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Al-Karaghouli M, Ventura-Cots M, Wong YJ, Genesca J, Bosques F, Brown RS, Mathurin P, Louvet A, Shawcross D, Vargas V, Verna EC, Schnabl B, Caballeria J, Shah VJ, Kamath PS, Lucey MR, Garcia-Tsao G, Bataller R, Abraldes JG. Relationship between updated MELD and prognosis in alcohol-associated hepatitis: Opportunities for more efficient trial design. Hepatol Commun 2024; 8:e0495. [PMID: 39082963 DOI: 10.1097/hc9.0000000000000495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/08/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is associated with significant mortality. Model for End-Stage Liver Disease (MELD) score is used to predict short-term mortality and aid in treatment decisions. MELD is frequently updated in the course of AH. However, once the most updated MELD is known, it is uncertain if previous ones still have prognostic value, which might be relevant for transplant allocation and trial design. We aimed to investigate the predictive performance of updated MELDs in a prospectively collected cohort of patients with AH by the InTeam consortium. METHODS Three hundred seven patients (with 859 MELD values within 60 d of admission) fulfilled the inclusion criteria. The main endpoint was time to death or transplant up to 90 days. We used a joint model approach to assess the predictive value of updated MELDs. RESULTS Updated MELD measurements had a strong prognostic value for death/transplant (HR: 1.20, 95% CI: 1.14-1.27) (p < 0.0001). Previous MELD values did not add predictive value to the most current MELD. We also showed that MELD at day 28 (MELD28) had a significant predictive value for subsequent mortality/transplant in a landmark analysis (HR: 1.18, 95% CI: 1.12-1.23). We show that the use of an ordinal scale including death, transplant, and MELD28 as a trial outcome could substantially reduce the sample size required to demonstrate short-term benefit of an intervention. CONCLUSION We show that updated MELDs during the trajectory of AH predict subsequent mortality or the need for transplant. MELD28 inclusion in an ordinal outcome (together with death or transplant) could increase the efficiency of randomized controlled trials.
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Affiliation(s)
- Mustafa Al-Karaghouli
- Division of Gastroenterology (Liver Unit). University of Alberta, Edmonton, Alberta, Canada
| | - Meritxell Ventura-Cots
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Yu Jun Wong
- Division of Gastroenterology (Liver Unit). University of Alberta, Edmonton, Alberta, Canada
| | - Joan Genesca
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Bosques
- Hospital Universitario Dr Jose E. Gonzalez, Servicio de Gastroenterologia, Universidad Autonoma de Nuevo Leon Monterrey, Mexico
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Philippe Mathurin
- University of Lille, Inserm, CHU Lille, U1286-INFINITI-Institute for Translational Research in Inflammation, Lille, France
| | - Alexandre Louvet
- University of Lille, Inserm, CHU Lille, U1286-INFINITI-Institute for Translational Research in Inflammation, Lille, France
| | - Debbie Shawcross
- Department of Inflammation Biology, Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Bernd Schnabl
- Medicine, University of California San Diego, La Jolla, California, USA
| | - Joan Caballeria
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Vijay J Shah
- Mayo Clinic and Mayo Medical School, Rochester, Minnesota, USA
| | | | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, Connecticut, USA
- Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ramon Bataller
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit). University of Alberta, Edmonton, Alberta, Canada
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Poli S, Grohmann C, Wenzel DA, Poli K, Tünnerhoff J, Nedelmann M, Fiehler J, Burghaus I, Lehmann M, Glauch M, Schadwinkel HM, Kalmbach P, Zeller J, Peters T, Eschenfelder C, Agostini H, Campbell BC, Fischer MD, Sykora M, Mac Grory B, Feltgen N, Kowarik M, Seiffge D, Strbian D, Albrecht M, Alzureiqi MS, Auffarth G, Bäzner H, Behnke S, Berberich A, Bode F, Bohmann FO, Cheng B, Czihal M, Danyel LA, Dimopoulos S, Pinhal Ferreira de Pinho JD, Fries FN, Gamulescu MA, Gekeler F, Gomez-Exposito A, Gumbinger C, Guthoff R, Hattenbach LO, Kellert L, Khoramnia R, Kohnen T, Kürten D, Lackner B, Laible M, Lee JI, Leithner C, Liegl R, Lochner P, Mackert M, Mbroh J, Müller S, Nagel S, Prasuhn M, Purrucker J, Reich A, Mundiyanapurath S, Royl G, Salchow DJ, Schäfer JH, Schlachetzki F, Schmack I, Thomalla G, Tieck Fernandez MP, Wakili P, Walter P, Wolf A, Wolf M, Bartz-Schmidt KU, Schultheiss M, Spitzer MS. Early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION): Study protocol of a phase III trial. Int J Stroke 2024; 19:823-829. [PMID: 38591748 DOI: 10.1177/17474930241248516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
RATIONALE Meta-analyses of case series of non-arteritic central retinal artery occlusion (CRAO) indicate beneficial effects of intravenous thrombolysis when initiated early after symptom onset. Randomized data are lacking to address this question. AIMS The REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION) investigates intravenous alteplase within 4.5 h of monocular vision loss due to acute CRAO. METHODS This study is the randomized (1:1), double-blind, placebo-controlled, multicenter adaptive phase III trial. STUDY OUTCOMES Primary outcome is functional recovery to normal or mildly impaired vision in the affected eye defined as best-corrected visual acuity of the Logarithm of the Minimum Angle of Resolution of 0.5 or less at 30 days (intention-to-treat analysis). Secondary efficacy outcomes include modified Rankin Score at 90 days and quality of life. Safety outcomes include symptomatic intracranial hemorrhage, major bleeding (International Society on Thrombosis and Haemostasis definition) and mortality. Exploratory analyses of optical coherence tomography/angiography, ultrasound and magnetic resonance imaging (MRI) biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 120 patients, up to 422 participants (211 per arm) would be needed for 80% power (one-sided alpha = 0.025) to detect a difference of 15%, assuming functional recovery rates of 10% in the placebo arm and 25% in the alteplase arm. DISCUSSION By enrolling patients within 4.5 h of CRAO onset, REVISION uses insights from meta-analyses of CRAO case series and randomized thrombolysis trials in acute ischemic stroke. Increased rates of early reperfusion and good neurological outcomes in stroke may translate to CRAO with its similar pathophysiology. TRIAL REGISTRATION ClinicalTrials.gov: NCT04965038; EU Trial Number: 2023-507388-21-00.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Carsten Grohmann
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel A Wenzel
- Department of Ophthalmology, University of Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Max Nedelmann
- Department of Neurology, Regio Kliniken GmbH, Pinneberg, Germany
| | - Jens Fiehler
- Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Ina Burghaus
- Coordination Centre for Clinical Trials (KKS), Medical Faculty & Heidelberg University Hospital, Germany
| | - Monika Lehmann
- Coordination Centre for Clinical Trials (KKS), Medical Faculty & Heidelberg University Hospital, Germany
| | - Monika Glauch
- Center for Rare Diseases, University of Tübingen, Germany
| | - Hauke M Schadwinkel
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Tobias Peters
- Department of Ophthalmology, University of Tübingen, Germany
| | | | | | - Bruce Cv Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - M Dominik Fischer
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, UK
- Nuffield Laboratory of Ophthalmology, University of Oxford, UK
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Brian Mac Grory
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Nicolas Feltgen
- Department of Ophthalmology, Universitätsspital Basel, Switzerland
| | - Markus Kowarik
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - David Seiffge
- Department of Neurology, University of Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Mohammad S Alzureiqi
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd Auffarth
- Department of Ophthalmology, University of Heidelberg, Germany
| | | | - Stefanie Behnke
- Department of Neurology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | | | - Felix Bode
- Department of Neurology, University Hospital Bonn, Germany
| | - Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Czihal
- Medical Clinic and Policlinic IV, Division of Vascular Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - Leon A Danyel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | | | - Fabian N Fries
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | | | | | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | | | - Rainer Guthoff
- Department of Ophthalmology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | | | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Ramin Khoramnia
- Department of Ophthalmology, University of Heidelberg, Germany
| | - Thomas Kohnen
- Department of Ophthalmology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - David Kürten
- Department of Ophthalmology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | - Mona Laible
- Department of Neurology, University Hospital Ulm, Germany
| | - John-Ih Lee
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Christoph Leithner
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Raffael Liegl
- Department of Ophthalmology, University Hospital Bonn, Germany
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Marc Mackert
- Department of Ophthalmology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital Ulm, Germany
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Germany
| | - Michelle Prasuhn
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Jan Purrucker
- Department of Neurology, University of Heidelberg, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | - Georg Royl
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Daniel J Salchow
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan H Schäfer
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | | | - Ingo Schmack
- Department of Ophthalmology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria P Tieck Fernandez
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Philip Wakili
- Department of Ophthalmology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | - Peter Walter
- Department of Ophthalmology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Armin Wolf
- Department of Ophthalmology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Germany
| | | | - Maximilian Schultheiss
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
- AugenChirurgie München, Eye Clinic Herzog Carl Theodor, Munich, Germany
| | - Martin S Spitzer
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Víteček J, Vítečková Wünschová A, Thalerová S, Gulati S, Kubala L, Capandová M, Hampl A, Robert Mikulík. Factors influencing the efficacy of recombinant tissue plasminogen activator: Implications for ischemic stroke treatment. PLoS One 2024; 19:e0302269. [PMID: 38843177 PMCID: PMC11156348 DOI: 10.1371/journal.pone.0302269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/31/2024] [Indexed: 06/09/2024] Open
Abstract
Intravenous thrombolysis with a recombinant tissue plasminogen activator (rt-PA) is the first-line treatment of acute ischemic stroke. However, successful recanalization is relatively low and the underlying processes are not completely understood. The goal was to provide insights into clinically important factors potentially limiting rt-PA efficacy such as clot size, rt-PA concentration, clot age and also rt-PA in combination with heparin anticoagulant. We established a static in vitro thrombolytic model based on red blood cell (RBC) dominant clots prepared using spontaneous clotting from the blood of healthy donors. Thrombolysis was determined by clot mass loss and by RBC release. The rt-PA became increasingly less efficient for clots larger than 50 μl at a clinically relevant concentration of 1.3 mg/l. A tenfold decrease or increase in concentration induced only a 2-fold decrease or increase in clot degradation. Clot age did not affect rt-PA-induced thrombolysis but 2-hours-old clots were degraded more readily due to higher activity of spontaneous thrombolysis, as compared to 5-hours-old clots. Finally, heparin (50 and 100 IU/ml) did not influence the rt-PA-induced thrombolysis. Our study provided in vitro evidence for a clot size threshold: clots larger than 50 μl are hard to degrade by rt-PA. Increasing rt-PA concentration provided limited thrombolytic efficacy improvement, whereas heparin addition had no effect. However, the higher susceptibility of younger clots to thrombolysis may prompt a shortened time from the onset of stroke to rt-PA treatment.
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Affiliation(s)
- Jan Víteček
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
| | - Andrea Vítečková Wünschová
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Anatomy, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Sandra Thalerová
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Sumeet Gulati
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
| | - Lukáš Kubala
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
| | - Michaela Capandová
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Aleš Hampl
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Robert Mikulík
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
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Han Q, You S, Maeda T, Wang Y, Ouyang M, Li Q, Song L, Zhao Y, Ren X, Chen C, Delcourt C, Zhou Z, Cao Y, Liu CF, Zheng D, Arima H, Robinson TG, Chen X, Lindley RI, Chalmers J, Anderson CS, Wang X. Predictors of Early versus Delayed Neurological Deterioration after Thrombolysis for Ischemic Stroke. Cerebrovasc Dis 2024:1-9. [PMID: 38749409 DOI: 10.1159/000539322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/26/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION We aimed to determine predictors of early (END) and delayed neurological deterioration (DND) and their association with the functional outcome in patients with acute ischemic stroke (AIS) who participated in the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). METHODS END and DND (without END) were defined as scores of a ≥2-point increase on the National Institutes of Health Stroke Scale (NIHSS) or a ≥1-point decrease on the Glasgow coma scale or death, from baseline to 24 h and 24-72 h, respectively. Multivariable logistic regression models were used to determine independent predictors of END and DND and their association with 90-day outcomes (dichotomous scores on the modified Rankin scale [mRS] of 2-6 vs. 0-1 and 3-6 vs. 0-2 and death). RESULTS Of 4,496 patients, 871 (19.4%) and 302 (8.4%) patients experienced END and DND, respectively. Higher baseline NIHSS score, older age, large-artery occlusion due to significant atheroma, cardioembolic stroke subtype, hemorrhagic infarction and parenchymatous hematoma within 24 h were all independent predictors for both END (all p ≤ 0.01) and DND (all p ≤ 0.024). Moreover, higher baseline systolic blood pressure (BP) (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12), higher diastolic BP variability within 24 h (OR 1.07, 95% CI 1.04-1.09), patients from Asia (OR 1.25, 95% CI 1.03-1.52) were the only independent predictors for END. However, Asian ethnicity was negatively associated with DND (OR 0.64, 95% CI 0.47-0.86). Hemorrhagic infarction and parenchymatous hematoma within 24 h were the key predictors of END across all stroke subtypes. END and DND were all associated with a poor functional outcome at 90 days (all p < 0.001). CONCLUSION We identified overlapping and unique demographic and clinical predictors of END and DND after thrombolysis for AIS. Both END and DND predict unfavorable outcomes at 90 days.
