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Salcher-Konrad M, Nguyen M, Savovic J, Higgins JPT, Naci H. Treatment Effects in Randomized and Nonrandomized Studies of Pharmacological Interventions: A Meta-Analysis. JAMA Netw Open 2024; 7:e2436230. [PMID: 39331390 PMCID: PMC11437387 DOI: 10.1001/jamanetworkopen.2024.36230] [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] [Indexed: 09/28/2024] Open
Abstract
Importance Randomized clinical trials (RCTs) are widely regarded as the methodological benchmark for assessing clinical efficacy and safety of health interventions. There is growing interest in using nonrandomized studies to assess efficacy and safety of new drugs. Objective To determine how treatment effects for the same drug compare when evaluated in nonrandomized vs randomized studies. Data Sources Meta-analyses published between 2009 and 2018 were identified in MEDLINE via PubMed and the Cochrane Database of Systematic Reviews. Data analysis was conducted from October 2019 to July 2024. Study Selection Meta-analyses of pharmacological interventions were eligible for inclusion if both randomized and nonrandomized studies contributed to a single meta-analytic estimate. Data Extraction and Synthesis For this meta-analysis using a meta-epidemiological framework, separate summary effect size estimates were calculated for nonrandomized and randomized studies within each meta-analysis using a random-effects model and then these estimates were compared. The reporting of this study followed the Guidelines for Reporting Meta-Epidemiological Methodology Research and relevant portions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Main Outcome and Measures The primary outcome was discrepancies in treatment effects obtained from nonrandomized and randomized studies, as measured by the proportion of meta-analyses where the 2 study types disagreed about the direction or magnitude of effect, disagreed beyond chance about the effect size estimate, and the summary ratio of odds ratios (ROR) obtained from nonrandomized vs randomized studies combined across all meta-analyses. Results A total of 346 meta-analyses with 2746 studies were included. Statistical conclusions about drug benefits and harms were different for 130 of 346 meta-analyses (37.6%) when focusing solely on either nonrandomized or randomized studies. Disagreements were beyond chance for 54 meta-analyses (15.6%). Across all meta-analyses, there was no strong evidence of consistent differences in treatment effects obtained from nonrandomized vs randomized studies (summary ROR, 0.95; 95% credible interval [CrI], 0.89-1.02). Compared with experimental nonrandomized studies, randomized studies produced on average a 19% smaller treatment effect (ROR, 0.81; 95% CrI, 0.68-0.97). There was increased heterogeneity in effect size estimates obtained from nonrandomized compared with randomized studies. Conclusions and Relevance In this meta-analysis of treatment effects of pharmacological interventions obtained from randomized and nonrandomized studies, there was no overall difference in effect size estimates between study types on average, but nonrandomized studies both overestimated and underestimated treatment effects observed in randomized studies and introduced additional uncertainty. These findings suggest that relying on nonrandomized studies as substitutes for RCTs may introduce additional uncertainty about the therapeutic effects of new drugs.
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Affiliation(s)
- Maximilian Salcher-Konrad
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- World Health Organization Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG)/Austrian National Public Health Institute, Vienna, Austria
| | - Mary Nguyen
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- Department of Family and Community Medicine, University of California, San Francisco
| | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
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Klail T, Sedova P, Vinklarek JF, Kovacova I, Bar M, Cihlar F, Cernik D, Kočí L, Jura R, Herzig R, Husty J, Kocher M, Kovar M, Nevšímalová M, Raupach J, Rocek M, Sanak D, Sevcik P, Skoloudik D, Sramek M, Vanicek J, Vaško P, Vaclavik D, Tomek A, Mikulik R. Safety and Efficacy of Baseline Antiplatelet Treatment in Patients Undergoing Mechanical Thrombectomy for Ischemic Stroke: Antiplatelets Before Mechanical Thrombectomy. J Vasc Interv Radiol 2023; 34:1502-1510.e12. [PMID: 37192724 DOI: 10.1016/j.jvir.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE To investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS Baseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months; secondary outcome was ICH. RESULTS Of the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84-1.20); OR, 1.05 (95% CI, 0.86-1.27); and OR, 0.88 (95% CI, 0.55-1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87-1.21); OR, 0.99 (95% CI, 0.83-1.18); OR, 1.10 (95% CI, 0.82-1.47); and OR, 1.43 (95% CI, 0.87-2.33), respectively. CONCLUSIONS Antiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.
