1
|
Zonneveld TP, Vermeer SE, van Zwet EW, Groot AED, Algra A, Aerden LAM, Alblas KCL, de Beer F, Brouwers PJAM, de Gans K, van Gemert HMA, van Ginneken BCAM, Grooters GS, Halkes PHA, van der Heijden-Montfroy TAMHG, Jellema K, de Jong SW, Lövenich-Ciccarello H, van der Meulen WDM, Peters EW, van der Ree TC, Remmers MJM, Richard E, Rovers JMP, Saxena R, van Schaik SM, Schonewille WJ, Schreuder TAHCML, de Schryver ELLM, Schuiling WJ, Spaander FH, van Tuijl JH, Visser MC, Zinkstok SM, Zock E, Dippel DWJ, Kappelle LJ, van Oostenbrugge RJ, Roos YBWEM, Vermeij FH, Wermer MJH, van der Worp HB, Nederkoorn PJ, Kruyt ND. Safety and efficacy of active blood-pressure reduction to the recommended thresholds for intravenous thrombolysis in patients with acute ischaemic stroke in the Netherlands (TRUTH): a prospective, observational, cluster-based, parallel-group study. Lancet Neurol 2024:S1474-4422(24)00177-7. [PMID: 38763149 DOI: 10.1016/s1474-4422(24)00177-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Intravenous thrombolysis is contraindicated in patients with ischaemic stroke with blood pressure higher than 185/110 mm Hg. Prevailing guidelines recommend to actively lower blood pressure with intravenous antihypertensive agents to allow for thrombolysis; however, there is no robust evidence for this strategy. Because rapid declines in blood pressure can also adversely affect clinical outcomes, several Dutch stroke centres use a conservative strategy that does not involve the reduction of blood pressure. We aimed to compare the clinical outcomes of both strategies. METHODS Thrombolysis and Uncontrolled Hypertension (TRUTH) was a prospective, observational, cluster-based, parallel-group study conducted across 37 stroke centres in the Netherlands. Participating centres had to strictly adhere to an active blood-pressure-lowering strategy or to a non-lowering strategy. Eligible participants were adults (≥18 years) with ischaemic stroke who had blood pressure higher than 185/110 mm Hg but were otherwise eligible for intravenous thrombolysis. The primary outcome was functional status at 90 days, measured using the modified Rankin Scale and assessed through telephone interviews by trained research nurses. Secondary outcomes were symptomatic intracranial haemorrhage, the proportion of patients treated with intravenous thrombolysis, and door-to-needle time. All ordinal logistic regression analyses were adjusted for age, sex, stroke severity, endovascular thrombectomy, and baseline imbalances as fixed-effect variables and centre as a random-effect variable to account for the clustered design. Analyses were done according to the intention-to-treat principle, whereby all patients were analysed according to the treatment strategy of the participating centre at which they were treated. FINDINGS Recruitment began on Jan 1, 2015, and was prematurely halted because of a declining inclusion rate and insufficient funding on Jan 5, 2022. Between these dates, we recruited 853 patients from 27 centres that followed an active blood-pressure-lowering strategy and 199 patients from ten centres that followed a non-lowering strategy. Baseline characteristics of participants from the two groups were similar. The 90-day mRS score was missing for 15 patients. The adjusted odds ratio (aOR) for a shift towards a worse 90-day functional outcome was 1·27 (95% CI 0·96-1·68) for active blood-pressure reduction compared with no active blood-pressure reduction. 798 (94%) of 853 patients in the active blood-pressure-lowering group were treated with intravenous thrombolysis, with a median door-to-needle time of 35 min (IQR 25-52), compared with 104 (52%) of 199 patients treated in the non-lowering group with a median time of 47 min (29-78). 42 (5%) of 852 patients in the active blood-pressure-lowering group had a symptomatic intracranial haemorrhage compared with six (3%) of 199 of those in the non-lowering group (aOR 1·28 [95% CI 0·62-2·62]). INTERPRETATION Insufficient evidence was available to establish a difference between an active blood-pressure-lowering strategy-in which antihypertensive agents were administered to reduce blood pressure below 185/110 mm Hg-and a non-lowering strategy for the functional outcomes of patients with ischaemic stroke, despite higher intravenous thrombolysis rates and shorter door-to-needle times among those in the active blood-pressure-lowering group. Randomised controlled trials are needed to inform the use of an active blood-pressure-lowering strategy. FUNDING Fonds NutsOhra.