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Affiliation(s)
- Qiao Han
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of SooChow University, Suzhou, China,
- Department of Neurology, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China,
| | - Shoujiang You
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of SooChow University, Suzhou, China
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Toshiki Maeda
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
| | - Yanan Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health China, Beijing, China
| | - Yang Zhao
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health China, Beijing, China
| | - Xinwen Ren
- The George Institute for Global Health China, Beijing, China
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health China, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Zien Zhou
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Yongjun Cao
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of SooChow University, Suzhou, China
| | - Chun-Feng Liu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of SooChow University, Suzhou, China
| | - Danni Zheng
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard I Lindley
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health China, Beijing, China
- Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Suzuki K, Katano T, Numao S, Nishi Y, Kutsuna A, Kanamaru T, Saito T, Aoki J, Nishiyama Y, Kimura K. Clinical significance of intracranial hemorrhage after thrombectomy detected solely by magnetic resonance imaging and not by computed tomography. J Neurol Sci 2024; 460:122999. [PMID: 38705135 DOI: 10.1016/j.jns.2024.122999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/01/2024] [Accepted: 04/07/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND OBJECTIVE Whether intracranial hemorrhage (ICH) detected using magnetic resonance imaging (MRI) affects the clinical outcomes of patients with large-vessel occlusion (LVO) treated with mechanical thrombectomy (MT) remains unclear. This study investigated the clinical features of ICH after MT detected solely by MRI. METHODS This was a retrospective analysis of patients with acute ischemic stroke and occlusion of the internal carotid artery or middle cerebral artery treated with MT between April 2011 and March 2021. Among 632 patients, patients diagnosed with no ICH using CT, with a pre-morbid modified Rankin Scale (mRS) score ≤ 2, and those who underwent MRI including T2* and computed tomography (CT) within 72 h from MT were enrolled. The main outcomes were the association between ICH detected solely by MRI and clinical outcomes at 90 days. Poor clinical outcomes were defined as mRS score > 2 at 90 days after onset. RESULTS Of the 246 patients, 29 (12%) had ICH on MRI (MRI-ICH(+)), and 217 (88%) were MRI-ICH(-). There was no significant difference between number of patients with MRI-ICH(+) experiencing poor (10 [12%]) and favorable (19 [12%]) outcomes. The mRS score at 90 days between patients with MRI-ICH (+) and MRI-ICH(-) was not significantly different (2 [1-4] vs. 2 [1-4], respectively). Higher age and lower ASPECTS were independent risk factors for poor outcomes, as shown by multivariate regression analysis. MRI-ICH(+) status was not associated with poor outcomes. CONCLUSIONS ICH detected by MRI alone did not influence clinical outcomes in patients with LVO treated with MT.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan.
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Yuji Nishi
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Akihito Kutsuna
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Takuya Kanamaru
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Tomonari Saito
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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6
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Chen CH, Lee CW, Hsieh YC, Lin CJ, Chen YW, Lin KH, Sung PS, Tang CW, Chu HJ, Tsai KC, Chou CL, Lin CH, Wei CY, Yen SY, Chen PL, Yeh HL, Chan L, Sung SF, Lee M, Liu HM, Lin YH, Lee IH, Yeh SJ, Lien LM, Chiou HY, Lee JT, Tang SC, Jeng JS. Comparing Low- or Standard-Dose Alteplase in Endovascular Thrombectomy: Insights From a Nationwide Registry. Stroke 2024; 55:532-540. [PMID: 38314590 PMCID: PMC10896194 DOI: 10.1161/strokeaha.123.045851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Timely intravenous thrombolysis and endovascular thrombectomy are the standard reperfusion treatments for large vessel occlusion stroke. Currently, it is unknown whether a low-dose thrombolytic agent (0.6 mg/kg alteplase) can offer similar efficacy to the standard dose (0.9 mg/kg alteplase). METHODS We enrolled consecutive patients in the multicenter Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke who had received combined thrombolysis (within 4.5 hours of onset) and thrombectomy treatment from January 2019 to April 2023. The choice of low- or standard-dose alteplase was based on the physician's discretion. The outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction score, 2b-3), symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score, and 90-day mortality. The outcomes between the 2 groups were compared using multivariable logistic regression and inverse probability of treatment weighting-adjusted analysis. RESULTS Among the 2242 patients in the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke, 734 (33%) received intravenous alteplase. Patients in the low-dose group (n=360) were older, had more women, more atrial fibrillation, and longer onset-to-needle time compared with the standard-dose group (n=374). In comparison to low-dose alteplase, standard-dose alteplase was associated with a lower rate of successful reperfusion (81% versus 87%; adjusted odds ratio, 0.63 [95% CI, 0.40-0.98]), a numerically higher incidence of symptomatic intracerebral hemorrhage (6.7% versus 3.9%; adjusted odds ratio, 1.81 [95% CI, 0.88-3.69]), but better 90-day modified Rankin Scale score (functional independence [modified Rankin Scale score, 0-2], 47% versus 31%; adjusted odds ratio, 1.91 [95% CI, 1.28-2.86]), and a numerically lower mortality rate (9% versus 15%; adjusted odds ratio, 0.73 [95% CI, 0.43-1.25]) after adjusting for covariates. Similar results were observed in the inverse probability of treatment weighting-adjusted models. The results were consistent across predefined subgroups and age strata. CONCLUSIONS Despite the lower rate of successful reperfusion and higher risk of symptomatic intracerebral hemorrhage with standard-dose alteplase, standard-dose alteplase was associated with a better functional outcome in patients receiving combined thrombolysis and thrombectomy.
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Affiliation(s)
- Chih-Hao Chen
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Chung-Wei Lee
- Medical Imaging (C.-W.L., Y.-H.L.), National Taiwan University Hospital, Taipei
| | - Yi-Chen Hsieh
- Program in Medical Neuroscience (Y.-C.H.), Taipei Medical University, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L., I.-H.L)
| | - Yu-Wei Chen
- Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan (Y.-W.C.)
| | - Kuan-Hung Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan (K.-H.L.)
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (P.-S.S.)
| | - Chih-Wei Tang
- Department of Neurology, Far Eastern Memorial Hospital, New Taipei City, Taiwan (C.-W.T.)
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan (H.-J.C.)
| | - Kun-Chang Tsai
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City (K.-C.T.)
| | - Chao-Liang Chou
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan (C.-L.C.)
| | - Ching-Huang Lin
- Department of Neurology, Kaohsiung Veterans General Hospital, Taiwan (C.-H.L.)
| | - Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhwa County, Taiwan (C.-Y.W.)
| | - Shang-Yih Yen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (S.-Y.Y., J.-T.L.)
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taiwan (P.-L.C.)
| | - Hsu-Ling Yeh
- Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (H.-L.Y., L.-M.L.)
| | - Lung Chan
- Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan (L.C.)
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan (S.-F.S.)
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Chiayi County, Taiwan (M.L.)
| | - Hon-Man Liu
- Department of Medical Imaging, Fu Jen Catholic University Hospital, New Taipei City, Taiwan (H.-M.L.)
| | - Yen-Heng Lin
- Medical Imaging (C.-W.L., Y.-H.L.), National Taiwan University Hospital, Taipei
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L., I.-H.L)
| | - Shin-Joe Yeh
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Li-Ming Lien
- Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (H.-L.Y., L.-M.L.)
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, (H.-Y.C.), Taipei Medical University, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (S.-Y.Y., J.-T.L.)
| | - Sung-Chun Tang
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
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Zhou Q, Ma J, Liu Q, Wu C, Yang Z, Yang T, Chen Q, Yue Y, Shang J. Traditional Chinese Medicine formula, Sanwujiao granule, attenuates ischemic stroke by promoting angiogenesis through early administration. JOURNAL OF ETHNOPHARMACOLOGY 2024; 321:117418. [PMID: 37979814 DOI: 10.1016/j.jep.2023.117418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/24/2023] [Accepted: 11/10/2023] [Indexed: 11/20/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ischemic stroke (IS) is one of the most lethal diseases with the insufficient pharmacology therapeutic approach. Sanwujiao granule (SW) is widely used for IS in China with little known about its underlying mechanism. AIM OF THE STUDY To investigate the characteristics of therapeutic effects and potential mechanisms of SW against IS. MATERIALS AND METHODS The fingerprint of SW was applied by high-performance liquid chromatography-mass spectrometry (HPLC-MS). Three different drug treatment strategies, including prophylactic administration, early administration and delayed administration, were applied in rats' permanent middle cerebral occlusion (pMCAO) model. The Garcia neurological deficit test, adhesive removal test, rotarod test, TTC and TUNEL staining were performed to evaluate the pathological changes. The transcriptomic analysis was used to predict the potential mechanism of SW. The vascular deficiency model of Tg(kdrl:eGFP) zebrafish larvae and oxygen-glucose deprivation model on bEnd.3 cells were used to verify SW's pharmacological effect. qRT-PCR, immunofluorescent staining and Western Blot were applied to detect the expression of genes and proteins. The network pharmacology approach was applied to discover the potential bioactive compounds in SW that contribute to its pharmacological effect. RESULTS SW early and delayed administration attenuated cerebral infarction, neurological deficit and cell apoptosis. The transcriptomic analysis revealed that SW activated angiogenesis-associated biological processes specifically by early administration. CD31 immunofluorescent staining further confirmed the microvessel intensity in peri-infarct regions was significantly elevated after SW early treatment. Additionally, on the vascular deficiency model of zebrafish larvae, SW showed the angiogenesis effect. Next, the cell migration and tube formation were also observed in the bEnd.3 cells with the oxygen-glucose deprivation induced cell injury. It's worth noting that both mRNA and protein levels of angiogenesis factor, insulin-like growth factor 1, were significantly elevated in the pMCAO rats' brains treated with SW. The network pharmacology approach was applied and chasmanine, karacoline, talatisamine, etc. were probably the main active compounds of SW in IS treatment as they affected the angiogenesis-associated targets. CONCLUSIONS These results demonstrate that SW plays a critical role in anti-IS via promoting angiogenesis through early administration, indicating that SW is a candidate herbal complex for further investigation in treating IS in the clinical.
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Affiliation(s)
- Qinyang Zhou
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Ji Ma
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Qiuyan Liu
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Changyue Wu
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Ziwei Yang
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Tingting Yang
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Qimeng Chen
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Yunyun Yue
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China.
| | - Jing Shang
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China; State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, 210009, China; Jiangsu Key Laboratory of TCM Evaluation and Translational Research, China Pharmaceutical University, Nanjing, 210009, China; NMPA Key Laboratory for Research and Evaluation of Cosmetics, National Institutes for Food and Drug Control, Beijing, 100050, China.
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8
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Suzuki K, Katano T, Numao S, Nishi Y, Kutsuna A, Kanamaru T, Saito T, Aoki J, Nishiyama Y, Kimura K. The effect of asymptomatic intracranial hemorrhage after mechanical thrombectomy on clinical outcome. J Neurol Sci 2024; 457:122868. [PMID: 38246126 DOI: 10.1016/j.jns.2024.122868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND OBJECTIVE Whether asymptomatic intracranial hemorrhage (ICH) affects the clinical outcomes in patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains unclear. This study aimed to address this uncertainty. METHODS We retrospectively analyzed patients with acute ischemic stroke and internal carotid or middle cerebral (M1 segment) artery occlusion treated with MT between April 2011 and March 2021 at a single center. All patients had a premorbid modified Rankin scale (mRS) score ≤ 2 and an anterior circulation occlusion and underwent magnetic resonance imaging at admission. Asymptomatic ICH was defined as ICH without symptomatic ICH defined by the SITS-MOST criteria. A favorable outcome was defined as an mRS score ≤ 2 at 90 days after stroke onset. RESULTS Our study included 349 patients; 62% were men, the median age was 76 [67-83] years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 15 [8-21]. As determined via computed tomography, 103 (30%) patients had ICH (20 symptomatic and 83 asymptomatic). The favorable outcome rate was significantly lower for asymptomatic vs. no ICH (30% vs. 67%, p < 0.01). In a multivariate regression analysis, a high NIHSS score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; p < 0.01) and low Alberta Stroke Program Early CT Score (OR, 0.78; 95% CI, 0.65-0.92; p < 0.01) were independent risk factors for ICH. CONCLUSIONS Asymptomatic ICH is associated with poor clinical outcome at 90 days after stroke onset.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan.
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Yuji Nishi
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Akihito Kutsuna
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Takuya Kanamaru
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Tomonari Saito
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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9
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Streib C. Tenecteplase for Acute Ischemic Stroke Thrombolysis: Practical Considerations and Real-World Implementation. Neurol Clin Pract 2024; 14:e200221. [PMID: 38223783 PMCID: PMC10786601 DOI: 10.1212/cpj.0000000000200221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/13/2023] [Indexed: 01/16/2024]
Abstract
The only FDA-approved medical treatment for acute ischemic stroke (AIS) is alteplase (commonly referred to as "tPA"). The utilization of a newer fibrinolytic agent, tenecteplase, in routine stroke care is increasing because of recent clinical trial findings, streamlined clinical workflows, and cost-effectiveness. The stroke community is monitoring this development with considerable interest and special attention to the following questions: (1) Does the current evidence support superiority or noninferiority of tenecteplase compared with standard-of-care alteplase? (2) What are the ramifications of off-label treatment with tenecteplase? (3) And what are the real-world considerations when transitioning from alteplase to tenecteplase for AIS thrombolysis? This commentary provides a practical synthesis of the current evidence and discusses our institutional experience with tenecteplase including treatment considerations, off-label use, patient consent, stroke center accreditation, and cost savings. Necessary "Code Stroke" workflow changes to ensure a safe transition from alteplase to tenecteplase are detailed.