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Affiliation(s)
- Tomas Klail
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Petra Sedova
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Jan F Vinklarek
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ingrid Kovacova
- International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital, Ostrava, Czech Republic; Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | - Filip Cihlar
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - David Cernik
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - Lubomir Kočí
- Neurocentre, Regional Hospital Liberec, Liberec, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital in Hradec Králové, Hradec Králové, Czech Republic
| | - Jakub Husty
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Radiology and Nuclear Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Kocher
- Department of Radiology, Palacky University Medical School and Hospital, Olomouc, Czech Republic
| | - Martin Kovar
- Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
| | - Miroslava Nevšímalová
- Department of Neurology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Miloslav Rocek
- Department of Radiology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Palacky Medical School and University Hospital, Comprehensive Stroke Center, Olomouc, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - David Skoloudik
- Center for Health Research, Medical Faculty, Ostrava University, Ostrava, Czech Republic
| | - Martin Sramek
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiri Vanicek
- Department of Medical Imaging, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Peter Vaško
- Department of Neurology, Faculty Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Daniel Vaclavik
- Neurology, Agel Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Robert Mikulik
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Noseda R, Rea F, Pagnamenta A, Agazzi P, Bianco G, Sihabdeen S, Seiffge D, Michel P, Nedeltchev K, Bonati L, Kägi G, Niederhauser J, Nyffeler T, Luft A, Wegener S, Schelosky L, Medlin F, Rodic B, Peters N, Renaud S, Mono ML, Carrera E, Fischer U, Ceschi A, Cereda CW. Sex Differences in Outcomes of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Preadmission Use of Antiplatelets. CNS Drugs 2023; 37:351-361. [PMID: 36976463 PMCID: PMC10126038 DOI: 10.1007/s40263-023-00997-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
AIM To compare safety and functional outcomes of intravenous thrombolysis (IVT) between females and males with acute ischaemic stroke (AIS) in relation to preadmission use of antiplatelets. METHODS Multicentre cohort study of patients admitted from 1 January 2014 to 31 January 2020 to hospitals participating in the Swiss Stroke Registry, presenting with AIS and receiving IVT. Primary safety outcome was in-hospital symptomatic intracerebral haemorrhage (sICH). Primary functional outcome was functional independence at 3 months after discharge. Multivariable logistic regression models were fitted to assess the association between sex and each outcome according to preadmission use of antiplatelets. RESULTS The study included 4996 patients (42.51 % females, older than males, median age 79 vs 71 years, p < 0.0001). Comparable proportions of females (39.92 %) and males (40.39 %) used antiplatelets before admission (p = 0.74). In total, 3.06 % females and 2.47 % males developed in-hospital sICH (p = 0.19), with similar odds (adjusted odds ratio, [AOR] 0.93, 95 % confidence interval, [CI] 0.63-1.39). No interaction was found between sex and preadmission use of either single or dual antiplatelets in relation to in-hospital sICH (p = 0.94 and p = 0.23). Males had higher odds of functional independence at 3 months (AOR 1.34, 95 % CI 1.09-1.65), regardless of preadmission use of antiplatelets (interaction between sex and preadmission use of either single or dual antiplatelets p = 0.41 and p = 0.58). CONCLUSION No sex differences were observed in the safety of IVT regarding preadmission use of antiplatelets. Males showed more favourable 3-month functional independence than females; however, this sex difference was apparently not explained by a sex-specific mechanism related to preadmission use of antiplatelets.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Federico Rea
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Pamela Agazzi
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Giovanni Bianco
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Shairin Sihabdeen
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Thomas Nyffeler
- Center of Neurology and Neurorehabilitation, Luzerner Kantonsspital, Luzern, Switzerland
| | - Andreas Luft
- Universitätsspital Zürich, Neurology, Zürich, Switzerland
| | | | - Ludwig Schelosky
- Division of Neurology, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Friedrich Medlin
- Division of Neurology, HFR Fribourg, Stroke Unit, Fribourg, Switzerland
| | - Biljana Rodic
- Kantonsspital Winterthur, Neurology, Winterthur, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, Hirslanden Hospital, Zurich, Switzerland
| | - Susanne Renaud
- Division of Neurology, Pourtalès Hospital, Neuchatel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Walter Cereda
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland.
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Tokuda K, Yamada Y, Uchida K, Sakakibara F, Sakai N, Imamura H, Yamagami H, Tanaka K, Ezura M, Nonaka T, Matsumoto Y, Shibata M, Ohta H, Morimoto M, Fukawa N, Hatano T, Enomoto Y, Takeuchi M, Ota T, Shimizu F, Kimura N, Kamiya Y, Shimamura N, Morimoto T, Yoshimura S. Effect of prior antiplatelet therapy on large vessel occlusion in patients with non-valvular atrial fibrillation newly initiated on apixaban. J Neurol Sci 2021; 428:117603. [PMID: 34384970 DOI: 10.1016/j.jns.2021.117603] [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: 05/15/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We evaluated the effect of prior antiplatelet therapy on large vessel occlusion (LVO) in patients with non-valvular atrial fibrillation (NVAF) newly initiated on apixaban. METHODS Patients with acute LVO with acute stroke due to NVAF or stenosis with NVAF started on apixaban within 14 days of onset were enrolled. We compared incidence of major bleeding, cerebral hemorrhage, ischemic events, cerebral infarction, and all-cause mortality between patients with and without prior antiplatelet therapy for acute LVO. We also compared these events between patients who continued antiplatelet therapy after onset (continued group) and those who discontinued it (discontinued group). Hazard ratios were estimated after adjusting for confounders; interaction was evaluated considering intravenous thrombolysis (IVT) or endovascular treatment (EVT) according to major bleeding. RESULTS The study comprised 686 eligible patients (excluded [n = 194]; enrolled [n = 492]). The antiplatelet group consisted of older patients (mean: 79 vs. 76 years; p = 0.006) and had a higher cumulative incidence of major bleeding (7.3% vs. 2.9%, p = 0.003). The incidence of ischemic events and all-cause mortality was similar between the groups. Among the 109 patients in the antiplatelet group, the cumulative incidence of major bleeding, ischemic events, and all-cause mortality was comparable between continued group (n = 26) and discontinued group (n = 83). There were no significant differences between groups with and without IVT/EVT. However, major bleeding occured more frequently in the antiplatelet group without IVT. CONCLUSION Prior antiplatelet therapy for LVO in patients with NVAF newly initiated on apixaban was associated with major bleeding, which was more frequent in the antiplatelet group without IVT.