Collapse
Affiliation(s)
- Thomas P Zonneveld
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Sarah E Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Adrien E D Groot
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Ale Algra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Julius Center, University Medical Center Utrecht, Netherlands; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Netherlands
| | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Kees C L Alblas
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, Netherlands
| | | | - Koen de Gans
- Department of Neurology, Groene Hart Hospital, Gouda, Netherlands
| | | | | | | | | | | | - Korné Jellema
- Department of Neurology, Haaglanden Medisch Centrum, The Hague, Netherlands; University Neurovascular Center Leiden-the Hague, Leiden, Netherlands; University Neurovascular Center Leiden-the Hague, the Hague, Netherlands
| | - Sonja W de Jong
- Department of Neurology, St Jansdal Hospital, Harderwijk, Netherlands
| | | | | | - Edwin W Peters
- Department of Neurology, Admiraal de Ruyter Hospital, Vlissingen, Netherlands
| | | | | | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Ritu Saxena
- Department of Neurology, Maasstad Hospital, Rotterdam, Netherlands
| | | | | | | | | | | | | | - Julia H van Tuijl
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Marieke C Visser
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | | | - Elles Zock
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | | | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht UMC+, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht UMC+, Maastricht, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Frederique H Vermeij
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | | | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands; University Neurovascular Center Leiden-the Hague, Leiden, Netherlands; University Neurovascular Center Leiden-the Hague, the Hague, Netherlands.
| |
Collapse
|
2
|
Olavarría VV. Challenging the management of blood pressure before intravenous thrombolysis in acute ischaemic stroke. Lancet Neurol 2024:S1474-4422(24)00208-4. [PMID: 38763150 DOI: 10.1016/s1474-4422(24)00208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/21/2024]
Affiliation(s)
- Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Clínica Alemana de Santiago, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.
| |
Collapse
|
3
|
Windon CC, Jackson AJ, Aguirre GA, Tucker M, Amuiri A, Hill-Jarrett T, Chen M, Pina Escuedro SD, Lieu K, Lopez L, Mei D, Tee BL, Watson CW, Agwu C, Kramer J, Lanata S. Underrepresented and Underserved Populations in Neurological Research. Semin Neurol 2024; 44:168-177. [PMID: 38485127 DOI: 10.1055/s-0044-1782516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Underserved and underrepresented populations have historically been excluded from neurological research. This lack of representation has implications for translation of research findings into clinical practice given the impact of social determinants of health on neurological disease risk, progression, and outcomes. Lack of inclusion in research is driven by individual-, investigator-, and study-level barriers as well as larger systemic injustices (e.g., structural racism, discriminatory practices). Although strategies to increase inclusion of underserved and underrepresented populations have been put forth, numerous questions remain about the most effective methodology. In this article, we highlight inclusivity patterns and gaps among the most common neurological conditions and propose best practices informed by our own experiences in engagement of local community organizations and collaboration efforts to increase underserved and underrepresented population participation in neurological research.