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10
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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11
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Lu J, Guo Y, Wang M, Luo Y, Zeng X, Miao X, Zaman A, Yang H, Cao A, Kang Y. Determining acute ischemic stroke onset time using machine learning and radiomics features of infarct lesions and whole brain. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2024; 21:34-48. [PMID: 38303412 DOI: 10.3934/mbe.2024002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Accurate determination of the onset time in acute ischemic stroke (AIS) patients helps to formulate more beneficial treatment plans and plays a vital role in the recovery of patients. Considering that the whole brain may contain some critical information, we combined the Radiomics features of infarct lesions and whole brain to improve the prediction accuracy. First, the radiomics features of infarct lesions and whole brain were separately calculated using apparent diffusion coefficient (ADC), diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences of AIS patients with clear onset time. Then, the least absolute shrinkage and selection operator (Lasso) was used to select features. Four experimental groups were generated according to combination strategies: Features in infarct lesions (IL), features in whole brain (WB), direct combination of them (IW) and Lasso selection again after direct combination (IWS), which were used to evaluate the predictive performance. The results of ten-fold cross-validation showed that IWS achieved the best AUC of 0.904, which improved by 13.5% compared with IL (0.769), by 18.7% compared with WB (0.717) and 4.2% compared with IW (0.862). In conclusion, combining infarct lesions and whole brain features from multiple sequences can further improve the accuracy of AIS onset time.
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Affiliation(s)
- Jiaxi Lu
- School of Applied Technology, Shenzhen University, Shenzhen 518060, China
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
| | - Yingwei Guo
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110169, China
| | - Mingming Wang
- Department of Radiology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Yu Luo
- Department of Radiology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai 200434, China
| | - Xueqiang Zeng
- School of Applied Technology, Shenzhen University, Shenzhen 518060, China
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
| | - Xiaoqiang Miao
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110169, China
| | - Asim Zaman
- School of Applied Technology, Shenzhen University, Shenzhen 518060, China
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
| | - Huihui Yang
- School of Applied Technology, Shenzhen University, Shenzhen 518060, China
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
| | - Anbo Cao
- School of Applied Technology, Shenzhen University, Shenzhen 518060, China
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
| | - Yan Kang
- College of Health Science and Environmental Engineering, Shenzhen Technology University, Shenzhen 518118, China
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110169, China
- Engineering Research Centre of Medical Imaging and Intelligent Analysis, Ministry of Education, Shenyang 110169, China
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12
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Martins SCO, Pontes-Neto OM, Pille A, Secchi TL, Miranda Alves MAD, Rebello LC, Oliveira-Filho J, Lange MC, de Freitas GR, de Andrade JBC, Rocha LJDA, Bezerra DDC, Souza ACD, Carbonera LA, Nogueira RG, Silva GS. Reperfusion therapy for acute ischemic stroke: where are we in 2023? ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1030-1039. [PMID: 38157871 PMCID: PMC10756810 DOI: 10.1055/s-0043-1777721] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.
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Affiliation(s)
- Sheila Cristina Ouriques Martins
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil.
- Hospital Moinhos de Vento, Porto Alegre RS, Brazil.
| | | | - Arthur Pille
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil.
- Hospital Moinhos de Vento, Porto Alegre RS, Brazil.
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13
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Thiebaut AM, Louet ER, Ianszen M, Guichard MJ, Hanley DF, Gaudin C, Parcq J. O2L-001, an innovative thrombolytic to evacuate intracerebral haematoma. Brain 2023; 146:4690-4701. [PMID: 37450572 PMCID: PMC10629768 DOI: 10.1093/brain/awad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/31/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023] Open
Abstract
Intracerebral haemorrhage is an unmet medical need affecting more than 3 million people worldwide every year and leading to the formation of an intracerebral haematoma. Updated guidelines (2022) for the management of intracerebral haemorrhage patients recognize that minimally invasive approaches for the evacuation of supratentorial intracerebral haemorrhage have demonstrated reductions in mortality compared with medical management alone. However, improvement of functional outcome with a procedure involving thrombolytic therapy was neutral in the last large phase 3 clinical trial and requires a more effective and safer thrombolytic agent than those currently available. Here, we demonstrate that O2L-001 allows for the extended release of W253R/R275S recombinant tissue-type plasminogen activator (rtPA). A new rtPA variant, called optimized tPA (OptPA), offers improved efficacy for haematoma evacuation as well as improved safety. OptPA was produced in a Chinese hamster ovary cell line before purification, nanoprecipitation using the NANOp2Lysis® technological platform followed by suspension in a solution of 17% poloxamer 407 to obtain O2L-001. Plasmin generation assays were performed to demonstrate O2L-001 safety. Ex vivo haematoma models using human blood were used to demonstrate O2L-001 thrombolysis properties and efficacy. For the best translational significance, a clinical sized haematoma was used to ensure catheter placement and to allow administration of the thrombolytic agent into the core of the haematoma via a minimally invasive procedure. The capacity of OptPA to convert plasminogen into plasmin is strongly decreased compared to rtPA, thereby reducing potential bleeding events. However, a clot lysis assay showed that OptPA had the same fibrinolytic activity as rtPA. We demonstrated that long-term exposure to a thrombolytic agent was essential to achieve high thrombolysis efficacy. Indeed, 24 h continuous exposure to 0.1 µg/ml rtPA had similar efficacy than repeated short exposure to 30 µg/ml rtPA. This finding led to the development of O2L-001, allowing the extended release of OptPA in the first 6 h following injection. An ex vivo model using human blood was used to demonstrate O2L-001 efficacy. Interestingly, unlike rtPA, O2L-001 was able to induce the complete lysis of the 5 ml haematoma. In clinical sized haematomas (obtained from 30 ml of human blood), a single injection of O2L-001 at 1 mg/ml into the core of the haematoma led to a 44% increase in thrombolysis compared to rtPA. Taken together, these results demonstrate that O2L-001 provides new hope for haematoma evacuation and the treatment of patients with intracerebral haemorrhage.
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Affiliation(s)
| | - Estelle R Louet
- Op2Lysis SAS, GIP Cyceron, 14000 Caen, France
- Normandie Univ, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France
| | | | | | - Daniel F Hanley
- The Johns Hopkins Medical Institutions, BIOS, Baltimore, MD 21202, USA
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14
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Shindo S, Uchida K, Yoshimura S, Sakai N, Yamagami H, Toyoda K, Matsumaru Y, Matsumoto Y, Kimura K, Ishikura R, Inoue M, Sakakibara F, Nakajima M, Ueda M, Morimoto T. Intravenous alteplase before endovascular therapy for acute large vessel occlusion with large ischemic core: subanalysis of a randomized clinical trial. J Neurointerv Surg 2023:jnis-2023-020846. [PMID: 37890987 DOI: 10.1136/jnis-2023-020846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The efficacy of endovascular therapy (EVT) in patients with large ischemic core has been reported, but it remains unclear whether IV alteplase (IVT) has beneficial effects in addition to EVT in such patients. We evaluated the efficacy and safety of EVT with or without IVT. METHODS The RESCUE-Japan LIMIT was an open-label, prospective, multicenter, randomized clinical trial to evaluate the efficacy and safety of EVT in stroke patients with large ischemic core, defined as Alberta Stroke Program Early CT Score (ASPECTS) 3-5. This subanalysis evaluated the differences in the effects of EVT with medical care (EVT group) compared with medical care alone (No-EVT group) between those who received IVT (IVT stratum) and those who did not (No-IVT stratum) before EVT. RESULTS Among 202 enrolled patients, 147 (73%) did not receive IVT. In the No-IVT stratum, the modified Rankin Scale (mRS) score of 0-3 at 90 days was significantly higher in the EVT group than in the No-EVT group (31.1% vs 12.3%, OR 3.21 (95% CI 1.37 to 7.53)). In the IVT stratum, the mRS score of 0-3 was 30.8% in the EVT group and 13.8% in the No-EVT group (OR 2.78 (95% CI 0.72 to 10.7)) (interaction p=0.77). The incidence of symptomatic intracranial hemorrhage was not different between the two groups in the No-IVT stratum (OR 1.20 (95% CI 0.35 to 4.12)), but it was significantly higher in the EVT group than in the No-EVT group in the IVT stratum (11.5% vs 0%, p=0.03). CONCLUSIONS There was no difference in efficacy of EVT with or without IVT, while IVT before EVT might increase symptomatic intracranial hemorrhage in patients with large ischemic core. TRIAL REGISTRATION INFORMATION NCT03702413.
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Affiliation(s)
- Seigo Shindo
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Bunkyo-ku, Japan
| | - Reiichi Ishikura
- Department of Diagnostic Radiology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumihiro Sakakibara
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | - Makoto Nakajima
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
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15
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Mutti M, Moreno DS, Restrepo-Córdoba M, Visram Z, Resch G, Corsini L. Phage activity against Staphylococcus aureus is impaired in plasma and synovial fluid. Sci Rep 2023; 13:18204. [PMID: 37875544 PMCID: PMC10598271 DOI: 10.1038/s41598-023-45405-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/19/2023] [Indexed: 10/26/2023] Open
Abstract
S. aureus is a pathogen that frequently causes severe morbidity and phage therapy is being discussed as an alternative to antibiotics for the treatment of S. aureus infections. In this in vitro and animal study, we demonstrated that the activity of anti-staphylococcal phages is severely impaired in 0.5% plasma or synovial fluid. Despite phage replication in these matrices, lysis of the bacteria was slower than phage propagation, and no reduction of the bacterial population was observed. The inhibition of the phages associated with a reduction in phage adsorption, quantified to 99% at 10% plasma. S. aureus is known to bind multiple coagulation factors, resulting in the formation of aggregates and blood clots that might protect the bacterium from the phages. Here, we show that purified fibrinogen at a sub-physiological concentration of 0.4 mg/ml is sufficient to impair phage activity. In contrast, dissolution of the clots by tissue plasminogen activator (tPA) partially restored phage activity. Consistent with these in vitro findings, phage treatment did not reduce bacterial burdens in a neutropenic mouse S. aureus thigh infection model. In summary, phage treatment of S. aureus infections inside the body may be fundamentally challenging, and more investigation is needed prior to proceeding to in-human trials.
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Affiliation(s)
| | | | | | | | - Grégory Resch
- Center for Research and Innovation in Clinical Pharmaceutical Sciences (CRISP), Lausanne Hospital (CHUV), Lausanne, Switzerland
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16
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Novotny V, Kvistad CE, Naess H, Logallo N, Fromm A, Khanevski AN, Thomassen L. Tenecteplase, 0.4 mg/kg, in Moderate and Severe Acute Ischemic Stroke: A Pooled Analysis of NOR-TEST and NOR-TEST 2A. J Am Heart Assoc 2023; 12:e030320. [PMID: 37830342 PMCID: PMC10757511 DOI: 10.1161/jaha.123.030320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
Background The optimal dose of tenecteplase in acute ischemic stroke remains to be defined. We present a pooled analysis of the 2 NOR-TESTs (Norwegian Tenecteplase Stroke Trials) exploring the efficacy and safety of tenecteplase, 0.4 mg/kg. Methods and Results We retrospectively reviewed 2 PROBE (Prospective Randomized Open, Blinded End-point) trials, NOR-TEST and NOR-TEST 2A. Patients were randomized to either tenecteplase, 0.4 mg/kg, or alteplase, 0.9 mg/kg. The primary end point was favorable functional outcome at 3 months (modified Rankin Scale score, 0-1) or return to baseline if prestroke modified Rankin Scale score was 2. Secondary end points included favorable functional and clinical outcome and safety data. The pooled analysis includes patients with National Institutes of Health Stroke Scale score ≥6 from both trials and an additional post hoc analysis of patients with National Institutes of Health Stroke Scale score ≤5 from NOR-TEST. The per-protocol analysis contains 483 patients, of whom 235 were assigned to tenecteplase and 248 were assigned to alteplase. In per-protocol analysis, functional outcome was better in the alteplase arm with cutoff modified Rankin Scale score of 2 (odds ratio [OR], 0.52 [95% CI, 0.33-0.80]; P=0.003) and expressed by ordinal shift analysis (OR, 1.64 [95% CI, 1.17-2.28]; P=0.004). Mortality at 3 months was higher in the tenecteplase arm (OR, 2.48 [95% CI, 1.20-5.10]; P=0.01). Mortality and intracranial hemorrhage rates were higher in the severe stroke group randomized to tenecteplase, whereas these rates were similar for alteplase and tenecteplase in moderate and mild stroke. Conclusions Tenecteplase, 0.4 mg/kg, is unsafe in moderate and severe stroke, and the risk of death and intracranial hemorrhage probably increases with stroke severity. A lower tenecteplase dose should be tested in future trials. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01949948, NCT03854500.