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Affiliation(s)
- Kou Tokuda
- Department of Neurosurgery, Nishinomiya Kyoritsu Hospital, Nishinomiya, Japan
| | - Yoshitaka Yamada
- Department of Neurosurgery, Nishinomiya Kyoritsu Hospital, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- 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
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Tadashi Nonaka
- Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Miyagi, Japan
| | | | - Hajime Ohta
- Department of Neurosurgery, Division of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Norihito Fukawa
- Department of Neurosurgery, Kindai University, Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | | | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Norito Shimamura
- Department of Neurosurgery, Hirosaki University Hospital, Hirosaki, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
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Guo Y, Zhao K, Guo X, Yang M. Antiplatelet therapy and outcomes following endovascular therapy for acute ischemic stroke: A systemic review and meta-analysis. J Clin Neurosci 2021; 90:332-344. [PMID: 34275572 DOI: 10.1016/j.jocn.2021.06.013] [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: 03/13/2021] [Revised: 05/31/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The outcomes of antiplatelet therapy (APT) in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT) remains controversial. Thus, we sought to make a systematic review and meta-analysis of recent clinical trials to confirm the safety and efficacy of APT. METHODS All of clinical trails were systematically retrieved from PubMed, Embase and Cochrane. The endpoints or main outcome measures included symptomatic intracranial hemorrhage (sICH), 3-month mortality, successful recanalisation (SR) and 3-month functional independence (FI). Odd ratios (ORs) with their 95% confidence intervals (CIs) were calculated to synthesize effect size by using random-effects models. Sensitivity analysis was performed via calculation of rest data owiting one by one. RESULTS 23 articles were included after screening. APT as an adjunct to EVT was associated with a higher likelihood of pooled successful recanalisation (OR 1.46, 95% CI 1.07-2.00) and 3-month FI (OR 1.24, 95% CI 1.01-1.51), no associated with sICH and 3-month mortality. However, Sensitivity analysis indicated that the association between APT and SR and 3-month FI were unstable. For patients with prior use of APT or receiving intravenous thrombolysis before EVT, no associated were found between APT and all of endpoints above. CONCLUSION Although adjuvant APT appears to increase the number of SR and 3-month FI, the results were unstable. Randomised controlled trials are needed to confirm the efficacy.
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Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, Qinghai 810016, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, Qinghai 810016, China
| | - Xinmei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, Yunnan 650504, China
| | - Mingfei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai 810007, China.
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Mowla A, Sharifian-Dorche M, Mehla S, Lail NS, Sharifian-Dorche A, Vaughn CB, Sawyer RN, Shirani P. Safety and efficacy of antiplatelet use before intravenous thrombolysis for acute Ischemic stroke. J Neurol Sci 2021; 425:117451. [PMID: 33882341 DOI: 10.1016/j.jns.2021.117451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/18/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022]
Abstract
AIM To study the effects of pretreatment with Antiplatelet (AP) before IV thrombolysis (IVT) on the rate of symptomatic intracranial hemorrhage (sICH) and functional outcome in patients with Acute Ischemic stroke (AIS). METHOD In this retrospective study, the medical records and cerebrovascular images of all the patients who received IVT for AIS in our center in a 9.6-year period were reviewed. Patients who took at least one dose of any APs in the last 24 h prior to IVT were identified. They were categorized according to the type of AP, single versus dual AP therapy (DAPT), and dose of AP. Rate of sICH and functional outcome at discharge were compared between the AP users and non-users. RESULTS A total of 834 patients received IVT for AIS in our center during a 9.6- year period. Multivariate models were adjusted for age, NIHSS on admission, history of atrial fibrillation, history of hypertension, INR on admission, history of stroke and diabetes mellitus. In multivariate regression analyses and after adjusting for the variables mentioned above, the use of any AP was not associated with an increased rate of sICH (OR = 1.28 [0.70-2.34], p = 0.425). Furthermore, the use of DAPT did not significantly increase the rate of sICH in multivariate regression analyses. (OR = 0.663 [0.15-2.84], p = 0.580). The patients on any AP had a lower chance of having good functional outcome in univariate analysis (OR = 0.735 [0.552-0.979], p = 0.035). However, when adjusted for age, baseline NIHSS, history of diabetes, hypertension and prior stroke, AP use was not associated with a decreased chance of having a good functional outcome at discharge. (OR = 0.967 [0.690-1.357], p = 0.848). In addition, no significant difference was noted in the rate of good functional outcome between patients on DAPT and no AP users in multivariate regression analyses. (OR = 1.174 [0.612-2.253], p = 0.629). CONCLUSION Our study did not show any significant association between the risk of sICH and good functional outcome after IVT for AIS patients on AP therapy (dual or single) in comparison with AP naïve patients.