Collapse
Affiliation(s)
- Charles C Windon
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Ashley J Jackson
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Gloria A Aguirre
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Miwa Tucker
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Alinda Amuiri
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Tanisha Hill-Jarrett
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Miranda Chen
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Stefanie D Pina Escuedro
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Kevin Lieu
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Lucia Lopez
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Diana Mei
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Boon Lead Tee
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
- Memory and Aging Center, Department of Neurology, Global Brain Health Institute, University of California, San Francisco, California
| | - Caitlin W Watson
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Chidera Agwu
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Joel Kramer
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| | - Serggio Lanata
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, California
| |
Collapse
|
4
|
Xu Y, Hu Y, Wu G, Niu L, Fang C, Li Y, Jiang L, Yuan C, Huang M. Specific inhibition on PAI-1 reduces the dose of Alteplase for ischemic stroke treatment. Int J Biol Macromol 2024; 257:128618. [PMID: 38070813 DOI: 10.1016/j.ijbiomac.2023.128618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023]
Abstract
Administration of recombinant tPA (rtPA, or trade name Alteplase®) is an FDA-approved therapy for acute ischemic stroke (AIS), but poses the risk of hemorrhagic complications. Recombinant tPA can be rapidly inactivated by the endogenous inhibitor, plasminogen activator inhibitor 1 (PAI-1). In this work, we study a novel treatment approach that combines a PAI-1 inhibitor, PAItrap4, with a reduced dose of rtPA to address the hemorrhagic concern of rtPA. PAItrap4 is a highly specific and very potent protein-based inhibitor of PAI-1, comprising of a variant of uPA serine protease domain, human serum albumin, and a cyclic RGD peptide. PAItrap4 efficiently targets and inhibits PAI-1 on activated platelets, and also possesses a long half-life in vivo. Our results demonstrate that PAItrap4 effectively counteracts the inhibitory effects of PAI-1 on rtPA, preserving rtPA activity based on amidolytic and clot lysis assays. In an in vivo murine stroke model, PAItrap4, together with low-dose rtPA, enhances the blood perfusion in the stroke-affected areas, reduces infarct size, and promotes neurological recovery in mice. Importantly, such treatment does not increase the amount of cerebral hemorrhage, thus reducing the risk of cerebral hemorrhage. In addition, PAItrap4 does not compromise the normal blood coagulation function in mice, demonstrating its safety as a therapeutic agent. These findings highlight this combination therapy as a promising alternative for the treatment of ischemic stroke, offering improved safety and efficacy.
Collapse
Affiliation(s)
- Yanyan Xu
- College of Chemical Engineering, Fuzhou University, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Yinping Hu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Guangqian Wu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Lili Niu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Chao Fang
- Department of Pharmacology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yongkun Li
- Department of Neurology, Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University, No. 134 Dong Street, Fuzhou, Fujian 350001, China
| | - Longguang Jiang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Cai Yuan
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian, 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China.
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China; National Joint Research Center on Biomedical Photodynamic Technology, Fuzhou University, Fuzhou, Fujian 350108, China.
| |
Collapse
|
5
|
Elawady SS, Saway BF, Matsukawa H, Uchida K, Lin S, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur A, Yoshimura S, Cuellar H, Grossberg JA, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Osbun J, Crosa R, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Dumont T, Williamson R, Navia P, Kan P, Leacy RD, Chowdhry S, Ezzeldin M, Spiotta AM, Kasab SA. Thrombectomy in Stroke Patients With Low Alberta Stroke Program Early Computed Tomography Score: Is Modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 Superior to mTICI 2b? J Stroke 2024; 26:95-103. [PMID: 38326708 PMCID: PMC10850454 DOI: 10.5853/jos.2023.02292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/13/2023] [Accepted: 10/04/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND AND PURPOSE Outcomes following mechanical thrombectomy (MT) are strongly correlated with successful recanalization, traditionally defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b. This retrospective cohort study aimed to compare the outcomes of patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS; 2-5) who achieved mTICI 2b versus those who achieved mTICI 2c/3 after MT. METHODS This study utilized data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combined databases from 32 thrombectomy-capable stroke centers between 2013 and 2023. The study included only patients with low ASPECTS who achieved mTICI 2b, 2c, or 3 after MT for internal carotid artery or middle cerebral artery (M1) stroke. RESULTS Of the 10,229 patients who underwent MT, 234 met the inclusion criteria. Of those, 98 (41.9%) achieved mTICI 2b, and 136 (58.1%) achieved mTICI 2c/3. There were no significant differences in baseline characteristics between the two groups. The 90-day favorable outcome (modified Rankin Scale score: 0-3) was significantly better in the mTICI 2c/3 group than in the mTICI 2b group (adjusted odds ratio 2.35; 95% confidence interval [CI] 1.18-4.81; P=0.02). Binomial logistic regression revealed that achieving mTICI 2c/3 was significantly associated with higher odds of a favorable 90-day outcome (odds ratio 2.14; 95% CI 1.07-4.41; P=0.04). CONCLUSION In patients with low ASPECTS, achieving an mTICI 2c/3 score after MT is associated with a more favorable 90-day outcome. These findings suggest that mTICI 2c/3 is a better target for MT than mTICI 2b in patients with low ASPECTS.