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Affiliation(s)
- Vojtech Novotny
- Department of NeurologyHaukeland University HospitalBergenNorway
| | - Christopher Elnan Kvistad
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Halvor Naess
- Department of NeurologyHaukeland University HospitalBergenNorway
- Centre for Age‐Related MedicineStavanger University HospitalStavangerNorway
| | - Nicola Logallo
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
| | - Annette Fromm
- Department of NeurologyHaukeland University HospitalBergenNorway
| | | | - Lars Thomassen
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
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17
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Chen J, Lin Y, Li J, Zhang P, Wang Y, Chen Y, Zhang C, Li C. Efficacy and safety of short-term high dosage dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis for acute ischemic stroke. Medicine (Baltimore) 2023; 102:e35099. [PMID: 37682162 PMCID: PMC10489488 DOI: 10.1097/md.0000000000035099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/16/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of short-term high-dose of dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis for acute ischemic stroke (AIS). METHODS All 208 patients with AIS were randomized into group 1 (103 cases, after 0.6 mg/kg rt-PA, 300 mg of oral aspirin(ASP) q.d. and 225 mg of oral clopidogrel (CLO) q.d. for for 5 days, then 100 mg of oral ASP q.d. for the next 85 days and 75 mg of oral CLO q.d. for the next 16 days) and group 2 (105 cases, after 0.9 mg/kg rt-PA, 100 mg of oral ASP q.d. for 90 days and 75 mg of oral CLO q.d. for 21 days).The efficacy index was the mRS score, NIHSS score and recurrence risk of stroke, while the safety index was the incidence of bleeding events and mortality. All parameters were evaluated at 30 and 90 days after thrombolysis. Patients whose characteristics may provide the best treatment benefit were further analyzed using the logistic regression model in group 1. RESULTS The proportion of mRS scores between 0 and 1 in group 1 was higher than that in group 2 at both 30 days (44.7% vs 32.4%, P < .05) and 90 days (50.5% vs 35.2%, P < .05). Compared to group 2, the proportion of NIHSS scores less than 4 was significantly higher in group 1 at both 30 days (37.9% vs 25.7%, P < .05) and 90 days (46.6% vs 30.5%, P < .05). At 90 days, Group 1 had a lower stroke recurrence risk than Group 2 (3.9% vs 10.5%, P < .05). The incidence of SICH was significantly different between the 2 groups at both 30 days (2.9% vs 9.5%, P < .05) and 90 days (2.9% vs 10.5%, P < .05). However, other bleeding events and mortality rates were not significantly different between the 2 groups. The lower the baseline NIHSS score and the shorter the OTT, the more favorable the outcomes obtained at 90 days. CONCLUSIONS Compared to standard doses, short term high-dose dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis may be a good choice for AIS patients.
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Affiliation(s)
- Jing Chen
- Department of Neurology, Characteristic Medical Centre of People’s Armed Police Force, Tianjin, P.R. China
- Tianjin Medical University, Tianjin, P.R. China
| | - Yanchen Lin
- Department of Rehabilitation, Characteristic Medical Centre of People’s Armed Police Force, Tianjin, P.R. China
- Army Medical University, Chongqing, P. R. China
| | - Jingjing Li
- Department of Pharmacy, Tianjin Fourth Central Hospital, Tianjin, P. R. China
| | - Peilan Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Yuxin Wang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Yan Chen
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Chenhao Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Chenhua Li
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
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18
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Xiao ZX, Zhang SD, Zeng L. Effect of Jin three needles combined with Tong Qiao and blood activation Tang on neurological function, coagulation function and serum level in stroke patients. Medicine (Baltimore) 2023; 102:e34459. [PMID: 37565882 PMCID: PMC10419501 DOI: 10.1097/md.0000000000034459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
To investigate the efficacy and safety of Jin three needles combined with Tong Qiao Wu Blood-streaming Tang in patients with acute ischemic stroke (AIS), this retrospective study analyzed the data of patients with AIS between January 2017 and December 2022. The National Institutes of Health Stroke Scale (NIHSS) scores, blood neuron-specific enolase, S100β protein (S100β), fibrinogen (FIB), cerebral infarct volume, D-dimer (D-D), prothrombin time (PT), activated partial thromboplastin time, hypersensitive c-reactive protein (hs-CRP), serum tumor necrosis factor-α (TNF-α), and homocysteine (Hcy) were compared between the 2 groups. The treatment effect was significantly better in the observation group than in the comparison group (P < .05). The NIHSS score, neuron-specific enolase, S100β, and cerebral infarct volume were significantly lower in both groups after treatment than before treatment (P < .05). FIB and D-D levels were significantly lower and APTT and PT levels were significantly higher in both groups after treatment than before treatment (P < .05). TNF-α, hs-CRP, and Hcy were significantly lower in both groups after treatment than before treatment, and TNF-α, hs-CRP and Hcy were significantly lower in the observation group than in the comparison group (P < .05). No statistically significant difference in the incidence of adverse reactions occurred between the 2 groups (P > .05). Combining Jin three needles can improve the therapeutic effect in patients with AIS, promote the recovery of neurological function, improve coagulation function, and reduce the inflammatory response with good safety.
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Affiliation(s)
- Zhong-Xiang Xiao
- Department of Rehabilitation, Wuhan No.9 Hospital, Wuhan, Hubei, China
| | - Shi-Dong Zhang
- Department of Traditional Chinese Medicine, Wuhan No.9 Hospital, Wuhan, Hubei, China
| | - Li Zeng
- Department of Pharmacy, Wuhan No.9 Hospital, Wuhan, Hubei, China
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19
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Zhai M, Cao S, Yang J, Cao X, Dong Z, Liu W, Fu Y, Guan Q, Wang Y, Liu H. Effect of Intravenous Thrombolytic Dose of Alteplase on Long-Term Prognosis in Patients with Acute Ischemic Stroke. Neurol Ther 2023; 12:1105-1118. [PMID: 37166676 PMCID: PMC10310604 DOI: 10.1007/s40120-023-00488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/21/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the long-term prognostic effects of different alteplase doses on patients with acute ischemic stroke (AIS). METHODS In this cohort study, we enrolled 501 patients with AIS treated with intravenous thrombolysis with alteplase, with the primary endpoint event of recurrence of ischemic stroke and the secondary endpoint event of death. The effects of different doses of alteplase on recurrence of ischemic stroke and death were analyzed using a Cox proportional risk model. RESULTS Among 501 patients with AIS treated with thrombolysis, 295 patients (58.9%) and 206 patients (41.1%) were treated with low-dose and standard-dose alteplase, respectively. During the study period, 61 patients (12.2%) had a confirmed recurrence of ischemic stroke. Multivariate Cox proportional risk analysis showed that standard-dose alteplase thrombolysis (HR 0.511, 95% CI 0.288-0.905, P = 0.021) was significantly associated with a reduced risk of long-term recurrence of AIS, whereas atrial fibrillation was associated with an increased risk of long-term recurrence of AIS. Thirty-nine (7.8%) patients died during the study period. Multivariate Cox proportional risk analysis showed that age, baseline National Institutes of Health Stroke Scale (NIHSS) score, and symptomatic steno-occlusion were associated with an increased long-term risk of death from AIS. The alteplase dose was not associated with the risk of death from AIS. CONCLUSIONS Standard-dose alteplase treatment reduced the risk of long-term recurrence of AIS after hospital discharge and the alteplase dose was not associated with the long-term risk of death from AIS.
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Affiliation(s)
- Mingfeng Zhai
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Shugang Cao
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, The Second People's Hospital of Hefei, Hefei, China
| | - Jinwei Yang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Xiaoyan Cao
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Zhong Dong
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Wanyin Liu
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Yongzhan Fu
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Qiyue Guan
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
- Anhui Public Health Clinical Center, Hefei, China.
| | - Hongbo Liu
- Department of Emergency, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, 236000, China.
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20
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Ha SH, Jeong S, Park JY, Yang SY, Cha MJ, Cho MS, Lee JS, Kim MJ, Chang JY, Kang DW, Kwon SU, Kim BJ. Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke. Cerebrovasc Dis 2023; 53:69-78. [PMID: 37399789 DOI: 10.1159/000531386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/29/2023] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION Patients with atrial fibrillation-related stroke (AF-stroke) are prone to developing rapid ventricular response (RVR). We investigated whether RVR is associated with initial stroke severity, early neurological deterioration (END) and poor outcome at 3 months. METHODS We reviewed patients who had AF-stroke between January 2017 and March 2022. RVR was defined as having heart rate >100 beats per minute on initial electrocardiogram. Neurological deficit was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission. END was defined as increase of ≥2 in total NIHSS score or ≥1 in motor NIHSS score within first 72 h. Functional outcome was score on modified Rankin Scale at 3 months. Mediation analysis was performed to examine potential causal chain in which initial stroke severity may mediate relationship between RVR and functional outcome. RESULTS We studied 568 AF-stroke patients, among whom 86 (15.1%) had RVR. Patients with RVR had higher initial NIHSS score (p < 0.001) and poor outcome at 3 months (p = 0.004) than those without RVR. The presence of RVR [adjusted odds ratio (aOR) = 2.13; p = 0.013] was associated with initial stroke severity, but not with END and functional outcome. Otherwise, initial stroke severity [aOR = 1.27; p = <0.001] was significantly associated with functional outcome. Initial stroke severity as a mediator explained 58% of relationship between RVR and poor outcome at 3 months. CONCLUSION In patients with AF-stroke, RVR was independently associated with initial stroke severity but not with END and functional outcome. Initial stroke severity mediated considerable proportion of association between RVR and functional outcome.
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Affiliation(s)
- Sang Hee Ha
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea,
- Department of Neurology, Gil Medical Center, Gachon University, Incheon, Republic of Korea,
| | - Soo Jeong
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
- Department of Neurology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jae Young Park
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - So Young Yang
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Myung-Jin Cha
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Min-Soo Cho
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Young Chang
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Dong-Wha Kang
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Bum Joon Kim
- Department of Neurology and Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
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Deguchi I, Takahashi S. Pathophysiology and Optimal Treatment of Intracranial Branch Atheromatous Disease. J Atheroscler Thromb 2023; 30:701-709. [PMID: 37183021 PMCID: PMC10322737 DOI: 10.5551/jat.rv22003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Intracranial branch atheromatous disease (BAD) is a pathological condition characterized by the occlusion of a relatively large perforating branch (700-800 µm) near the orifice of a parent artery due to atherosclerotic plaque-based thrombus (microatheroma). BAD is refractory to treatment and follows a course of progressive exacerbation, especially motor paralysis. Uniform treatment for common atherothrombotic cerebral infarction or lacunar infarction does not prevent the progressive exacerbation of BAD, and consequently affects functional prognosis. To date, various combinations of treatments have been investigated and proposed to attenuate the worsening symptoms of BAD. However, no therapy with established efficacy is yet available for BAD. Since it is the most difficult condition to treat in the area of cerebral infarction, the establishment of optimal treatment methods for BAD is keenly awaited. This review presents an overview of the acute treatments available for BAD and discusses the prospects for optimal treatment.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan
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22
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Cao X, Luo J, Xu B, Xiao Y, Yang T, Sun X, Sui Y. Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study. J Neurol Sci 2023; 451:120706. [PMID: 37379725 DOI: 10.1016/j.jns.2023.120706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES The efficacy and safety of intravenous thrombolysis uncertain in patients with non-disabling mild ischemic stroke. Our aim was to investigate whether best medical management only is noninferior to intravenous thrombolysis plus best medical management therapy for achieving favorable functional outcome at 90 days. MATERIALS AND METHODS In a prospective acute ischemic stroke registry from 2018 through 2020, 314 non-disabling mild ischemic stroke patients received best medical management only and 638 underwent intravenous thrombolysis plus best medical management. The primary outcome was modified Rankin Scale ≤1 at Day 90. The noninferiority margin was -5%. Secondary outcomes of hemorrhagic transformation, early neurologic deterioration and mortality were also evaluated. RESULTS The best medical management only was noninferior to the combined therapy of intravenous thrombolysis and best medical management with regard to the primary outcome (unadjusted risk difference, 1.16%; 95% CI, -3.48% ∼ 5.8%; p = 0.0046 for noninferiority; adjusted risk difference, 3.01%; 95% CI, -3.39% ∼ 9.41%). After propensity score matching, p < 0.0001 for noninferiority. RD, 4.03%; 95% CI, -1.59% ∼ 9.69%. p < 0.0001 for noninferiority. Adjusted RD, 5.23%; 95% CI, -1.88% ∼ 9.97%. The occurrence of hemorrhagic transformation was significantly increased in the group of combination therapy (OR, 4.26; 95% CI, 1.30 to 13.99; p = 0.008), while no significant difference was detected in early neurologic deterioration (OR, 1.11; 95% CI, 0.49-2.52; p = 0.808) and mortality (OR, 0.57; 95% CI, 0.20 to 1.69; p = 0.214) between groups. CONCLUSIONS In the present study, we found the best medical management only was noninferior to the combination therapy of intravenous thrombolysis plus best medical management for non-disabling mild ischemic stroke within 4.5 h after onset. Best medical management may be a treatment of choice for non-disabling mild ischemic stroke patients. Further randomized controlled studies are warranted.