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Affiliation(s)
- Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
| | - Maryam Sharifian-Dorche
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Sandhya Mehla
- Ayer Neurosciences Institute, Hartford HealthCare Medical Group, University of Connecticut School of Medicine, Norwich, CT, United States of America
| | - Navdeep S Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | | | - Caila B Vaughn
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 519] [Impact Index Per Article: 173.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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8
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Lieschke F, Zheng Y, Foerch C, van Leyen K. Thrombolysis in acute stroke under dual antiplatelet therapy: perspectives arising from translational studies. Neural Regen Res 2021; 16:113-114. [PMID: 32788459 PMCID: PMC7818874 DOI: 10.4103/1673-5374.284906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Franziska Lieschke
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Yi Zheng
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Christian Foerch
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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9
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Brunser AM, Mazzon E, Cavada G, Mansilla E, Rojo A, Almeida J, Olavarría VV, Muñoz-Venturelli P, Lavados PM. Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:681-686. [PMID: 33331463 DOI: 10.1590/0004-282x20200048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/12/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. OBJECTIVE We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. METHODS Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. RESULTS 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. CONCLUSIONS Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.
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Affiliation(s)
- Alejandro Michel Brunser
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Departamento de Urgencia, Santiago, Chile.,Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile
| | - Enrico Mazzon
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile
| | - Gabriel Cavada
- Clínica Alemana de Santiago, Unidad de Investigación y Ensayos Clínicos, Departamento Científico Docente, Santiago, Chile
| | - Eloy Mansilla
- Servicio de Neurología, Hospital Clínico Herminda Martin de Chillán, Servicio de Salud Ñuble, Chillán, Chile
| | - Alexis Rojo
- Servicio de Neurología, Hospital Clínico Herminda Martin de Chillán, Servicio de Salud Ñuble, Chillán, Chile
| | - Juan Almeida
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile
| | - Verónica Viviana Olavarría
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile
| | - Paula Muñoz-Venturelli
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile
| | - Pablo Manuel Lavados
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Departamento de Neurología y Psiquiatría, Santiago, Chile
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10
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Frey BM, Boutitie F, Cheng B, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Ford I, Galinovic I, Königsberg A, Puig J, Roy P, Wouters A, Magnus T, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Safety and efficacy of intravenous thrombolysis in stroke patients on prior antiplatelet therapy in the WAKE-UP trial. Neurol Res Pract 2020; 2:40. [PMID: 33324940 PMCID: PMC7678217 DOI: 10.1186/s42466-020-00087-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/01/2020] [Indexed: 11/13/2022] Open
Abstract
Background One quarter to one third of patients eligible for systemic thrombolysis are on antiplatelet therapy at presentation. In this study, we aimed to assess the safety and efficacy of intravenous thrombolysis in stroke patients on prescribed antiplatelet therapy in the WAKE-UP trial. Methods WAKE-UP was a multicenter, randomized, double-blind, placebo-controlled clinical trial to study the efficacy and safety of MRI-guided intravenous thrombolysis with alteplase in patients with an acute stroke of unknown onset time. The medication history of all patients randomized in the WAKE-UP trial was documented. The primary safety outcome was any sign of hemorrhagic transformation on follow-up MRI. The primary efficacy outcome was favorable functional outcome defined by a score of 0–1 on the modified Rankin scale at 90 days after stroke, adjusted for age and baseline stroke severity. Logistic regression models were fitted to study the association of prior antiplatelet treatment with outcome and treatment effect of intravenous alteplase. Results Of 503 randomized patients, 164 (32.6%) were on antiplatelet treatment. Patients on antiplatelet treatment were older (70.3 vs. 62.8 years, p < 0.001), and more frequently had a history of hypertension, atrial fibrillation, diabetes, hypercholesterolemia, and previous stroke or transient ischaemic attack. Rates of symptomatic intracranial hemorrhage and hemorrhagic transformation on follow-up imaging did not differ between patients with and without antiplatelet treatment. Patients on prior antiplatelet treatment were less likely to achieve a favorable outcome (37.3% vs. 52.6%, p = 0.014), but there was no interaction of prior antiplatelet treatment with intravenous alteplase concerning favorable outcome (p = 0.355). Intravenous alteplase was associated with higher rates of favorable outcome in patients on prior antiplatelet treatment with an adjusted odds ratio of 2.106 (95% CI 1.047–4.236). Conclusions Treatment benefit of intravenous alteplase and rates of post-treatment hemorrhagic transformation were not modified by prior antiplatelet intake among MRI-selected patients with unknown onset stroke. Worse functional outcome in patients on antiplatelets may result from a higher load of cardiovascular co-morbidities in these patients.