Collapse
Affiliation(s)
- Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brian Fabian Saway
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Steven Lin
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | | | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown, WV, USA
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Marios-Nikos Psychogios
- Department of Interventional and Diagnostical Neuroradiology, University of Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Adam Arthur
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hugo Cuellar
- Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport, LA, USA
| | - Jonathan A. Grossberg
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Ali Alawieh
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Daniele G. Romano
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Isabel Fragata
- Department of Neuroradiology, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Min S. Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael R. Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Mark Moss
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, AZ, USA
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurological Surgery, University of Texas Medical Branch - Galveston, TX, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Shakeel Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL, USA
| | - Mohamad Ezzeldin
- University of Houston, Department of Clinical Neuroscience, HCA Houston Healthcare Kingwood, Houston, TX, USA
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - on behalf of the STAR Collaborators
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Radiology, West Virginia School of Medicine, Morgantown, WV, USA
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
- Department of Interventional and Diagnostical Neuroradiology, University of Basel, Basel, Switzerland
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport, LA, USA
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Salerno, Italy
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Neuroradiology, Hospital São José Centro Hospitalar, Lisboa, Portugal
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, AZ, USA
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
- Department of Neurological Surgery, University of Texas Medical Branch - Galveston, TX, USA
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL, USA
- University of Houston, Department of Clinical Neuroscience, HCA Houston Healthcare Kingwood, Houston, TX, USA
| |
Collapse
|
6
|
Kulkarni S, Glover M, Kapil V, Abrams SML, Partridge S, McCormack T, Sever P, Delles C, Wilkinson IB. Management of hypertensive crisis: British and Irish Hypertension Society Position document. J Hum Hypertens 2023; 37:863-879. [PMID: 36418425 PMCID: PMC10539169 DOI: 10.1038/s41371-022-00776-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/12/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022]
Abstract
Patients with hypertensive emergencies, malignant hypertension and acute severe hypertension are managed heterogeneously in clinical practice. Initiating anti-hypertensive therapy and setting BP goal in acute settings requires important considerations which differ slightly across various diagnoses and clinical contexts. This position paper by British and Irish Hypertension Society, aims to provide clinicians a framework for diagnosing, evaluating, and managing patients with hypertensive crisis, based on the critical appraisal of available evidence and expert opinion.
Collapse
Affiliation(s)
- Spoorthy Kulkarni
- Department of Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB20QQ, UK.
| | - Mark Glover
- Division of Therapeutics and Molecular Medicine, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Vikas Kapil
- William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, Queen Mary University London, London, EC1M 6BQ, UK
- Barts BP Centre of Excellence, Barts Heart Centre, London, EC1A 7BE, UK
| | - S M L Abrams
- Clinical Pharmacology and Therapeutics, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
| | - Sarah Partridge
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, BN1 9PH, UK
| | - Terry McCormack
- Institute of Clinical and Applied Health Research, Hull York Medical School, Hull, HU6 7RX, UK
| | - Peter Sever
- Imperial College School of Medicine, London, SW7 1LY, UK
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, G12 8TA, UK
| | - Ian B Wilkinson
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, CB2 0QQ, UK
| |
Collapse
|
7
|
Ho-Tin-Noé B, Desilles JP, Mazighi M. Thrombus composition and thrombolysis resistance in stroke. Res Pract Thromb Haemost 2023; 7:100178. [PMID: 37538503 PMCID: PMC10394565 DOI: 10.1016/j.rpth.2023.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 08/05/2023] Open
Abstract
A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.
