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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reasons and predictors of non-thrombolysis in patients with acute ischemic stroke admitted within 4.5 h

Objectives

Thrombolytic treatment in acute ischemic stroke (AIS) reduces stroke‐related disability. Nearly 40% of all patients with AIS (<4.5 h) receive thrombolysis, but there is a large variation in the use between hospitals. Little is known about reasons and predictors for not giving thrombolytic treatment. Therefore, we aimed to investigate reasons for non‐thrombolysis in patients admitted within 4.5 h.

Methods

All patients with AIS (<4.5 h) admitted to Akershus University Hospital, Norway, between January 2015 and December 2017 were examined. Patient characteristics and reasons for not giving thrombolysis were registered. Descriptive statistics and logistic regression analyses were performed.

Results

Of 535 patients admitted with AIS (<4.5 h), 250 (47%) did not receive thrombolysis and of these only 26% had an absolute contraindication to treatment. Among the 74% with relative contraindications, the most common reasons given were mild and improving symptoms. Previous stroke (OR 3.32, 95%CI 1.99–5.52), arriving between 3 h and 4.5 h after onset (OR 7.76, 95%CI 3.73–16.11) or having mild symptoms (OR 2.33, 95%CI 1.56–3.49) were all significant predictors of not receiving thrombolytic treatment in the multivariable logistic regression model.

Conclusion

A large proportion of patients with AIS do not receive thrombolysis. This study highlights up‐to‐date findings that arriving late in the time window, mild symptoms, and previous stroke are strong predictors of non‐treatment. It is uncertain whether there is an underuse of thrombolysis in AIS. Increasing the utility of thrombolysis in the 4.5 h time window must be weighed against possible harms.

Role of dyslipidemia in ischemic stroke patients treated in the telestroke network

PURPOSE

The relationship between the telestroke technology and clinical risk factors in a dysplipidemic ischemic stroke population and neurologic outcomes is not fully understood. This issue was investigated in this study.

PATIENTS AND METHODS

We analyzed retrospective data collected from a regional stroke registry to identify demographic and clinical risk factors in patients with improving (NIHSS ​≤ ​7) or worsening (NIHSS ​> ​7) neurologic outcome in dyslipidemic ischemic stroke population. We used logistic multivariate models to identify independent predictors of improving or worsening outcome based on dyslipidemia disease status in ischemic stroke patients.

RESULTS

In the adjusted analysis for dyslipidemic ischemic stroke population, cholesterol reducer use (odd ratio; [OR] ​= ​0.393, 95% confidence interval [CI], 0.176-0.879, P ​= ​0.023) and direct admission (OR ​= ​0.435, 95% CI, 0.199-0.953, P ​= ​0.037) were more likely to be associated with neurologic improvement and no clinical or demographic factors were associated with poor neurologic outcome in dyslipidemic ischemic stroke patients treated in the telestroke network. For the ischemic stroke population without dyslipidemia, increasing age (OR ​= ​1.070, 95% CI, 1.031-1.109, P ​< ​0.001), coronary artery disease (OR ​= ​3.633, 95% CI, 1.307-10.099, P ​= ​0.013), history of drug or alcohol abuse (OR ​= ​6.548, 95% CI, 1.106-38.777, P ​= ​0.038), and improvement in ambulatory outcome (OR ​= ​2.880, 95% CI, 1.183-7.010, P ​= ​0.020) were associated with worsening neurological functions, while being Caucasian (OR ​= ​0.294, 95% CI, 0.098-0.882, P ​= ​0.029) was associated with improving neurologic functions.

CONCLUSION

Demographic and clinical risk factors among the dysplipidemic ischemic stroke population in the telestroke network were not associated with worsening neurologic functions.

Obstructive sleep apnea and stroke severity: Impact of clinical risk factors

BACKGROUND

Specific clinical and demographic risk factors may be associated with improving or worsening neurologic outcomes within a population of acute ischemic stroke (AIS) patients with a history of obstructive sleep apnea (OSA). The objective of this study was to determine the changes in neurologic outcome during a 14-day recovery as it relates to initial stroke severity in AIS patients with OSA.

METHODS

This retrospective study analyzed baseline clinical risk factors and demographic data collected in a regional stroke center from January 2010 to June 2016. Our primary endpoint measure was the National Institutes of Health Stroke Scale (NIHSS) score and our secondary endpoint measures included the clinical factors associated with improving (NIHSS score ≤7) or worsening (NIHSS score >7) neurological outcome. The relative contribution of each variable to stroke severity and related outcome was determined using a logistic regression. The regression models were checked for the overall correct classification percentage using a Hosmer-Lemeshow test, and the sensitivity of our models was determined by the area under the receiver operating characteristic curve.

RESULTS

A total of 5469 AIS patients were identified. Of this, 96.89% did not present with OSA while 3.11% of AIS patients presented with OSA. Adjusted multivariate analysis demonstrated that in the AIS population with OSA, atrial fibrillation (AF) (odds ratio [OR] = 3.36, 95% confidence interval [CI], 1.289-8.762, P = 0.013) and changes in ambulatory status (OR = 2.813, 95% CI, 1.123-7.041, P = 0.027) showed an association with NIHSS score >7 while being Caucasian (OR = 0.214, 95% CI, 0.06-0.767, P = 0.018) was associated with NIHSS score ≤7.