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Affiliation(s)
- Benedikt M Frey
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, F-69003 Lyon, France.,Université Lyon 1, F-69100 Villeurbanne, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, F-69100 Villeurbanne, France
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany.,Neurologie der Rehaklinik Medical Park Humboldtmühle, An der Mühle 2-9, 13507 Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, University Avenue, Glasgow, G12 8QQ UK
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Alina Königsberg
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, 17190 Salt, Girona, Spain
| | - Pascal Roy
- Hospices Civils de Lyon, Service de Biostatistique, F-69003 Lyon, France.,Université Lyon 1, F-69100 Villeurbanne, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, F-69100 Villeurbanne, France
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Oude Markt 13, bus 5005, 3000 Leuven, Belgium.,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Herestraat 49, bus 602, 3000 Leuven, Belgium
| | - Tim Magnus
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC 3084 Australia.,Department of Neurology, Austin Health, 145 Studley Road, Heidelberg, VIC 3084 Australia
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Oude Markt 13, bus 5005, 3000 Leuven, Belgium.,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Herestraat 49, bus 602, 3000 Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow, G12 8QQ UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, 17190 Salt, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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11
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Zheng Y, Lieschke F, Schaefer JH, Wang X, Foerch C, van Leyen K. Dual Antiplatelet Therapy Increases Hemorrhagic Transformation Following Thrombolytic Treatment in Experimental Stroke. Stroke 2019; 50:3650-3653. [PMID: 31587659 DOI: 10.1161/strokeaha.119.027359] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Dual antiplatelet treatment poses a risk for increased hemorrhagic transformation (HT) following intravenous thrombolysis and mechanical thrombectomy. The aim of this study was to implement a model of experimental stroke with tissue-type plasminogen activator (tPA)-associated HT in mice on dual antiplatelet treatment to enable mechanistic studies and also to allow for an initial assessment of therapeutic approaches to limit HT. Methods- Male C57BL6 mice were fed with Aspirin and Clopidogrel via drinking water for 3 days. Subsequently, mice were subjected to 2-hour transient middle cerebral artery occlusion, and tPA was infused when indicated. HT was quantified by measuring hemorrhaged areas in brain sections with ImageJ. TTC staining was used to determine infarct size. Platelet function was tested in vitro using flow cytometry and in vivo with standard tail bleeding tests. Results- Both flow cytometry and tail bleeding volumes indicated significantly reduced platelet function following Aspirin and Clopidogrel treatment. While tPA administered 2 hours after onset of middle cerebral artery occlusion did not cause bleeding in control mice (0.51±0.13 mm2), HT significantly increased by 18.9±5.4 mm2 (P=0.0045) in Aspirin and Clopidogrel mice treated with tPA. HT in aspirin and clopidogrel mice not treated with tPA was nonsignificantly elevated by 8.0±4.6 mm2 (P=0.3784) compared with controls. Infarct sizes did not differ between groups. The HT persisted when the tPA dosage was reduced. Conclusions- We successfully established a translational stroke model of tPA treatment under dual antiplatelet treatment. The impaired platelet function led to an increased risk for HT in tPA-treated mice. Reducing the dosage of tPA did not prevent this hemorrhagic complication.
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Affiliation(s)
- Yi Zheng
- From the Neuroprotection Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.Z., F.L., X.W., K.v.L.)
| | - Franziska Lieschke
- From the Neuroprotection Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.Z., F.L., X.W., K.v.L.).,Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany (F.L., J.H.S., C.F.)
| | - Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany (F.L., J.H.S., C.F.)
| | - Xiaoying Wang
- From the Neuroprotection Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.Z., F.L., X.W., K.v.L.)
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany (F.L., J.H.S., C.F.)
| | - Klaus van Leyen
- From the Neuroprotection Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown (Y.Z., F.L., X.W., K.v.L.)