Collapse
Affiliation(s)
- Benoit Ho-Tin-Noé
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| |
Collapse
|
8
|
Grotta JC. Intravenous Thrombolysis for Acute Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:425-442. [PMID: 37039403 DOI: 10.1212/con.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the "time is brain" versus "tissue clock" approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions. LATEST DEVELOPMENTS The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the "time is brain" concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose "tissue clock" is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the "drip and ship" versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis. ESSENTIAL POINTS IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.
Collapse
|
9
|
Broderick JP, Aziz YN, Adeoye OM, Grotta JC, Naidech AM, Barreto AD, Derdeyn CP, Sucharew HJ, Elm JJ, Khatri P. Recruitment in Acute Stroke Trials: Challenges and Potential Solutions. Stroke 2023; 54:632-638. [PMID: 36533521 PMCID: PMC9870937 DOI: 10.1161/strokeaha.122.040071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Randomized clinical trials of acute stroke have led to major advances in acute stroke therapy over the past decade. Despite these successes, recruitment in acute trials is often difficult. We outline challenges in recruitment for acute stroke trials and present potential solutions, which can increase the speed and decrease the cost of identifying new treatments for acute stroke. One of the largest opportunities to increase the speed of enrollment and make trials more generalizable is expansion of inclusion criteria whose impact on expected recruitment can be assessed by epidemiologic and registry databases. Another barrier to recruitment besides the number of eligible patients is availability of study investigators limited to business hours, which may be helped by financial support for after-hours call. The wider use of telemedicine has accelerated quicker stroke treatment at many hospitals and has the potential to accelerate research enrollment but requires training of clinical investigators who are often inexperienced with this approach. Other potential solutions to enhance recruitment include rapid prehospital notification of clinical investigators of potential patients, use of mobile stroke units, advances in the process of emergency informed consent, storage of study medication in the emergency department, simplification of study treatments and data collection, education of physicians to improve equipoise and enthusiasm for randomization of patients within a trial, and clear recruitment plans, and even potentially coenrollment, when there are competing trials at sites. Without successful recruitment, scientific advances and clinical benefit for acute stroke patients will lag.
Collapse
Affiliation(s)
- Joseph P. Broderick
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - Yasmin N. Aziz
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University, St. Louis, Mo. USA
| | - James C. Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| | - Andrew M. Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andrew D. Barreto
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, TX, USA
| | - Colin P. Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Heidi J. Sucharew
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jordan J. Elm
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| |
Collapse
|
10
|
Nepal G, Kharel S, Kumar Yadav J, Kumar Yadav S, Bhagat R, Ka Shing Y, Coghlan M, Lal Bhattarai S, Sigdel K, Chandra Mahat B. Low-dose alteplase for the management of acute ischemic stroke in South Asians: A systematic review on cost, efficacy and safety. J Clin Neurosci 2022; 103:92-99. [PMID: 35853390 DOI: 10.1016/j.jocn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION South Asia is responsible for more than 40% of the stroke burden and stroke mortality in the developing world. South Asia, which is home to one-fourth of the world's population, is the most densely populated and one of the poorest regions. The majority of patients in this region are unable to afford intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). If low-dose alteplase proves effective and safe in South Asians, it may be a more cost-effective treatment option. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Researchers searched PubMed, EMBASE, and Google Scholar for English literature from 2005 to 2021. END, ENI, good functional outcome, SICH, and all-cause mortality were used to assess efficacy and safety. RESULTS In the low-dose alteplase treated patients, different studies reported 32 to 57% ENI 24 h after IVT, and 7% to 9.7% END. At 3 months follow-up, good functional outcome was achieved by 48%-76.92% of low-dose alteplase treated patients. SICH rates ranged from 0% to 16.6% across studies. Asymptomatic ICH occurred in 5-14% of patients. The mortality rate in all included studies varied from none to 25%. CONCLUSION Our systematic review demonstrates that the use of low-dose alteplase for AIS in the South Asians offer comparable efficacy and reduced risk of SICH at a significantly lower cost than standard alteplase dose. Future well-randomized clinical trials are necessary to validate the findings of our study.
