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Chiu WT, Hong CT, Chi NF, Hu CJ, Hu HH, Chan L. The risk of intravenous thrombolysis-induced intracranial hemorrhage in Taiwanese patients with unruptured intracranial aneurysm. PLoS One 2017; 12:e0180021. [PMID: 28662192 PMCID: PMC5491104 DOI: 10.1371/journal.pone.0180021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/08/2017] [Indexed: 11/23/2022] Open
Abstract
Background The presence of an intracranial aneurysm is contraindicated to recombinant tissue plasminogen activator (r-tPA) treatment for acute ischemic stroke. However, it is difficult to exclude asymptomatic intracranial aneurysms by using conventional, noncontrast head computed tomography (CT), which is the only neuroimaging suggested before r-tPA. Recent case reports and series have shown that administering r-tPA to patients with a pre-existing aneurysm does not increase the bleeding risk. However, Asians are known to have a relatively higher bleeding risk, and little evidence is available regarding the risk of using r-tPA on Asian patients with intracranial aneurysms. Methods Medical records from the Shuang Ho hospital stroke registration between July 2010 and December 2014 were retrospectively reviewed, and 144 patients received r-tPA. Unruptured intracranial aneurysms were detected using CT, or magnetic resonance or conventional angiography after r-tPA. The primary and secondary outcomes were the difference in overall intracranial hemorrhage (ICH) and symptomatic ICH after r-tPA. The differences were analyzed using Fisher’s exact or Mann–Whitney U tests, and p < 0.05 was defined as the statistical significance. Results A total of 144 patients were reviewed, and incidental unruptured intracranial aneurysms were found in 11 of them (7.6%). No significant difference was observed in baseline demographic data between the aneurysm and nonaneurysm groups. Among patients with an unruptured aneurysm, two had giant aneurysms (7.7 and 7.4 mm, respectively). The bleeding risk was not significant different between aneurysm group (2 out of 11, 18%) with nonaneurysm group (7 out of 133, 5.3%) (p = 0.14). None of the patients with an unruptured aneurysm had symptomatic ICH, whereas one patient without an aneurysm exhibited symptomatic ICH. Conclusions The presence of an unruptured intracranial aneurysm did not significantly increase the risk of overall and symptomatic ICH in Taiwanese patients after they received r-tPA.
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Affiliation(s)
- Wei Ting Chiu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Stroke Centre, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chien Tai Hong
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Stroke Centre, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Nai Fang Chi
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Stroke Centre, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chaur Jong Hu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Stroke Centre, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Han Hwa Hu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Stroke Centre, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Lung Chan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Stroke Centre, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- * E-mail:
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Goyal N, Tsivgoulis G, Zand R, Sharma VK, Barlinn K, Male S, Katsanos AH, Bodechtel U, Iftikhar S, Arthur A, Elijovich L, Alexandrov AW, Alexandrov AV. Systemic thrombolysis in acute ischemic stroke patients with unruptured intracranial aneurysms. Neurology 2015; 85:1452-8. [PMID: 26408492 DOI: 10.1212/wnl.0000000000002068] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/29/2015] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE We sought to determine the safety of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients harboring unruptured intracranial aneurysm (UIA) in a multicenter study and a comprehensive meta-analysis of available case series. METHODS We analyzed prospectively collected data from consecutive AIS patients treated with IVT during a 4-year period at 4 tertiary-care stroke centers. All patients routinely underwent CT or magnetic resonance angiography during hospitalization. The presence of UIA was documented on the basis of neuroradiology reports. Symptomatic intracranial hemorrhage (sICH) was defined as imaging evidence of ICH combined with an increase in NIH Stroke Scale score of ≥4 points. A systematic meta-analysis of case series reporting safety of IVT in AIS with concomitant UIA was conducted according to PRISMA recommendations. RESULTS Among 1,398 AIS patients treated with IVT, we identified 42 cases (3.0%) harboring a total of 48 UIAs. The rates of symptomatic and asymptomatic ICH were 2.4% (95% confidence interval [CI] by adjusted Wald method: 0%-12.6%) and 7.1% (95% CI: 1.8%-19.7%), respectively. A total of 5 case series met our inclusion criteria for meta-analysis, and the pooled rate of sICH among 120 IVT-treated AIS patients harboring UIA was 6.7% (95% CI: 3.1%-13.7%). In the overall analysis of 5 case-series studies, the risk ratio of sICH did not differ between AIS patients with and without UIA (risk ratio = 1.60; 95% CI: 0.54-4.77; p = 0.40) with no evidence of heterogeneity across included studies (I(2) = 22% and p = 0.27 for Cochran Q test). CONCLUSIONS Our prospectively collected multicenter data, coupled with the findings of the meta-analysis, indicate the potential safety of IVT in AIS patients with UIA.
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Affiliation(s)
- Nitin Goyal
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Georgios Tsivgoulis
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Ramin Zand
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Vijay K Sharma
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Kristian Barlinn
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Shailesh Male
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Aristeidis H Katsanos
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Ulf Bodechtel
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Sulaiman Iftikhar
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Adam Arthur
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Lucas Elijovich
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Anne W Alexandrov
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia
| | - Andrei V Alexandrov
- From the Department of Neurology (N.G., G.T., R.Z., S.M., S.I., L.E., A.W.A., A.V.A.), The University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon" Hospital, School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), Department of Neurology, St. Anne's University Hospital in Brno, Czech Republic; Department of Neurology (V.K.S.), National University Hospital, Singapore; Department of Neurology (K.B., U.B.), Carl Gustav Carus University Hospital, Dresden University Stroke Center, Germany; Department of Neurosurgery (A.A., L.E.), The University of Tennessee Health Science Center, Memphis; and Australian Catholic University (A.W.A.), School of Nursing, Sydney, Australia.
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