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Affiliation(s)
- Xiaopan Cao
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China; Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, 223 Handan Road, Yangpu District, Shanghai 200436, China.
| | - Bing Xu
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Ying Xiao
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Tuo Yang
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China
| | - Xiaohong Sun
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China.
| | - Yi Sui
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
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Wu H, Liu Y, Miao G, Ge J, You S, Zhang X, Liu H, Zhou Y, Lu T, Cao Y, Shi J. Effect of the interaction between atrial fibrillation and rt-PA dose on the prognosis of acute ischaemic stroke with intravenous thrombolysis. Postgrad Med J 2023; 99:588-594. [PMID: 37319158 DOI: 10.1136/postgradmedj-2022-141710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/09/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The association between atrial fibrillation (AF) and the prognosis of acute ischaemic stroke (AIS) remains controversial; whether the recombinant tissue plasminogen activator dose influences this association remains poorly understood. METHODS Patients who had an AIS were enrolled from eight stroke centres in China. According to the recombinant tissue plasminogen activator dose, patients treated with intravenous recombinant tissue plasminogen activator within 4.5 hours after symptom onset were divided into a low-dose group (recombinant tissue plasminogen activator <0.85 mg/kg) and a standard-dose group (recombinant tissue plasminogen activator ≥0.85 mg/kg). Patients who had an AIS in the low-dose group and the standard dose group were divided into whether or not they had AF. The main outcomes were major disability (modified Rankin scale (mRS) score 3-5), mortality and vascular events occurring within 3 months. RESULTS The study included 630 patients who received recombinant tissue plasminogen activator after AIS, including 391 males and 239 females, with a mean age of 65.8 years. Of these patients, 305 (48.4%) received low-dose recombinant tissue plasminogen activator and 325 (51.6%) received standard dose recombinant tissue plasminogen activator. The recombinant tissue plasminogen activator dose significantly influenced the association between AF and death or major disability (p-interaction=0.036). After multivariate adjustment, AF was associated with an increased risk of death or major disability (OR 2.90, 95% CI 1.47 to 5.72, p=0.002), major disability (OR 1.93, 95% CI 1.04 to 3.59, p=0.038) and vascular events (HR 5.01, 95% CI 2.25 to 11.14, p<0.001) within 3 months in patients with standard-dose recombinant tissue plasminogen activator. No significant association was found between AF and any clinical outcome in patients with low-dose recombinant tissue plasminogen activator (all p>0.05). With AF, the mRS score distribution showed a significantly worse shift in patients with standard-dose recombinant tissue plasminogen activator (p=0.016) than in those with low-dose recombinant tissue plasminogen activator (p=0.874). CONCLUSIONS AF may be a strong predictor of poor prognosis in patients who had an AIS receiving standard-dose recombinant tissue plasminogen activator, suggesting that low-dose recombinant tissue plasminogen activator should be administered to patients who had a stroke with AF to improve their prognosis. WHAT IS ALREADY KNOWN ON THIS TOPIC WHAT THIS STUDY ADDS HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
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Affiliation(s)
- Huan Wu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Neurology, Huangshan City People's Hospital, Huangshan, Anhui, China
| | - Yuanyuan Liu
- Department of Electrocardiography, The Affiliated Guangji Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Guihua Miao
- Department of Neurology, The First People's Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Jian Ge
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shoujiang You
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xia Zhang
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Huihui Liu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yi Zhou
- Department of Neurology, The First People's Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Taosheng Lu
- Department of Neurology, The First People's Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Yongjun Cao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jijun Shi
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Ringleb P, Bauer G, Purrucker J. [Intravenous thrombolysis of ischemic stroke-Current status]. DER NERVENARZT 2023:10.1007/s00115-023-01500-9. [PMID: 37249597 DOI: 10.1007/s00115-023-01500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023]
Abstract
Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5‑h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.
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Affiliation(s)
- Peter Ringleb
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Gregor Bauer
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Jan Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Wang X, You S, Zhou Z, Delcourt C, Wardlaw J, Mair G, Robinson T, Chen X, Yoshimura S, Torii-Yoshimura T, Carcel C, Malavera A, Anderson C, Lindley RI. Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial. J Neurol 2023; 270:2567-2575. [PMID: 36939933 PMCID: PMC10130001 DOI: 10.1007/s00415-023-11580-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/18/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND We aimed to assess the association of atrial fibrillation (AF) on outcomes in a post hoc analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) and how this association is modified by baseline imaging features. METHODS Inverse probability of treatment weight was used to remove baseline imbalances between those with and without AF. The primary outcome was the modified Rankin Scale (mRS) scores at 90 days. Secondary outcomes were symptomatic intracerebral haemorrhage (sICH), early neurological deterioration or death within 24 h, and death at 90 days. The logistic regression model was used to determine the associations. RESULTS Of the 3285 patients included in this analysis, 636 (19%) had AF at baseline. Compared with non-AF, AF was not significantly associated with an unfavourable shift of mRS (odds ratio 1.09; 95% confidence interval, 0.96-1.24), but with sICH (2.82; 1.78-4.48; IST-3 criteria), early neurological deterioration or death within 24 h (1.31; 1.01-1.70), and death (1.42; 1.12-1.79). Among patients with acute ischaemic signs (presence, extent, swelling and attenuation of acute lesions), AF was associated with the increased risk of all the poor outcomes (all P < 0.04 for interaction). CONCLUSIONS We found AF increased risk of sICH, early neurological deterioration or death and death, but not unfavourable functional recovery at day 90 after thrombolysis in patients with AIS. The presence of acute ischaemic brain imaging signs at stroke presentation could be used to improve risk stratification in the presence of AF. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (NCT01422616).
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
| | - Shoujiang You
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zien Zhou
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences,, Macquarie University, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Joanna Wardlaw
- Edinburgh Imaging, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Grant Mair
- Edinburgh Imaging, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences,, Macquarie University, Sydney, Australia
| | - Sohei Yoshimura
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takako Torii-Yoshimura
- Division of Neurology, Department of Stroke and Cerebrovascular Diseases, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology and Neuroscience, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences,, Macquarie University, Sydney, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
| | - Craig Anderson
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richard I Lindley
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia.
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Siddiqi AZ, Wadhwa A. Treatment of Acute Stroke: Current Practices and Future Horizons. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:56-65. [PMID: 36443221 DOI: 10.1016/j.carrev.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/06/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE This review will discuss revascularization of acute ischemic stroke (AIS), discussing the concept of the ischemic penumbra and how thrombolysis and thrombectomy take advantage of it. SUMMARY The goal of AIS revascularization is to rescue the ischemic penumbra and the approach to has gone from a time-based to tissue-based approach. Patients must be carefully selected for thrombolysis, which traditionally was limited to those whose last known normal time (LKNT) was known and within 4.5 h. However, newer imaging techniques involving MRI and CT perfusion (CTP) can select patients for thrombolysis whose LKNT is unknown. Alteplase, or tPA, is still the agent of choice for thrombolysis in patients with AIS but tenecteplase (TNK) may be just as effective and more efficient to use. Endovascular thrombectomy (EVT) has shown considerable efficacy for treating large-vessel occlusions and using CTP, patients can be selected for hours after symptom-onset if viable tissue remains. Further research is underway to determine if EVT can be used for medium vessel occlusions and for basilar artery thromboses as well as to determine whether an "EVT-alone" strategy is superior to "tPA + EVT" strategy.
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Affiliation(s)
- A Zohaib Siddiqi
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
| | - Ankur Wadhwa
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
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Nilanont Y, Chanyagorn P, Shukij K, Pengtong W, Kongmuangpuk M, Wongmayurachat K, Nittayaboon K, Wongsawat Y, Sirovetnukul R, Chakorn T, Riyapan S, Kaveeta C, Chotik-Anuchit S, Tongdee T, Thabmontian P, Saeheng P, Nopmaneejumruslers C, Vamvanij V. Comparing performance measures and clinical outcomes between mobile stroke units and usual care in underserved areas. Neurol Sci 2023; 44:1261-1271. [PMID: 36515765 PMCID: PMC10023765 DOI: 10.1007/s10072-022-06550-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of mobile stroke units (MSUs) in improving acute ischemic stroke (AIS) care in developing countries is unknown. We compared performance measures and stroke outcomes in AIS patients between MSU and usual care: emergency medical services (EMS) and walk-in. METHODS We enrolled patients > 18 years of age with an AIS within 4.5 h after onset. Demographic data, types, and time of reperfusion therapies and clinical outcomes were recorded. A favorable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 3 months. RESULTS A total of 978 AIS patients (MSU = 243, EMS = 214, walk-in = 521) were enrolled between June 1, 2018, and April 30, 2021. The mean age (± SD) was 66 (± 14) years, and 510 (52.1%) were male. AIS time metrics were the shortest in the MSU with a mean (± SD) door to needle (DN) time of 20 (± 7), 29 (± 13), and 35 (± 16) min (p < 0.001) and door to puncture (DP) time of 73 ± 19, 86 ± 33, and 101 ± 42 min (p < 0.001) in MSU, EMS, and walk-in, respectively. Participants in the MSU (56.8%) received higher rate of reperfusion therapie(s) when compared to the EMS (51.4%) and walk-in (31.5%) (p < 0.001). After adjustment for any potential confounders and using the EMS as a reference, the MSU has the highest likelihood of achieving a favorable outcome (adjusted OR 2.15; 95% CI 1.39-3.32). CONCLUSIONS In underserved populations, MSUs significantly reduced DN time, increased the likelihood of receiving reperfusion treatment, and achieved independency at 3 months when compared to usual care.
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Affiliation(s)
- Yongchai Nilanont
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Pornchai Chanyagorn
- Department of Electrical Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Karuna Shukij
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Waitayaporn Pengtong
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mananchaya Kongmuangpuk
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokkarn Wongmayurachat
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kittiya Nittayaboon
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yodchanan Wongsawat
- Department of Biomedical Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Ronnachai Sirovetnukul
- Department of Industrial Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chitapa Kaveeta
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Songkram Chotik-Anuchit
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Trongtum Tongdee
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ploypailin Thabmontian
- Siriraj Stroke Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Porntep Saeheng
- Bangkok Emergency Medical Service, Medical Service Department, Bangkok, Thailand
| | - Cherdchai Nopmaneejumruslers
- Office of the Director of Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Visit Vamvanij
- Office of the Director of Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Li JX, Wang X, Henry A, Anderson CS, Hammond N, Harris K, Liu H, Loffler K, Myburgh J, Pandian J, Smyth B, Venkatesh B, Carcel C, Woodward M. Sex differences in pain expressed by patients across diverse disease states: individual patient data meta-analysis of 33,957 participants in 10 randomized controlled trials. Pain 2023:00006396-990000000-00275. [PMID: 36972472 DOI: 10.1097/j.pain.0000000000002884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/28/2022] [Indexed: 03/29/2023]
Abstract
ABSTRACT The experience of pain is determined by many factors and has a significant impact on quality of life. This study aimed to determine sex differences in pain prevalence and intensity reported by participants with diverse disease states in several large international clinical trials. Individual participant data meta-analysis was conducted using EuroQol-5 Dimension (EQ-5D) questionnaire pain data from randomised controlled trials published between January 2000 and January 2020 and undertaken by investigators at the George Institute for Global Health. Proportional odds logistic regression models, comparing pain scores between females and males and fitted with adjustments for age and randomized treatment, were pooled in a random-effects meta-analysis. In 10 trials involving 33,957 participants (38% females) with EQ-5D pain score data, the mean age ranged between 50 and 74. Pain was reported more frequently by females than males (47% vs 37%; P < 0.001). Females also reported greater levels of pain than males (adjusted odds ratio 1.41, 95% CI 1.24-1.61; P < 0.001). In stratified analyses, there were differences in pain by disease group (P for heterogeneity <0.001), but not by age group or region of recruitment. Females were more likely to report pain, and at a higher level, compared with males across diverse diseases, all ages, and geographical regions. This study reinforces the importance of reporting sex-disaggregated analysis to identify similarities and differences between females and males that reflect variable biology and may affect disease profiles and have implications for management.
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An Update on the Treatment of Basilar Artery Occlusion. Curr Treat Options Neurol 2023. [DOI: 10.1007/s11940-023-00748-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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30
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Chen C, Ouyang M, Ong S, Zhang L, Zhang G, Delcourt C, Mair G, Liu L, Billot L, Li Q, Chen X, Parsons M, Broderick JP, Demchuk AM, Bath PM, Donnan GA, Levi C, Chalmers J, Lindley RI, Martins SO, Pontes-Neto OM, Venturelli PM, Olavarría V, Lavados P, Robinson TG, Wardlaw JM, Li G, Wang X, Song L, Anderson CS. Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial. EClinicalMedicine 2023; 57:101849. [PMID: 36820100 PMCID: PMC9938155 DOI: 10.1016/j.eclinm.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
Background Intensive blood pressure lowering may adversely affect evolving cerebral ischaemia. We aimed to determine whether intensive blood pressure lowering altered the size of cerebral infarction in the 2196 patients who participated in the Enhanced Control of Hypertension and Thrombolysis Stroke Study, an international randomised controlled trial of intensive (systolic target 130-140 mm Hg within 1 h; maintained for 72 h) or guideline-recommended (systolic target <180 mm Hg) blood pressure management in patients with hypertension (systolic blood pressure >150 mm Hg) after thrombolysis treatment for acute ischaemic stroke between March 3, 2012 and April 30, 2018. Methods All available brain imaging were analysed centrally by expert readers. Log-linear regression was used to determine the effects of intensive blood pressure lowering on the size of cerebral infarction, with adjustment for potential confounders. The primary analysis pertained to follow-up computerised tomography (CT) scans done between 24 and 36 h. Sensitivity analysis were undertaken in patients with only a follow-up magnetic resonance imaging (MRI) and either MRI or CT at 24-36 h, and in patients with any brain imaging done at any time during follow-up. This trial is registered with ClinicalTrials.gov, number NCT01422616. Findings There were 1477 (67.3%) patients (mean age 67.7 [12.1] y; male 60%, Asian 65%) with available follow-up brain imaging for analysis, including 635 patients with a CT done at 24-36 h. Mean achieved systolic blood pressures over 1-24 h were 141 mm Hg and 149 mm Hg in the intensive group and guideline group, respectively. There was no effect of intensive blood pressure lowering on the median size (ml) of cerebral infarction on follow-up CT at 24-36 h (0.3 [IQR 0.0-16.6] in the intensive group and 0.9 [0.0-12.5] in the guideline group; log Δmean -0.17, 95% CI -0.78 to 0.43). The results were consistent in sensitivity and subgroup analyses. Interpretation Intensive blood pressure lowering treatment to a systolic target <140 mm Hg within several hours after the onset of symptoms may not increase the size of cerebral infarction in patients who receive thrombolysis treatment for acute ischaemic stroke of mild to moderate neurological severity. Funding National Health and Medical Research Council of Australia; UK Stroke Association; UK Dementia Research Institute; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.