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12
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Sun C, Song B, Jiang C, Zou JJ. Effect of antiplatelet pretreatment on safety and efficacy outcomes in acute ischemic stroke patients after intravenous thrombolysis: a systematic review and meta-analysis. Expert Rev Neurother 2019; 19:349-358. [PMID: 30807235 DOI: 10.1080/14737175.2019.1587295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Chao Sun
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Baili Song
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chunlian Jiang
- Department of Pathology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jian-Jun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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13
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Lee SH, Kim BJ, Han MK, Park TH, Lee KB, Lee BC, Yu KH, Oh MS, Cha JK, Kim DH, Nah HW, Lee J, Lee SJ, Kim JG, Park JM, Kang K, Cho YJ, Hong KS, Park HK, Choi JC, Kim JT, Choi K, Kim DE, Ryu WS, Kim WJ, Shin DI, Yeo M, Sohn SI, Hong JH, Lee J, Lee JS, Khatri P, Bae HJ. Futile reperfusion and predicted therapeutic benefits after successful endovascular treatment according to initial stroke severity. BMC Neurol 2019; 19:11. [PMID: 30646858 PMCID: PMC6332890 DOI: 10.1186/s12883-019-1237-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 01/07/2019] [Indexed: 01/01/2023] Open
Abstract
Background Futile reperfusion (poor functional status despite successful reperfusion) was observed in up to 67% of patients enrolled in recent endovascular treatment (EVT) clinical trials. We investigated the impact of baseline stroke severity on both futile reperfusion and therapeutic benefit of successful EVT. Methods Using a prospective multicenter stroke registry, we identified consecutive ischemic stroke patients with anterior circulation large artery occlusion, who were reperfused successfully by EVT (Thrombolysis in Cerebral Infarction grade 2b–3). The rate of futile reperfusion was assessed across the initial National Institutes of Health Stroke Scale (NIHSS) scores. The frequency of poor outcomes (modified Rankin scale [mRS] 3–6) according to NIHSS scores was compared between patients revascularized successfully by EVT and those who did not receive EVT, after standardizing for age. Results Among 21,591 patients with ischemic stroke, 972 (4.5%) received EVT within 12 h of onset, including 440 who met study eligibility criteria. Futile reperfusion was observed in 226 of the 440 study-eligible patients (51.4%) and was associated with stroke severity: 20.9% in NIHSS scores ≤5, 34.6% in 6–10, 58.9% in 11–20, and 63.8% in > 20 (p < 0.001). Nonetheless, the therapeutic benefit of EVT also increased with increasing stroke severity (p for interaction < 0.001): 0.1% in NIHSS ≤5, 18.6% in 6–10, 28.7% in 11–20, and 34.3% in > 20. Conclusions EVT is more beneficial with increasing stroke severity, although futile reperfusion also increases with higher stroke severity. Electronic supplementary material The online version of this article (10.1186/s12883-019-1237-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University Hospital, Pusan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Pusan, Korea
| | - Hyun-Wook Nah
- Department of Neurology, Dong-A University Hospital, Pusan, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kangho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Wook-Joo Kim
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Minju Yeo
- Department of Neurology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea.
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14
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Tsivgoulis G, Kargiotis O, Alexandrov AV. Intravenous thrombolysis for acute ischemic stroke: a bridge between two centuries. Expert Rev Neurother 2018. [PMID: 28644924 DOI: 10.1080/14737175.2017.1347039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intravenous tissue-plasminogen activator (tPA) remains the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke. Accumulating real-word experience for over 20 years regarding tPA safety and effectiveness led to re-appraisal of original contraindications for intravenous thrombolysis (IVT). Areas covered: This narrative review focuses on fast yet appropriate selection of patients for safe administration of tPA per recently expanded indications. Novel strategies for rapid patient assessment will be discussed. The potential for mobile stroke units (MSU) that shorten onset-to-needle time and increase tPA treatment rates is addressed. The use of IVT in the era of non-vitamin K antagonist oral anticoagulants (NOACs) is highlighted. The continuing role of IVT in large vessel occlusion (LVO) patients eligible for mechanical thrombectomy (MT) is discussed with regards to 'drip and ship' vs. 'mothership' treatment paradigms. Promising studies of penumbral imaging to extend IVT beyond the 4.5-hour window and in wake-up strokes are summarized. Expert commentary: This review provides an update on the role of IVT in specific conditions originally considered tPA contraindications. Novel practice challenges including NOAC's, MSU proliferation and bridging therapy (IVT&MT) for LVO patients, and the potential extension of IVT time-window using penumbral imaging are emerging as safe and potentially effective IVT applications.