Collapse
Affiliation(s)
- Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Sanjeev Kharel
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Sushil Kumar Yadav
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore.
| | - Megan Coghlan
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Kaushal Sigdel
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Bishow Chandra Mahat
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
11
|
How Frequent is the One-Hour tPA Infusion Interrupted or Delayed? J Stroke Cerebrovasc Dis 2022; 31:106471. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/20/2022] [Indexed: 11/17/2022] Open
|
12
|
Padrick MM, Brown W, Lyden PD. Intravenous Thrombolysis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Dicpinigaitis AJ, Gandhi CD, Shah SP, Galea VP, Cooper JB, Feldstein E, Shapiro SD, Kamal H, Kurian C, Kaur G, Tyagi R, Biswas A, Rosenberg J, Bauerschmidt A, Bowers CA, Mayer SA, Al-Mufti F. Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients. J Neurol Sci 2022; 434:120168. [DOI: 10.1016/j.jns.2022.120168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
|
14
|
Grotta JC. Fifty Years of Acute Ischemic Stroke Treatment: A Personal History. Cerebrovasc Dis 2021; 50:666-680. [PMID: 34649237 PMCID: PMC8639727 DOI: 10.1159/000519843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/23/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It has been 50 years since the first explorations of the physiology of cerebral ischemia by measuring cerebral blood flow (CBF), and 25 years since the approval of tissue plasminogen activator for treating acute ischemic stroke. My personal career began and matured during those eras. Here, I provide my perspective on the evolution of acute stroke research and treatment from 1971 to the present, with some in-depth discussion of the National Institutes of Neurologic Disease and Stroke (NINDS) tissue-type plasminogen activator (tPA) stroke trial and development of mobile stroke units. SUMMARY Studies of CBF and metabolism in acute stroke patients revealed graded tissue injury that was dependent on the duration of ischemia. Subsequent animal research unraveled the biochemical cascade of events occurring at the cellular level after cerebral ischemia. After a decade of failed translation, the development of a relatively safe thrombolytic allowed us to achieve reperfusion and apply the lessons from earlier research to achieve positive clinical results. The successful conduct of the NINDS tPA stroke study coupled with positive outcomes from companion tPA studies around the world created the specialty of vascular neurology. This was followed by an avalanche of research in imaging, a focus on enhancing reperfusion through thrombectomy, and improving delivery of faster treatment culminating in mobile stroke units. Key Messages: The last half century has seen the birth and evolution of successful acute stroke treatment. More research is needed in developing new drugs and catheters to build on the advances we have already made with reperfusion and also in evolving our systems of care to get more patients treated more quickly in the prehospital setting. The history of stroke treatment over the last 50 years exemplifies that medical "science" is an evolving discipline worth an entire career's dedication. What was impossible 50 years ago is today's standard of care, what we claim as dogma today will be laughed at a decade from now, and what appears currently impossible will be tomorrow's realities.
Collapse
Affiliation(s)
- James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| |
Collapse
|
15
|
Adapting Clinical Practice of Thrombolysis for Acute Ischemic Stroke Beyond 4.5 Hours: A Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:106059. [PMID: 34464927 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106059] [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: 05/17/2021] [Revised: 07/23/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022] Open
Abstract
Several clinical trials have demonstrated that advanced neuroimaging can select patients for recanalization therapy in an extended time window. The favorable functional outcomes and safety profile of these studies have led to the incorporation of neuroimaging in endovascular treatment guidelines, and most recently, also extended to decision making on thrombolysis. Two randomized clinical trials have demonstrated that patients who are not amenable to endovascular thrombectomy within 4.5 hours from symptoms discovery or beyond 4.5 hours from the last-known-well time may also be safely treated with intravenous thrombolysis and have a clinical benefit above the risk of safety concerns. With the growing aging population, increased stroke incidence in the young, and the impact of evolving medical practice, healthcare and stroke systems of care need to adapt continuously to provide evidence-based care efficiently. Therefore, understanding and incorporating appropriate screening strategies is critical for the prompt recognition of potentially eligible patients for extended-window intravenous thrombolysis. Here we review the clinical trial evidence for thrombolysis for acute ischemic stroke in the extended time window and provide a review of new enrolling clinical trials that include thrombolysis intervention beyond the 4.5 hour window.