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Affiliation(s)
- Chen Chen
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Menglu Ouyang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Sheila Ong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Luyun Zhang
- The George Institute for Global Health China, Beijing, China
- Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang, China
| | - Guobin Zhang
- The George Institute for Global Health China, Beijing, China
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Grant Mair
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Leibo Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, UNSW, Sydney, Australia
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Christopher Levi
- Neurology Department, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Richard I. Lindley
- University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Sheila O. Martins
- Stroke Division of Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - Paula Muñoz Venturelli
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica Olavarría
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Pablo Lavados
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gang Li
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Craig S. Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
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Karedath J, Avanteeka FNU, Nouman Aslam M, Nadeem A, Yousaf RA, Shah S, Palleti SK, Khan A. 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. Cureus 2023; 15:e35571. [PMID: 37007347 PMCID: PMC10062115 DOI: 10.7759/cureus.35571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 03/04/2023] Open
Abstract
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.
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Zheng W, Lei H, Ambler G, Werring DJ, Lin H, Lin X, Tang Y, Wu J, Lin Z, Liu N, Du H. A comparison of low- versus standard-dose bridging alteplase in acute ischemic stroke mechanical thrombectomy using indirect methods. Ther Adv Neurol Disord 2023; 16:17562864221144806. [PMID: 36741353 PMCID: PMC9896089 DOI: 10.1177/17562864221144806] [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: 09/22/2022] [Accepted: 11/25/2022] [Indexed: 02/04/2023] Open
Abstract
Background Whether low-dose alteplase is similar to standard-dose bridging alteplase prior to endovascular mechanical thrombectomy in patients with acute ischemic stroke (AIS) remains uncertain. Aims The aim of this study was to compare the efficacy and safety outcomes of low- versus standard-dose bridging alteplase therapy (BT) in patients with acute ischemic stroke (AIS) who are eligible for intravenous thrombolysis (IVT) within 4.5 h after onset. Methods We conducted an indirect comparison of low- versus standard-dose bridging alteplase before mechanical thrombectomy in AIS of current available clinical randomized controlled trials (RCTs) that compared direct mechanical thrombectomy treatment (dMT) to BT. Primary efficacy outcomes were functional independence and excellent recovery defined as a dichotomized modified Rankin Scale (mRS) 0-2 and 0-1 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and any intracranial hemorrhage (ICH). Results We included six RCTs of 2334 AIS patients in this analysis, including one trial using low-dose bridging alteplase (n = 103) and five trials using standard-dose bridging alteplase (n = 1067) against a common comparator (dMT). Indirect comparisons of low- to standard-dose bridging alteplase yielded an odds ratio (OR) of 0.84 (95% CI 0.47-1.50) for 90-day mRS 0-2, 1.18 (95% CI 0.65-2.12) for 90-day mRS 0-1, 1.21 (95% CI 0.44-3.36) for mortality, and 1.11 (95% CI 0.39-3.14) for successful recanalization. There were no significant differences in the odds for sICH (OR 1.05, 95% CI 0.32-3.41) or any ICH (OR 1.71, 95% CI 0.94-3.10) between low- and standard-dose bridging alteplase. Conclusion Indirect evidence shows that the effects of low- and standard-dose bridging alteplase are similar for key efficacy and safety outcomes. Due to the wide confidence intervals, larger randomized trials comparing low- and standard-dose alteplase bridging therapy are required.
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Affiliation(s)
- Wei Zheng
- Department of Neurology, Fujian Provincial
Geriatric Hospital, Fuzhou, China,Fujian Medical University Teaching Hospital,
Fuzhou, China
| | - Hanhan Lei
- Stroke Research Center, Department of
Neurology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Gareth Ambler
- Department of Statistical Science, University
College London, London, UK
| | - David J. Werring
- Stroke Research Center, UCL Queen Square
Institute of Neurology, London, UK
| | - Huiying Lin
- Stroke Research Center, Department of
Neurology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiaojuan Lin
- Department of Neurology, Fujian Provincial
Geriatric Hospital, Fuzhou, China,Fujian Medical University Teaching Hospital,
Fuzhou, China
| | - Yi Tang
- Department of Neurology, Fujian Provincial
Geriatric Hospital, Fuzhou, China,Fujian Medical University Teaching Hospital,
Fuzhou, China
| | - Jing Wu
- Department of Neurology, Fujian Provincial
Geriatric Hospital, Fuzhou, China,Fujian Medical University Teaching Hospital,
Fuzhou, China
| | - Zhaomin Lin
- Department of Neurology, Fujian Provincial
Geriatric Hospital, Fuzhou, China,Fujian Medical University Teaching Hospital,
Fuzhou, China
| | - Nan Liu
- Stroke Research Center, Department of
Neurology, Fujian Medical University Union Hospital, Fuzhou, China,Department of Rehabilitation, Fujian Medical
University Union Hospital, Fuzhou, China
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Kneer K, Adeyemi AK, Sartor-Pfeiffer J, Wilke V, Blum C, Ziemann U, Poli S, Mengel A, Feil K. Intravenous thrombolysis in acute ischemic stroke after antagonization of unfractionated heparin with protamine: case series and systematic review of literature. Ther Adv Neurol Disord 2023; 16:17562864221149249. [PMID: 36710724 PMCID: PMC9880584 DOI: 10.1177/17562864221149249] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/13/2022] [Indexed: 01/26/2023] Open
Abstract
Background and aims Intravenous thrombolysis (IVT) is standard of care for disabling acute ischemic stroke (AIS) within a time window of ⩽ 4.5 h. Some AIS patients cannot be treated with IVT due to limiting contraindications, including heparin usage in an anticoagulating dose within the past 24 h or an elevated activated prothrombin time (aPTT) > 15 s. Protamine is a potent antidote to unfractionated heparin. Objectives The objective of this study was to investigate the safety and efficacy of IVT in AIS patients after antagonization of unfractionated heparin with protamine. Methods Patients from our stroke center (between January 2015 and September 2021) treated with IVT after heparin antagonization with protamine were analyzed. National Institutes of Health Stroke Scale (NIHSS) was used for stroke severity and modified Rankin Scale (mRS) for outcome assessment. Substantial neurological improvement was defined as the difference between admission and discharge NIHSS of ⩾8 or discharge NIHSS of ⩽1. Good outcome at follow-up after 3 months was defined as mRS 0-2. Safety data were obtained for mortality, symptomatic intracerebral hemorrhage (sICH), and for adverse events due to protamine. Second, a systematic review was performed searching PubMed and Scopus for studies and case reviews presenting AIS patients treated with IVT after heparin antagonization with protamine. The search was limited from January 1, 2011 to September 29, 2021. Furthermore, we conducted a propensity score matching comparing protamine-treated patients to a control IVT group without protamine (ratio 2:1, match tolerance 0.2). Results A total of 16 patients, 5 treated in our hospital and 11 from literature, [65.2 ± 13.1 years, 37.5% female, median premorbid mRS (pmRS) 1 (IQR 1, 4)] treated with IVT after heparin antagonization using protamine were included and compared to 31 IVT patients [76.2 ± 10.9 years, 45% female, median pmRS 1 (IQR 0, 2)]. Substantial neurological improvement was evident in 68.8% of protamine-treated patients versus 38.7% of control patients (p = 0.028). Good clinical outcome at follow-up was observed in 56.3% versus 58.1% of patients (p = 0.576). No adverse events due to protamine were reported, one patient suffered sICH after secondary endovascular thrombectomy of large vessel occlusion. Mortality was 6.3% versus 22.6% (p = 0.236). Conclusion IVT after heparin antagonization with protamine seems to be safe and, prospectively, may extend the number of AIS patients who can benefit from reperfusion treatment using IVT. Further prospective registry trials would be helpful to further investigate the clinical applicability of heparin antagonization.
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Affiliation(s)
- Katharina Kneer
- Centre for Neurovascular Diseases Tübingen
(ZNET), Tübingen, Germany,Department of Neurology and Epileptology,
Eberhard Karl University of Tübingen, Tübingen, Germany,Hertie Institute for Clinical Brain Research,
Tübingen, Germany
| | | | | | - Vera Wilke
- Department of Neurology & Stroke, Eberhard
Karl University of Tübingen, Tübingen, Germany
| | - Corinna Blum
- Department of Neurology & Stroke, Eberhard
Karl University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Centre for Neurovascular Diseases Tübingen
(ZNET), Tübingen, Germany,Department of Neurology & Stroke, Eberhard
Karl University of Tübingen, Tübingen, Germany,Hertie Institute for Clinical Brain Research,
Tübingen, Germany
| | - Sven Poli
- Centre for Neurovascular Diseases Tübingen
(ZNET), Tübingen, Germany,Department of Neurology & Stroke, Eberhard
Karl University of Tübingen, Tübingen, Germany,Hertie Institute for Clinical Brain Research,
Tübingen, Germany
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Wang Z, Ji K, Fang Q. Low-dose vs. standard-dose intravenous alteplase for acute ischemic stroke with unknown time of onset. Front Neurol 2023; 14:1165237. [PMID: 37188314 PMCID: PMC10175638 DOI: 10.3389/fneur.2023.1165237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Background Standard-dose intravenous alteplase for acute ischemic stroke (AIS) in the unknown or extended time window beyond 4.5 h after symptom onset is both effective and safe for certain patients who were selected based on multimodal neuroimaging. However, uncertainty exists regarding the potential benefit of using low-dose alteplase among the Asian population outside the 4.5-h time window. Methods Consecutive AIS patients who received intravenous alteplase between 4.5 and 9 h after symptom onset or with an unknown time of onset guided by multimodal computed tomography (CT) imaging were identified from our prospectively maintained database. The primary outcome was excellent functional recovery, defined as having a modified Rankin scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (an mRS score of 0-2 at 90 days), early major neurologic improvement (ENI), early neurologic deterioration (END), any intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality. Propensity score matching (PSM) and multivariable logistic regression models were used to adjust for confounding factors and compare the clinical outcomes between the low- and standard-dose groups. Results From June 2019 to June 2022, a total of 206 patients were included in the final analysis, of which 143 were treated with low-dose alteplase and 63 were treated with standard-dose alteplase. After accounting for confounding factors, we observed that there were no statistically significant differences between the standard- and low-dose groups with respect to excellent functional recovery [adjusted odds ratio = 1.22 (aOR), 95% confidence interval (CI): 0.62-2.39; adjusted rate difference (aRD) = 4.6%, and 95% CI: -11.2 to 20.3%]. Patients of both groups had similar rates of functional independence, ENI, END, any ICH, sICH, and 90-day mortality. In the subgroup analysis, patients aged ≥70 years were more likely to achieve excellent functional recovery when receiving standard-dose rather than low-dose alteplase. Conclusion The effectiveness of low-dose alteplase might be comparable to that of standard-dose alteplase in AIS patients aged <70 years with favorable perfusion-imaging profiles in the unknown or extended time window but not in those aged ≥70 years. Furthermore, low-dose alteplase did not significantly reduce the risk of sICH compared to standard-dose alteplase.
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Xu J, Chen X, Xie Y, Wang Y, Chen S, Dong Q, Dong Y, Fang K. Low-dose vs. standard-dose alteplase for Chinese patients with acute ischemic stroke: A propensity score analysis. Front Neurol 2023; 14:1120547. [PMID: 36895900 PMCID: PMC9989159 DOI: 10.3389/fneur.2023.1120547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/01/2023] [Indexed: 02/25/2023] Open
Abstract
Background and purpose Previous studies have stimulated debates on low-dose alteplase administration in acute ischemic stroke (AIS) among the Asian population. We sought to evaluate the safety and efficacy of low-dose alteplase in Chinese patients with AIS using a real-world registry. Methods We analyzed data from the Shanghai Stroke Service System. Patients receiving alteplase intravenous thrombolysis within 4.5 hours were included. These patients were divided into the low-dose alteplase group (0.55-0.65 mg/kg) and the standard-dose alteplase group (0.85-0.95 mg/kg). Baseline imbalances were adjusted by using the propensity score matching. The primary outcome was mortality or disability, which was defined as the modified Rankin scale (mRS) score ranging from 2 to 6 at discharge. The secondary outcomes were in-hospital mortality, symptomatic intracranial hemorrhage (sICH) and functional independence (mRS score 0-2). Results From January 2019 to December 2020, a total of 1,334 patients were enrolled and 368 (27.6%) were treated with low-dose alteplase. The median age of the patients was 71 years, and 38.8% were female. Our study showed that the low-dose group had significantly higher rates of death or disability (adjusted odds ratio (aOR) = 1.49, 95% confidence interval (CI) [1.12, 1.98]) and less functional independence (aOR = 0.71, 95%CI [0.52, 0.97]) than the standard-dose group. There was no significant difference in sICH or in-hospital mortality between the standard-dose and low-dose alteplase groups. Conclusions Low-dose alteplase was related to a poor functional outcome without lowering the risk of sICH, compared with standard-dose alteplase for AIS patients in China.