CONCLUSION

In AIS patients with OSA, AF and changes in ambulatory status were associated with worsening neurological outcome while Caucasian patients were associated with improving neurological outcome. Our findings may have significant implications for patient stratification when determining treatment protocols with respect to neurologic outcomes in AIS patients with OSA.

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.

Re-examining the exclusion criterion of early recurrent ischemic stroke in intravenous thrombolysis: A meta-analysis

BACKGROUND

Current guidelines preclude the administration of intravenous tissue plasminogen activator in patients with early recurrent stroke (prior ischemic stroke within three months).

OBJECTIVES

This is a meta-analysis that aimed to determine the safety and efficacy of thrombolysis in patients with early recurrent stroke.

SUMMARY OF REVIEW

Pubmed, Cochrane, Scopus, Embase and Clinicaltrials.gov were searched for studies comparing the outcomes of acute ischemic stroke patients undergoing intravenous thrombolysis between those with early recurrent stroke and those without. Random-effects meta-analysis was used to evaluate the outcomes in terms of symptomatic intracranial hemorrhage, mortality and good functional outcomes at 3 months (modified Rankin Score ≤ 2). Three retrospective cohort studies with a total of 48,459 thrombolysed patients (824 with early recurrent stroke and 47,635 without early recurrent stroke) were included in the meta-analysis. There was no significant difference between thrombolysed patients with early recurrent stroke and those without in terms of symptomatic intracranial hemorrhage (Odds Ratio [OR] 1.39, 95% Confidence Interval [CI] 0.75-2.58), mortality (OR 1.36, 95% CI 0.60-3.09) and good functional outcomes at 3 months (OR 0.74, 95% CI 0.47-1.16).

CONCLUSIONS

Patients who received thrombolysis despite early recurrent stroke were not found to be at an increased risk of adverse outcomes compared to patients without early recurrent stroke. Our meta-analysis suggests that there is insufficient evidence to substantiate excluding patients with early recurrent stroke from receiving thrombolysis. Further studies to re-examine early recurrent stroke as an exclusion criterion for receiving thrombolysis are warranted.

Risk Factors for Early Intracerebral Hemorrhage after Intravenous Thrombolysis with Alteplase

Aim: Intracerebral hemorrhage (ICH) is one of the most severe complications of thrombolysis. Symptomatic ICHs are associated with adverse outcomes. It has been reported that symptomatic ICHs most commonly occur within the first few hours after the initiation of intravenous thrombolysis. Our aim here was to determine the risk factors for early ICH (within 12 h) after thrombolysis.

Methods: We analyzed patients with acute ischemic stroke who received intravenous alteplase at two hospitals affiliated to Wenzhou Medical University between March 2008 and November 2017. The ICH diagnosis time was defined as the time from the intravenous administration of alteplase to the first detection of hemorrhage on computed tomography. Demographic data, medical history, clinical features, and laboratory examination results were collected. Univariate analysis followed by multivariable logistic regression analysis was performed to determine the predictors of early ICH (within 12 h) after thrombolysis.

Results: Among 197 patients, early ICH (within 12 h) after thrombolysis occurred in 13 patients (6.6%). In the univariate analysis, patients with early ICHs were significantly correlated with prior stroke (P = 0.04). After adjusting for potential confounders in the multivariate analysis, prior stroke (odds ratio [OR]: 5.752, 95% confidence interval [CI]: 1.487–22.248; P = 0.011) and atrial fibrillation (OR: 5.428, 95% CI: 1.427–20.640; P = 0.013) were associated with early ICH.

Conclusions: Prior stroke and atrial fibrillation are independent risk factors for early ICHs (within 12 h) after intravenous thrombolysis with alteplase.

The Association Between an Antecedent of Transient Ischemic Attack Prior to Onset of Stroke and Functional Ambulatory Outcome

BACKGROUND

Specific clinical risk factors linked to transient ischemic attack (TIA) could affect functional ambulatory outcome following thrombolytic therapy in patients having ischemic stroke with a prior TIA (TIA-ischemic stroke). This issue was investigated in this study.

METHODS

We retrospectively analyzed data from 6379 ischemic stroke patients of which 1387 presented with an antecedent TIA prior to onset of stroke. We used logistic regression model to identify demographic and clinical risk factors that are associated with functional ambulatory outcome in patients with TIA-ischemic stroke treated with thrombolytic therapy.

RESULTS

In a population of TIA-ischemic stroke who received recombinant tissue plasminogen activator, patients with a history of stroke (odds ratio [OR] = 3.229, 95% confidence interval [CI] = 1.494-6.98, P = .003) were associated with increasing odds of improvement in functional ambulation, while the female gender (OR = 0.462, 95% CI = 0.223-0.956, P = .037) was associated with reducing odds of improvement. In the non-TIA group, dyslipidemia (OR = 1.351, 95% CI = 1.026-1.781, P = .032) and blood glucose (OR = 1.003, 95% CI = 1.0-1.005, P = .041) were associated with the increasing odds of improvement while older patients (OR = 0.989, 95% CI = 0.98-0.999, P = .029) with heart failure (OR = 0.513, 95% CI = 0.326-0.808, P = .004) and higher lipid level (OR = 0.834, 95% CI = 0.728-0.955, P = .009) were associated with reducing odds of improvement in ambulation.