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Affiliation(s)
- Georgios Tsivgoulis
- a Second Department of Neurology , National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital , Athens , Greece.,b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
| | | | - Andrei V Alexandrov
- b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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Robinson TG, Wang X, Arima H, Bath PM, Billot L, Broderick JP, Demchuk AM, Donnan GA, Kim JS, Lavados PM, Lee TH, Lindley RI, Martins SCO, Olavarria VV, Pandian JD, Parsons MW, Pontes-Neto OM, Ricci S, Sato S, Sharma VK, Nguyen TH, Wang JG, Woodward M, Chalmers J, Anderson CS. Low- Versus Standard-Dose Alteplase in Patients on Prior Antiplatelet Therapy. Stroke 2017; 48:1877-1883. [DOI: 10.1161/strokeaha.116.016274] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Thompson G. Robinson
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Xia Wang
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Hisatomi Arima
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Philip M. Bath
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Laurent Billot
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Joseph P. Broderick
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Andrew M. Demchuk
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Geoffery A. Donnan
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Jong S. Kim
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Pablo M. Lavados
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Tsong-Hai Lee
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Richard I. Lindley
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Sheila C. O. Martins
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Veronica V. Olavarria
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Jeyaraj D. Pandian
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Mark W. Parsons
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Octavio M. Pontes-Neto
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Stefano Ricci
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Shoichiro Sato
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Vijay K. Sharma
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Thang H. Nguyen
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Ji-Guang Wang
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Mark Woodward
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - John Chalmers
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
| | - Craig S. Anderson
- From the Department of Cardiovascular Sciences, National Institute for Health Research Biomedical Research Unit, University of Leicester, (T.G.R.); George Institute for Global Health, Neurological and Mental Health Division (X.W., H.A., L.B., R.I.L., M.W., J.C., C.S.A.), Faculty of Medicine, University of New South Wales (X.W., H.A., L.B., M.W., J.C., C.S.A.), and Department of Geriatric Medicine, Westmead Clinical School (R.I.L.), University of Sydney, Australia; Stroke Trials Unit, Division of
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Carroll BJ, Goldhaber SZ, Liu PY, Piazza G. Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis in elderly patients with pulmonary embolism: A SEATTLE II sub-analysis. Vasc Med 2017. [DOI: 10.1177/1358863x17693102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Elderly patients with acute pulmonary embolism (PE) have higher mortality than non-elderly patients, but receive systemic fibrinolysis less frequently. In this sub-analysis of the SEATTLE II trial, we evaluated the efficacy and safety of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis in elderly patients with submassive and massive PE. We compared patients ⩾65 years old with those <65 years old. Eligible patients had proximal PE and a right ventricular-to-left ventricular (RV/LV) diameter ratio ⩾0.9 on chest computed tomography (CT). The primary efficacy outcome was the change in chest CT-measured RV/LV diameter ratio at 48 hours after procedure initiation. The primary safety outcome was major bleeding within 72 hours. Sixty-two patients were ⩾65 years of age and 88 were <65 years of age. The RV/LV diameter ratio decreased in both groups 48 hours post-procedure, with a mean change of −0.47 in those ⩾65 and −0.39 in those <65 years old, with no difference between groups ( p = 0.31). Major bleeding occurred in nine (15%) of those ⩾65 and in six (7%) of those <65 years old ( p = 0.17). Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis resulted in a similar reduction in RV/LV diameter ratio in elderly patients with massive and submassive PE compared with non-elderly patients.
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Affiliation(s)
- Brett J Carroll
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiology Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ping-Yu Liu
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Gregory Piazza
- Cardiology Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Antiplatelet pretreatment and outcomes in intravenous thrombolysis for stroke: a systematic review and meta-analysis. J Neurol 2017; 264:1227-1235. [DOI: 10.1007/s00415-017-8520-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/15/2017] [Indexed: 12/22/2022]
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Tateishi Y, Hamabe J, Kanamoto T, Nakaoka K, Morofuji Y, Horie N, Izumo T, Morikawa M, Tsujino A. Subacute lesion volume as a potential prognostic biomarker for acute ischemic stroke after intravenous thrombolysis. J Neurol Sci 2016; 369:77-81. [DOI: 10.1016/j.jns.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
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Choi JC, Lee JS, Park TH, Cho YJ, Park JM, Kang K, Lee KB, Lee SJ, Kim JG, Lee J, Park MS, Choi KH, Kim JT, Yu KH, Lee BC, Oh MS, Cha JK, Kim DH, Nah HW, Kim DE, Ryu WS, Kim BJ, Bae HJ, Kim WJ, Shin DI, Yeo MJ, Sohn SI, Hong JH, Lee J, Hong KS. Prestroke Antiplatelet Effect on Symptomatic Intracranial Hemorrhage and Functional Outcome in Intravenous Thrombolysis. J Stroke 2016; 18:344-351. [PMID: 27733024 PMCID: PMC5066428 DOI: 10.5853/jos.2016.00185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose About 30%-40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with intravenous tissue plasminogen activator (IV-TPA) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA. Methods From a prospective stroke registry, we identified patients treated with IV-TPA between October 2009 and November 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge modified Rankin Scale (mRS) score and in-hospital mortality. Results Of 1,715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have multiple vascular risk factors. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs. 3.0%; adjusted odds ratio [OR] 1.79 [1.05-3.04]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72-1.14]), mRS 0-1 outcome (34.2% vs. 33.7%; adjusted OR 1.27 [0.94-1.72), mRS 0-2 outcome (52.4% vs. 52.9%; adjusted OR 1.21 [0.90-1.63]), and in-hospital mortality (6.1% vs. 4.2%; adjusted OR 1.19 [0.71-2.01]). Conclusions Despite an increased risk of SICH, prestroke antiplatelet users compared to non-users had comparable functional outcomes and in-hospital mortality with IV-TPA therapy. Our results support the use of IV-TPA in eligible patients taking antiplatelet therapy before their stroke onset.