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Affiliation(s)
- Jiawen Xu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xi Chen
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanan Xie
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shidong Chen
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Fang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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Leys D, Mas JL. Quelles pistes d’avenir pour le traitement de l’infarctus cérébral aigu ? BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2023. [DOI: 10.1016/j.banm.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Kobkitsuksakul C, Namphol N, Sirilert B, Kritfuangfoo T, Chanthanaphak E, Apirakkan M, Somboonnithiphol K, Boonyakarnkul S, Lueangapapong P, Thongborisuth T, Sujirakul T. VIsion Salvage Using Intra-Ophthalmic Arterial Alteplase Combine with Nimodipine in Central Retinal Artery Occlusion (VISION). Clin Ophthalmol 2023; 17:1215-1222. [PMID: 37128471 PMCID: PMC10148670 DOI: 10.2147/opth.s407617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/04/2023] [Indexed: 05/03/2023] Open
Abstract
Purpose To investigate the efficacy and safety of selective intra-ophthalmic arterial combined nimodipine and alteplase infusion in patients with central retinal artery occlusion (CRAO). Design Non-randomized, prospective interventional study. Methods All patients with CRAO who presented at our institute within 24 hours from CRAO onset from August 2020 to July 2022 were included. Intra-arterial nimodipine and alteplase were given selectively into the ophthalmic artery. Visual acuity was recorded during and after the procedure. Change in best corrected visual acuity (BCVA) 1 month post-treatment, relative to baseline, was set as the primary outcome measure. Significant improvement in vision and adverse events are reported as secondary outcomes. Patients Nine patients with non-arteritic CRAO were enrolled. Results A total of nine patients with CRAO underwent selective intra-ophthalmic arterial nimodipine and alteplase injection. Overall, BCVA had statistically significantly improved by 0.78 logarithm of the minimum angle of resolution (logMAR) at 1 month compared with baseline (95% confidence interval: (-1.24, -0.31), p-value = 0.001). Seven (77.8%) patients had significant visual improvement (≥0.3 logMAR) at 1-month post-treatment. There were minor adverse events during administration of the nimodipine, including chemosis and headache, which resolved after the discontinuation of nimodipine. There were also asymptomatic thromboembolic events in 2 patients (22.2%) after the intervention procedure, without any morbidity or mortality. Conclusion The use of selective intra-ophthalmic arterial combined nimodipine and alteplase was efficacious in improving BCVA at 1 month for patients with non-arteritic CRAO presenting between 24 hours from onset, with minor adverse events but no serious adverse events.
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Affiliation(s)
- Chai Kobkitsuksakul
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nasathapot Namphol
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Bandit Sirilert
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanaporn Kritfuangfoo
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ekachat Chanthanaphak
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mungkorn Apirakkan
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kittiphop Somboonnithiphol
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surawan Boonyakarnkul
- Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Peerapong Lueangapapong
- Department of Neurosurgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thitiporn Thongborisuth
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tharikarn Sujirakul
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Tharikarn Sujirakul, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Thanon Rama VI, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand, Tel +6622011526, Fax +6622012729, Email
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Meiping Dong, Cao L, Mao Y, Zhao Z. Alteplase Improves Neurological Function and Affects Expression of SDF-1 and Claudin-5 in Rats with Acute Cerebral Infarction. NEUROCHEM J+ 2022. [DOI: 10.1134/s1819712422040055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Yuan J, Wu R, Xiang J, Deng J, Zhang X, Lu K, Cao F, Zhao F, Zhao Y, Wang F. Analyses on safety and efficacy of non-standard dose of r-tPA in intravenous thrombolysis-treated AIS patients. Front Neurol 2022; 13:1007167. [DOI: 10.3389/fneur.2022.1007167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
BackgroundIntravenous 0.9 mg/kg recombinant tissue plasminogen activator (r-tPA) is one of the most effective treatments in acute ischemic stroke patients. Practically, the dose of r-tPA is still a topic that is constantly being discussed.MethodsFor this observational study, data were obtained from 537 patients who received r-tPA thrombolysis at Shanghai Sixth People's Hospital stroke center over 5 years (2014–2019). Patients were divided into two groups: a non-standard dose group (0.6 mg/kg ≤ dose < 0.9 mg/kg) and a standard dose group (0.9 mg/kg). Different outcomes were observed: efficacy: 3 months mRS 0-1 (3m-mRS0-1); safety: symptomatic intracranial hemorrhage within 24 h (24h-sICH) and 3 months mortality (3m-death). We also observed the effect of r-tPA dose coefficient on outcomes in different age groups and baseline National Institute of Health stroke scale (NIHSS) score subgroups.ResultsThere were 265 patients who gave the standard dose treatment and 272 gave the nonstandard dose. There was no significant difference between the non-standard dose group and the standard dose group in 3m-mRS0-1, 3m-death, and 24h-sICH (p = 0.567, 0.327, and 0.415, respectively). The dose coefficient presents a significant negative correlation (p = 0.034, B = −4.290) with 3m-death in NIHSS < 16 sub-group. Door-to-needle time (DNT) is the most important independent outcome-influential factor (MIOIF) in the NIHSS ≥16 sub-group. The diabetes history and baseline NIHSS score were the MIOIF in the age ≥80-year sub-group.ConclusionsThe non-standard dose group (0.6 mg/kg ≤ dose < 0.9 mg/kg) shows no difference in safety and effectiveness than the standard dose group (0.9 mg/kg) in our study. The standard dose should be considered first according to current evidence and Guidelines, but the non-standard dose (0.6 mg/kg ≤ dose < 0.9 mg/kg) might be an option in the actual diagnosis and treatment process considering the patient's clinical profile and financial condition.
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Ganesh RV, Luoma V, Reddy U. Acute management of ischaemic stroke. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shao H, Chen X, Ma Q, Shao Z, Du H, Chan LWC. The feasibility and accuracy of machine learning in improving safety and efficiency of thrombolysis for patients with stroke: Literature review and proposed improvements. Front Neurol 2022; 13:934929. [PMID: 36341121 PMCID: PMC9630915 DOI: 10.3389/fneur.2022.934929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022] Open
Abstract
In the treatment of ischemic stroke, timely and efficient recanalization of occluded brain arteries can successfully salvage the ischemic brain. Thrombolysis is the first-line treatment for ischemic stroke. Machine learning models have the potential to select patients who could benefit the most from thrombolysis. In this study, we identified 29 related previous machine learning models, reviewed the models on the accuracy and feasibility, and proposed corresponding improvements. Regarding accuracy, lack of long-term outcome, treatment option consideration, and advanced radiological features were found in many previous studies in terms of model conceptualization. Regarding interpretability, most of the previous models chose restrictive models for high interpretability and did not mention processing time consideration. In the future, model conceptualization could be improved based on comprehensive neurological domain knowledge and feasibility needs to be achieved by elaborate computer science algorithms to increase the interpretability of flexible algorithms and shorten the processing time of the pipeline interpreting medical images.
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Affiliation(s)
- Huiling Shao
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Qilin Ma
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhiyu Shao
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Heng Du
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Lawrence Wing Chi Chan
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- *Correspondence: Lawrence Wing Chi Chan
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Kakinuma T, Fujita T, Iwamoto T, Mizushiri T, Yazawa Y. Effects of tissue plasminogen activator on medium-term functional independence: A propensity score-matched analysis. Medicine (Baltimore) 2022; 101:e31108. [PMID: 36253995 PMCID: PMC9575812 DOI: 10.1097/md.0000000000031108] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study revealed the effects of tissue plasminogen activator (tPA) on medium-term functional independence in patients with stroke. We retrospectively examined 240 patients from April 2016 to March 2019 and selected 68 who met our criteria. After adjusting the functional status at the onset by propensity score matching, the functional independence measure (FIM) on admission to and discharge from the convalescent rehabilitation wards was compared between the groups classified by the presence or absence of tPA. Twelve pairs were derived by propensity score matching. Upon admission to the convalescent rehabilitation ward, the median score of the FIM was significantly higher in the tPA group than in the non-tPA group (P = .028). Patients in the tPA group had higher median FIM scores at discharge than those in the non-tPA group (P = .060). The difference in the independence level of activities of daily living (ADL) between the groups with and without tPA may gradually decrease with continuous inpatient rehabilitation. However, the tPA group tended to have high levels of independence in ADL at the time of discharge.
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Affiliation(s)
- Tomohiro Kakinuma
- Department of Health and Welfare Services, National Institute of Public Health, Wako City, Saitama, Japan
- *Correspondence: Tomohiro Kakinuma, Department of Health and Welfare Services, National Institute of Public Health, Wako City, Saitama 351-0197, Japan (e-mail: )
| | - Takaaki Fujita
- Department of Occupational Therapy, School of Health Sciences, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Tetsuya Iwamoto
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Wako City, Saitama, Japan
| | - Tsuyoshi Mizushiri
- Department of Rehabilitation Medicine, Koeki Zaidan Hojin Miyagi Kosei Kyokai Nagamachi Hospital, Sendai City, Miyagi, Japan
| | - Yukako Yazawa
- Department of Stroke Neurology, Kohnan Hospital, Sendai City, Miyagi, Japan
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Liu J, Chen X, Guo X, Xu R, Wang Y, Liu M. Machine learning prediction of symptomatic intracerebral hemorrhage after stroke thrombolysis: a cross-cultural validation in Caucasian and Han Chinese cohort. Ther Adv Neurol Disord 2022; 15:17562864221129380. [PMID: 36225969 PMCID: PMC9549180 DOI: 10.1177/17562864221129380] [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: 05/16/2022] [Accepted: 09/09/2022] [Indexed: 11/05/2022] Open
Abstract
Background Previous studies found that Asians seemed to have higher risk of HT after thrombolysis than Caucasians due to its race differences in genetic polymorphism. Whether the model developed by Caucasians could predict risk of symptomatic intracerebral hemorrhage (sICH) in Asians was unknown. Objectives To develop a machine learning-based model for predicting sICH after stroke thrombolysis in Caucasians and externally validate it in an independent Han Chinese cohort. Design The derivation Caucasian sample included 1738 ischemic stroke (IS) patients from the Virtual International Stroke Trials Archive (VISTA) data set, and the external validation Han Chinese cohort included 296 IS patients who were treated with intravenous thrombolysis. Methods Twenty-eight variables were collected across both samples. According to their properties, we classified them into six distinct clusters (ie, demographic variables, medical history, previous medication, baseline blood biomarkers, neuroimaging markers on initial CT scan and clinical characteristics). A support vector machine (SVM) model, which consisted of data processing, model training, testing and a 10-fold cross-validation, was developed to predict the risk of sICH after stroke thrombolysis. The receiving operating characteristic (ROC) was used to assess the prediction performance of the SVM model. A domain contribution analysis was then performed to test which cluster had the highest influence on the performance of the model. Results In total, 85 (4.9%) patients developed sICH in the Caucasians, and 29 (9.8%) patients developed sICH in the Han Chinese cohort. Eight features including age, NIHSS score, SBP (systolic blood pressure), DBP (diastolic blood pressure), ALP (alkaline phosphatase), ALT (alanine transaminase), glucose, and creatine level were included in the final model, all of which were from demographic, clinical characteristics, and blood biomarkers clusters, respectively. The SVM model showed a good predictive performance in both Caucasians (AUC = 0.87) and Han Chinese patients (AUC = 0.74). Domain contribution analysis showed that inclusion/exclusion of clinical characteristic cluster (NIHSS score, SBP, and DBP), had the highest influence on the performance of predicting sICH in both Caucasian and Han Chinese cohorts. Conclusion The established SVM model is feasible for predicting the risk of sICH after thrombolysis quickly and efficiently in both Caucasian and Han Chinese cohort.
