showed a significant interaction with IVT for outcome prediction. The application of IVT in patients with an ASPECTS of <6 might have detrimental effects on outcome and may only be considered carefully. This article is protected by copyright. All rights reserved.

Factors Associated with Unfavorable Functional Outcomes After Intravenous Thrombolysis in Patients with Acute Ischemic Stroke

Purpose

Intravenous thrombolysis (IVT) has become a standard treatment for eligible ischemic stroke patients. However, functional outcomes after receiving IVT varied widely. Hence the primary goal of this study is to identify characteristics related to poor outcomes.

Patients and Methods

The study enrolled acute ischemic stroke patients aged 18 or older who received IVT within 4.5 hours after onset between January 2018 and December 2020. The data were retrospectively collected from medical records. The patients were classified as having an excellent (0–2) or poor (3–6) outcomes based on the 90-day modified Rankin Scale (mRS). Univariable and multivariable logistic regression analyses were used to evaluate the results. The predictive model was determined and developed the score using regression coefficients. The prediction power was validated using the area under the receiver operating characteristic curve analysis.

Results

The study included 138 eligible participants. Forty-eight patients had unfavorable functional outcomes. With multivariable logistic regression analysis, factors significantly associated with poor outcomes were age (adjusted odds ratio (AOR), 1.03; 95% confidence interval (CI), 0.99–1.07; P = 0.05), diabetes (3.96; 1.61–9.37; P = 0.003), admission National Institute of Health Stroke Scale (NIHSS) (1.08; 1.01–1.15; P = 0.02) and initial Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (0.56; 0.37–0.86; P = 0.009). The predictive model developed from the findings demonstrated good discrimination power (AuROC 0.803, 95% CI 0.728–0.877).

Conclusion

The current study found that older age, diabetes, atrial fibrillation, higher admission NIHSS, and lower ASPECTS on the initial NCCT brain were related to unfavorable functional outcomes following IVT and served as good predictors of patient functional outcomes.

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.