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Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Hyun-Wook Nah
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan, Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Min-Ju Yeo
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
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Luo S, Zhuang M, Zeng W, Tao J. Intravenous Thrombolysis for Acute Ischemic Stroke in Patients Receiving Antiplatelet Therapy: A Systematic Review and Meta-analysis of 19 Studies. J Am Heart Assoc 2016; 5:JAHA.116.003242. [PMID: 27207999 PMCID: PMC4889195 DOI: 10.1161/jaha.116.003242] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The safety and long-term outcome of systemic thrombolysis in patients receiving antiplatelet medications remain subjects of great clinical significance. The objective of this meta-analysis was to determine how prestroke antiplatelet therapy affects the risks and benefits of intravenous thrombolysis in patients with acute ischemic stroke. METHODS AND RESULTS A dual-reviewer search was conducted in PubMed and EMBASE databases through November 2015, from which 19 studies involving a total of 108 588 patients with acute ischemic stroke were identified based on preset inclusion criteria. Information on study designs, patient characteristics, exposures, outcomes, and adjusting confounders was extracted, and estimates were combined by using random-effects models. The pooled crude estimates suggested that taking long-term antiplatelet medications was associated with higher odds of symptomatic intracranial hemorrhage (odds ratio [OR] 1.70, 95% CI 1.47-1.97) and death (OR 1.46, 95% CI 1.22-1.75) and lower odds of favorable functional outcomes (OR 0.86, 95% CI 0.80-0.93). However, the combined confounder-adjusted results only confirmed a relatively weak positive association between prior antiplatelet therapy and symptomatic intracranial hemorrhage (OR 1.21, 95% CI 1.02-1.44) and demonstrated no significant relationship between antiplatelet therapy and the other 2 outcomes (favorable outcome OR 1.09, 95% CI 0.96-1.24; death OR 1.02, 95% CI 0.98-1.07). Subgroup analyses revealed that the associations between prestroke antiplatelet therapy and outcomes were dependent on time and antiplatelet agents. CONCLUSIONS Patients with acute ischemic stroke receiving long-term antiplatelet medications were associated with greater risks of developing symptomatic intracranial hemorrhage after systemic thrombolysis. However, the overall independent association between prestroke antiplatelet therapy and unfavorable outcomes or mortality was insignificant.
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Affiliation(s)
- Shengyuan Luo
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mei Zhuang
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wutao Zeng
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jun Tao
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Comparative Efficacy and Safety of Nine Anti-Platelet Therapies for Patients with Ischemic Stroke or Transient Ischemic Attack: a Mixed Treatment Comparisons. Mol Neurobiol 2016; 54:1456-1466. [PMID: 26846361 DOI: 10.1007/s12035-016-9739-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
Abstract
Anti-platelet treatments, an effective anti-thrombotic therapy, are widely used in non-cardioembolic ischemic stroke or transient ischemic attack (TIA), including aspirin, cilostazol, clopidogrel, and other mono or dual therapies, while the optimal choice remains uncertain. All the literatures of 38 eligible randomized control trials were searched in PubMed, Embase, and China National Knowledge Internet (CNKI) without language limitation. And, nine anti-platelet therapies were assessed, including aspirin, clopidogrel, cilostazol, ticlopidine, triflusal, terutroban, sarpogrelate, dipyridamole plus aspirin, and clopidogrel plus aspirin. Additionally, we extract data of composite vascular events, major bleeding, ischemic stroke, intracranial hemorrhage, and all-cause death, as indicators of efficacy and safety. And among them, composite vascular events were the primary outcome. The binary outcomes were expressed as odds ratios (ORs) with corresponding 95 % confidence intervals (CIs). Both traditional meta-analysis and network meta-analysis were performed. Besides, for each outcome, the rank order was applied to reflect the superiority of every therapy compared with others, using the surface under the cumulative ranking curve (SUCRA). A cluster analysis was also conducted. Through the network meta-analysis, the synthesized data shows that cilostazol performed best on composite vascular events compared with placebo (OR = 0.62, 95 % CI 0.46-0.83) and aspirin (OR = 0.71, 95 % CI 0.53-0.95). In terms of ischemic stroke, clopidogrel plus aspirin seems the optimal, and it has significant difference between placebo (OR = 0.53, 95 % CI 0.35-0.74) and aspirin (OR = 0.75, 95 % CI 0.61-0.95). Meanwhile, cilostazol is also the first rank in major bleeding, especially when it is in contrast to aspirin (OR = 0.13, 95 % CI 0.02-0.70) and clopidogrel plus aspirin (OR = 0.09, 95 % CI 0.01-0.50). There is no significant difference among these nine treatments and placebo, as to all-cause death and intracranial hemorrhage. According to the cluster analysis, cilostazol can be the best choice with comprehensive assessment of composite vascular events, ischemic stroke and major bleeding. Based on this network meta-analysis, cilostazol was recommended as the optimal choice with good performance in both efficacy and safety for patient with ischemic stroke or TIA among nine anti-platelet therapies.
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