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Affiliation(s)
- Junfeng Liu
- Department of Neurology, West China Hospital,
Sichuan University, Chengdu, China
| | - Xinyue Chen
- CT Collaboration, Siemens Healthineers,
Chengdu, China
| | - Xiaonan Guo
- School of Information Science and Engineering,
Yanshan University, Qinhuangdao, China
| | - Renjie Xu
- Department of Respiratory Medicine, West China
Hospital, Sichuan University, Chengdu, China
| | - Yanan Wang
- Department of Neurology, West China Hospital,
Sichuan University, Chengdu, China
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Ding K, Chen H, Wang Y, Liu H, Ceceke B, Zhang W, Geng L, Deng G, Sun T, Zhang W, Wu Y. Emergency medical service utilization among acute ischemic stroke patients in Beijing: An observational study. Front Neurol 2022; 13:969947. [PMID: 36147042 PMCID: PMC9485477 DOI: 10.3389/fneur.2022.969947] [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: 06/15/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To investigate emergency medical service (EMS) utilization and its associated factors in patients with acute ischemic stroke (AIS), and further explore the urban-rural differences. Methods Medical records for AIS in all emergency departments in Beijing were obtained from the Beijing Emergency Care Database from January 2018 to December 2021. EMS utilization was described and factors associated with EMS use were examined by multivariable logistic regression models with the generalized estimating equations. Results were compared between urban and rural districts. Results A total of 24,296 AIS patients were included in the analysis, and 11,190 (46.1%) were transported to hospitals by EMS. The percentage of EMS usage in urban areas was significantly higher than that in rural areas (53.6 vs. 34.4%, P < 0.001). From 2018 to 2021, EMS utilization was on the increase (P-value for trend <0.001) with a higher average annual growth rate in rural areas (12.6%) than in urban (6.4%). Factors associated with EMS utilization were age (OR: 1.20 per 10-year increase, 95% CI: 1.17–1.23), NIHSS scores, off-hour arrival (OR: 1.32, 95% CI: 1.23–1.37), treatment in tertiary hospitals (OR: 1.75, 95% CI: 1.60–1.92), and possessing comorbidities such as coronary artery disease (OR: 1.15, 95% CI: 1.17–1.24), atrial fibrillation (OR: 1.56, 95% CI: 1.41–1.73), prior stroke (OR: 0.84, 95% CI: 0.78-0.90) or dyslipidemia (OR: 0.78, 95% CI: 0.71–0.85). Conclusion This study demonstrated an inadequate use of EMS among AIS patients in Beijing, especially in rural areas, and revealed several associated factors. Enhanced education programs and EMS accessibility are necessary particularly for high-risk individuals and regions.
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Affiliation(s)
- Kexin Ding
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Hui Chen
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center, Beijing, China
| | - Yong Wang
- Beijing Emergency Medical Center, Beijing, China
| | - Hongmei Liu
- Beijing Emergency Medical Center, Beijing, China
| | - Bayier Ceceke
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center, Beijing, China
| | - Wei Zhang
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center, Beijing, China
| | - Ling Geng
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center, Beijing, China
| | - Guifang Deng
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center, Beijing, China
| | - Tao Sun
- Department of Internet Management and Quality Control, Beijing Emergency Medical Center, Beijing, China
| | | | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
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Okada T, Yoshimoto T, Wada S, Yoshimura S, Chiba T, Egashira S, Kimura S, Shiozawa M, Inoue M, Ihara M, Toyoda K, Takashima H, Koga M. Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants. J Am Heart Assoc 2022; 11:e025809. [PMID: 36129032 PMCID: PMC9673692 DOI: 10.1161/jaha.122.025809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- Takashi Okada
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Takeshi Yoshimoto
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management National Cerebral and Cardiovascular Center Suita Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shuhei Egashira
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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Cui Y, Yao ZG, Chen HS. Intravenous thrombolysis with 0.65 mg/kg r-tPA may be optimal for Chinese mild-to-moderate stroke. Front Neurol 2022; 13:989907. [PMID: 36203975 PMCID: PMC9530342 DOI: 10.3389/fneur.2022.989907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background Intravenous recombinant tissue plasminogen activator (r-tPA) with 0.9 mg/kg is the standard treatment for acute ischemic stroke, but it remains unclear whether it is optimal for all patients. We aimed to determine the optimal dose of r-tPA for Chinese stroke based on the data from the INTRECIS study. Methods From the INTRECIS cohort, patients receiving intravenous r-tPA within 4.5 h of onset were included. According to r-tPA dose, patients were assigned into seven groups (from 0.60 to 0.90 mg/kg). The primary outcomes were the proportion of excellent functional outcomes and symptomatic intracranial hemorrhage. Results Overall, 2,666 patients were included: 156 in 0.60 mg/kg group, 117 in 0.65 mg/kg group, 127 in 0.70 mg/kg group, 188 in 0.75 mg/kg group, 154 in 0.80 mg/kg group, 359 in 0.85 mg/kg group, and 1,565 in 0.90 mg/kg group. After adjustment for baseline characteristics, only 0.65 mg/kg group had significantly higher proportion of excellent functional outcome than 0.90 mg/kg group (79.5 vs. 71.4%, odds ratio = 1.833, 95% CI = 1.006–3.341, adjusted p = 0.048). The subgroup analysis showed no evidence of differences in the odds of having a primary outcome between the two groups by age, admission NIHSS, onset to thrombolysis time, and TOAST classification. There was no significant difference in symptomatic intracranial hemorrhage between groups. Conclusion Our study presented the first evidence that intravenous thrombolysis with 0.65 mg/kg r-tPA may be optimal for Chinese mild-to-moderate stroke. Registration https://www.clinicaltrials.gov, identifier: NCT 02854592.
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Li XQ, Cui Y, Wang XH, Chen HS. Early Antiplatelet for Minor Stroke following Thrombolysis (EAST): Rationale and Design. Int J Stroke 2022; 18:615-619. [PMID: 35899772 DOI: 10.1177/17474930221118900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Early neurological deterioration (END) occurs in about 10% of patients after intravenous thrombolysis (IVT), and is related to poor outcome. In theory, early antiplatelet following IVT could reduce END by preventing re-occlusion and stroke progression, but current guidelines recommend starting antiplatelet treatment at 24 hours after IVT due to concerns about hemorrhagic transformation. Given higher risk of hemorrhagic transformation in severe stroke, we hypothesized that minor stroke patients following IVT can safely benefit from early antiplatelet treatment. AIMS To explore the efficacy and safety of early antiplatelet in minor stroke patients after IVT.Sample size estimates: A maximum of 1022 patients are required to test the superiority hypothesis with 80% power according to a two-side 0.05 level of significance, stratified by age, gender, history of stroke or transient ischemic attack, history of hypertension, history of diabetes mellitus, systolic blood pressure at admission, time from IVT to treatment, thrombolysis drug, stroke territory, and stroke etiology. DESIGN Early antiplatelet for minor stroke following thrombolysis is a prospective, double blinded, multicenter, randomized and placebo-controlled trial. Minor stroke patients within 6h following IVT are randomly assigned into experimental group and control group with the ratio of 1:1. The experimental group is orally administered with 300 mg clopidogrel and 100 mg aspirin, and control group with placebo. Subsequently, both groups received guideline-based antithrombotic treatment from 24 hours after IVT to 90 days. OUTCOME The primary efficacy endpoint is excellent functional outcome, defined as the modified Rankin Scale 0-1 at 90 days after randomization, while primary safety endpoint is symptomatic intracerebral hemorrhage, defined as National Institutes of Health Stroke Scale score increase ≥4 caused by intracranial hemorrhage within 36 hours after randomization. CONCLUSIONS The results of EAST will provide us powerful early antiplatelet evidence for minor stroke population following intravenous thrombolysis in clinical practice.
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Affiliation(s)
- Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
| | - Xin-Hong Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
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Nepal G, Kharel S, Kumar Yadav J, Kumar Yadav S, Bhagat R, Ka Shing Y, Coghlan M, Lal Bhattarai S, Sigdel K, Chandra Mahat B. Low-dose alteplase for the management of acute ischemic stroke in South Asians: A systematic review on cost, efficacy and safety. J Clin Neurosci 2022; 103:92-99. [PMID: 35853390 DOI: 10.1016/j.jocn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION South Asia is responsible for more than 40% of the stroke burden and stroke mortality in the developing world. South Asia, which is home to one-fourth of the world's population, is the most densely populated and one of the poorest regions. The majority of patients in this region are unable to afford intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). If low-dose alteplase proves effective and safe in South Asians, it may be a more cost-effective treatment option. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Researchers searched PubMed, EMBASE, and Google Scholar for English literature from 2005 to 2021. END, ENI, good functional outcome, SICH, and all-cause mortality were used to assess efficacy and safety. RESULTS In the low-dose alteplase treated patients, different studies reported 32 to 57% ENI 24 h after IVT, and 7% to 9.7% END. At 3 months follow-up, good functional outcome was achieved by 48%-76.92% of low-dose alteplase treated patients. SICH rates ranged from 0% to 16.6% across studies. Asymptomatic ICH occurred in 5-14% of patients. The mortality rate in all included studies varied from none to 25%. CONCLUSION Our systematic review demonstrates that the use of low-dose alteplase for AIS in the South Asians offer comparable efficacy and reduced risk of SICH at a significantly lower cost than standard alteplase dose. Future well-randomized clinical trials are necessary to validate the findings of our study.
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Affiliation(s)
- Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Sanjeev Kharel
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Sushil Kumar Yadav
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore.
| | - Megan Coghlan
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Kaushal Sigdel
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Bishow Chandra Mahat
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Mitchell PJ, Yan B, Churilov L, Dowling RJ, Bush SJ, Bivard A, Huo XC, Wang G, Zhang SY, Ton MD, Cordato DJ, Kleinig TJ, Ma H, Chandra RV, Brown H, Campbell BCV, Cheung AK, Steinfort B, Scroop R, Redmond K, Miteff F, Liu Y, Duc DP, Rice H, Parsons MW, Wu TY, Nguyen HT, Donnan GA, Miao ZR, Davis SM. Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial. Lancet 2022; 400:116-125. [PMID: 35810757 DOI: 10.1016/s0140-6736(22)00564-5] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy). METHODS DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants. FINDINGS Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84). INTERPRETATION We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment. FUNDING Australian National Health and Medical Research Council and Stryker USA.
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Affiliation(s)
- Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Melbourne Medical School, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Richard J Dowling
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Steven J Bush
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Andrew Bivard
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Xiao Chuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
| | - Guoqing Wang
- Department of Neurology, Bin Zhou People's Hospital, Shandong Province, China
| | - Shi Yong Zhang
- Department of Interventional Neuroradiology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Mai Duy Ton
- Stroke Centre, Bach Mai Hospital, Ha Noi Medical University, Ha Noi, Vietnam
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, University of New South Wales, Liverpool, Sydney, NSW, Australia; South Western Sydney Clinical School, University of New South Wales Medicine, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Sydney, NSW, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Monash Health Centre, Clayton, VIC, Australia
| | - Ronil V Chandra
- NeuroInterventional Radiology, Department of Imaging, School of Clinical Sciences, Monash University, Monash Health Centre, Clayton, VIC, Australia
| | - Helen Brown
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Florey Institute of Neuroscience and Mental Health, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Andrew K Cheung
- Department of Neurointerventional Radiology, Liverpool Hospital, University of New South Wales, Liverpool, Sydney, NSW, Australia; South West Sydney Clinical Campuses, University of New South Wales Medicine, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Sydney, NSW, Australia
| | - Brendan Steinfort
- Department of Neurosurgery, Neurointervention Unit, Interventional Neuroradiology Department, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Rebecca Scroop
- Department of Radiology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kendal Redmond
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - Yan Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
| | - Dang Phuc Duc
- Department of Stroke, Military Hospital 103, Ha Noi, Vietnam
| | - Hal Rice
- Department of Neurointervention, Gold Coast University Hospital, Southport, QLD, Australia
| | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Liverpool, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Sydney, NSW, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Huy-Thang Nguyen
- Pham Ngoc Thach University of Medicine, The People's Hospital 115, Ho Chi Minh, Vietnam
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Zhong Rong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Requiao LE, Oliveira RS, Reis LS, B Assis AP, G Moreno BN, Cordeiro LR, Solla DF. Short-Term Efficacy Outcomes of Tenecteplase versus Alteplase for Acute Ischemic Stroke: A Meta-Analysis of 5 Randomized Trials. Neurol India 2022; 70:1454-1459. [PMID: 36076643 DOI: 10.4103/0028-3886.355108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Tenecteplase (TNK) has been shown to be noninferior to Alteplase (ALT) for long term efficacy and safety outcomes. Whether this also applies to short term efficacy outcomes such as early clinical improvement and recanalization is unknown. To compare TNK and ALT regarding the short term efficacy outcomes: early neurological improvement and recanalization. The PRISMA was used to conduct a meta analysis, adapted to noninferiority analysis. The primary outcome was early (24-72 h) neurological improvement, defined as either NIHSS score 0 or reduction of at least 8 points compared to baseline. Recanalization was a secondary outcome. The noninferiority margin was set at 6.5%. Search strategy yielded 5 randomized clinical trials (1585 patients: 828 TNK, 757 ALT). Mean age was 70.8, 58.8% were men, mean baseline NIHSS was 7, and mean onset to treatment time was 148 min. Patients in intervention group received TNK at doses of 0.1 mg/kg (6.8%), 0.25 mg/kg (24.6%), and 0.4 mg/kg (68.6%), while all ALT patients received 0.9 mg/kg. In random effects meta analysis, TNK was noninferior to ALT for the primary outcome, early major neurological improvement (risk difference 8% in favor of TNK, 95% CI 1%-15%). Recanalization was also noninferior for the TNK compared to the ALT group (risk difference 9% in favor of TNK, 95% CI 6% to 23%). Fixed effects models yielded similarly noninferior results and signaled for a possible TNK superiority for both early neurological improvement and recanalization. TNK is noninferior to ALT at the short term efficacy outcomes: early neurological improvement and recanalization.
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Affiliation(s)
- Leticia E Requiao
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | | | - Lorena S Reis
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Ana P B Assis
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | | | - Luisa R Cordeiro
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Davi F Solla
- Division of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
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