Collapse
|
16
|
Jacob AP, Wang M, Okpala M, Yamal JM, Grotta JC, Parker SA. Dosing Tissue Plasminogen Activator on a Mobile Stroke Unit: Comparison Between Estimated and Hospital-Measured Weights. J Neurosci Nurs 2021; 53:166-169. [PMID: 34091516 DOI: 10.1097/jnn.0000000000000598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Prehospital tissue plasminogen activator dosing in a mobile stroke unit (MSU) is estimated by the paramedic and nurse. We aimed to determine the accuracy of the estimated weight method compared with the actual weight of patients treated with tissue plasminogen activator on the MSU. METHODS: We prospectively collected the estimated weight used on the MSU for treatment and the first-documented hospital-measured weight (bed scale) within 24 hours of hospital arrival. Median absolute and percent difference in weights were calculated; less than 10% of difference in weights was considered acceptable. To compare the estimated and measured weights, we conducted a Wilcoxon signed rank test and Fisher exact test to explore the association between weight difference of greater than 10% and patient outcomes. RESULTS: Among 337 patients, median estimated and hospital-measured weights were 79.0 kg (interquartile range [IQR], 66.0-94.5) and 78.5 kg (IQR, 65.0-91.7), respectively. The median of the absolute value of the difference in estimated versus measured weight was 2.7 kg (IQR, 0.6-7.6; P < .0001). The median percent difference in weight was 3.6% (IQR, 0.8%-9.4%). The median difference between the tissue plasminogen activator dosage administered on the MSU and the recommended dose based on the actual weight was 1.3 mg (IQR, 0.06-4.8) in absolute value. In 56 patients (16.6% of the entire sample) with overestimation of weight by greater than 10%, there were no symptomatic intracerebral hemorrhages. There was no association between weight difference and discharge modified Rankin score (P = .59). CONCLUSION: Weight estimation on an MSU can lead to similar tissue plasminogen activator dosing for 83.4% of subjects compared with if dosing were determined based on actual weight. Weight overestimation or underestimation had no detected impact on tissue plasminogen activator outcomes.
Collapse
|
17
|
Maximum intravenous alteplase dose for obese stroke patients is not associated with greater likelihood of worse outcomes. Thromb Res 2021; 204:76-80. [PMID: 34153647 DOI: 10.1016/j.thromres.2021.06.002] [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: 11/19/2020] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND IV alteplase is a primary treatment for acute ischemic stroke (AIS) at a weight-based dose (WBD) of 0.9 mg/kg and maximum dose (MD) of 90 mg. There are conflicting data regarding outcomes for those weighing ≥100 kg. There is also a paucity of data in Hispanics. The prevalence of adult obesity in the US has progressively increased; hence, the percentage of patients receiving the maximum dose also is expected to rise. We examined differences between patients treated with WBD vs. MD. METHODS A retrospective review of our center's Get With The Guidelines-Stroke database was performed for IV alteplase cases between October 2013-February 2017. Selection criteria included age ≥18 years, IV alteplase administration, and a recorded measured weight. Patients were dichotomized into WBD group weighing <100 kg and MD group weighing ≥100 kg. Categorical variables were analyzed using Chi square tests and continuous variables were analyzed using independent samples t-tests. Multivariable logistic regression analysis was performed to determine whether MD in combination with other variables was associated with poor outcomes. RESULTS There were 328 patients included in the study, 38 (11.6%) received MD. Proportions of younger, male, and non-Hispanic were higher in the MD group. There were no statistically significant differences for initial NIHSS, discharge modified Rankin Scale (mRS), 90-day mRS, symptomatic intracerebral hemorrhage (sICH), or systemic hemorrhage between groups. CONCLUSION One in ten patients thrombolysed for the treatment of AIS received MD. In a predominantly Hispanic population, those who received MD and WBD had similar rates of sICH, discharge disposition, and functional outcome (mRS) at discharge and at 90 days. Limitations include small sample size and attrition for the 90-day mRS.