CONCLUSION

In a population of TIA-ischemic stroke with thrombolytic therapy and a clearly defined TIA without focal ischemic injury, regardless of associated clinical risk factors, a TIA prior to a stroke is not associated with reducing odds of improved ambulatory outcome, except in female patients with TIA-ischemic stroke.

Why not Intravenous Thrombolysis in Patients with Recurrent Stroke within 3 Months?

Acute ischemic stroke continues to be a very severe disorder that has significant impact on human health. Its treatment options are limited and alteplase remains the only American Food and Drug Administration-approved drug for patients with acute ischemic stroke. Furthermore, intravenous thrombolysis remains substantially underutilized, because it has rigorous indications and contraindications. Most patients simply do not meet these criteria and cannot receive thrombolytic treatment. Guidelines in many countries currently include a history of stroke within months as one of the exclusion criteria for intravenous thrombolysis. Although this is based on previous data, it lacks strong evidentiary support. Several recent studies suggested that intravenous thrombolysis may be beneficial for this patient population. We reviewed relevant publications of intravenous thrombolysis or repeated intravenous thrombolysis in patients with a history of stroke in the past 3 months. We found that intravenous thrombolysis in these patients is not as hazardous as previously believed. Among patients with relatively small infarctions and a good prognosis, intravenous thrombolysis may be a good treatment option. We hope that more research will be carried out on this topic to reexamine the criteria for intravenous thrombolysis to allow more patients to benefit from treatment.

Repeated Intravenous Thrombolysis for Early Recurrent Stroke: Challenging the Exclusion Criterion

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) within 4.5 hours from symptom onset improves functional outcome in patients with acute ischemic stroke. Its use in patients with previous stroke within the preceding 3 months is contraindicated because of the assumed higher risk of intracranial hemorrhage. In addition, tissue-type plasminogen activator may itself promote neurotoxicity and blood-brain barrier disruption. However, safety and effectiveness of repeated IVT is essentially unknown in patients with early (<3 months) recurrent stroke (ERS), because they were excluded from thrombolysis trials. This article reports the largest case series of repeated IVT in ERS.

METHODS

We reviewed databases of prospectively collected patient data of 8 European stroke centers for the presence of patients with ERS, who received IVT for both the index stroke and ERS. Demographics, clinical and radiological data, bleeding complications, and functional outcome were analyzed.

RESULTS

We identified 19 subjects with repeated IVT in ERS. Mean age was 68±12 years, and 37% of them were female. Median interthrombolysis interval was 30 days (interquartile range, 13-50). Functional independence (modified Rankin scale score ≤2) was achieved in 79% of patients after the first and in 47.4% after repeated IV tissue-type plasminogen activator, respectively. There was no symptomatic intracranial hemorrhage. Median final infarct volume after the first IVT was 1.5 cm(3) (interquartile range, 0.5-3.1).

CONCLUSIONS

Patients with small infarct volumes and robust clinical improvement might be considered for repeated IVT within 3 months. Studies following strict protocols and larger registries incorporating these patients might serve to identify selection criteria for the safe use of repeated IVT in ERS.

Intravenous Thrombolysis for Stroke Recurring Within 3 Months From the Previous Event

Background and Purpose—

According to the European license, alteplase can be given no sooner than 3 months after previous stroke. However, it is not known whether past history of stroke influences the effect of treatment. Our aim was to evaluate safety and functional outcome after intravenous thrombolysis administered in everyday practice to patients with previous stroke ≤3 months compared with those with first-ever stroke.

Methods—

We analyzed consecutive cases treated with alteplase between October 2003 and July 2014 contributed to the Safe Implementation of Thrombolysis for Stroke–Eastern Europe registry from 12 countries. Odds ratios were calculated using unadjusted and adjusted logistic regression.

Results—

Of 13 007 patients, 11 221 (86%) had no history of stroke and 249 (2%) experienced previous stroke ≤3 months before admission. Patients with previous stroke ≤3 months had a higher proportion of hypertension and hyperlipidemia. There were no significant differences in outcome, including symptomatic intracerebral hemorrhage according to European Cooperative Acute Stroke Study (unadjusted odds ratio 1.27, 95% confidence interval: 0.74–2.15), and being alive and independent at 3 months (odds ratio 0.81, 95% confidence interval: 0.61–1.09).

Conclusions—

Patients currently treated with alteplase, despite a history of previous stroke ≤3 months, do not seem to achieve worse outcome than those with first-ever stroke. Although careful patient selection was probably of major importance, our findings provide reassurance that this group of patients may safely benefit from thrombolysis and should not be arbitrarily excluded as a whole. Further studies are needed to identify the shortest safe time lapse from the previous event to treatment with alteplase.