Collapse
|
18
|
Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and 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 made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
Collapse
Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - 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, Tennessee, USA
| |
Collapse
|
19
|
Davies L, Delcourt C. Current approach to acute stroke management. Intern Med J 2021; 51:481-487. [PMID: 33890368 DOI: 10.1111/imj.15273] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
There have been marked improvements in the management of stroke in Australia over the past two decades. The greatest benefit has accrued from public health measures including reduced smoking rates and treatment of hypertension and hypercholesterolaemia. Recent advances in recanalisation therapy offer the chance of recovery to a subset of people who have a stroke. For many patients, stroke remains an illness with a devastating impact on their quality of life. Reducing the burden of stroke requires intervention across the health system from primary prevention through diagnosis, acute treatment, rehabilitation and secondary prevention. In this review, we will cover the changes in the epidemiology of stroke, public health measures in primary prevention of stroke, and acute management and secondary prevention of ischaemic stroke and primary intracerebral haemorrhage.
Collapse
Affiliation(s)
- Leo Davies
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
20
|
Hassan AE, Ringheanu VM, Preston L, Tekle W, Qureshi AI. IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion? J Neurointerv Surg 2020; 13:114-118. [PMID: 32620575 DOI: 10.1136/neurintsurg-2020-016045] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) is a widely proved method to treat patients diagnosed with intracranial large vessel occlusions (LVOs); however, there has been controversy about the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT. OBJECTIVE To compare the outcomes of all patients with LVO treated with IV tPA +EVT versus EVT alone within 4.5 hours of stroke onset. METHODS A prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2019 was used to examine variables such as demographics, comorbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (ICH), mortality rate, and good/poor outcomes as shown by the modified Thrombolysis in Cerebral Infarction score and modified Rankin Scale (mRS) assessment at discharge. The outcomes between patients receiving IV tPA+EVT on admission and patients who underwent EVT alone were compared. RESULTS Of 588 patients with acute ischemic stroke treated with EVT, a total of 189 met the criteria for the study (average age 70.44±12.90 years, 42.9% women). Analysis of 109 patients from the group receiving EVT+IV tPA (average age 68.17±14.28 years, 41.3% women), and 80 patients from the EVT alone group was performed (average age 73.54±9.84 years, 45.0% women). Four patients (5.0%) in the EVT alone group experienced symptomatic ICH versus 15 patients (13.8%) in the IV tPA+EVT group (p=0.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; p=0.0056). CONCLUSION IV tPA in addition to EVT was associated with an increase in the rate of ICH in patients with LVO treated within 4.5 hours and in patients' length of stay. Further research is required to determine whether EVT treatment alone in patients with LVO treated within 4.5 hours is a more effective option.
Collapse
Affiliation(s)
- Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA .,Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Victor M Ringheanu
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Laurie Preston
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Wondwossen Tekle
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.,Department of Neurology, University of Missouri School of Medicine, Columbia, Missouri, USA
| |
Collapse
|
21
|
Dong Y, Han Y, Shen H, Wang Y, Ma F, Li H, Wang Y, Dong Q. Who may benefit from lower dosages of intravenous tissue plasminogen activator? Results from a cluster data analysis. Stroke Vasc Neurol 2020; 5:348-352. [PMID: 32611728 PMCID: PMC7804063 DOI: 10.1136/svn-2020-000388] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 01/05/2023] Open
Abstract
Background The risk of symptomatic intracranial haemorrhage (sICH) after thrombolysis is low but severe. Lower dose of alteplase may reduce the risk of sICH. We aim to identify subsets of patients who could benefit from lower dose of alteplase compared with standard dose. Methods Data from two observational registries were pooled together. A total of 3479 patients who had acute ischaemic stroke were entered into the interaction tree model. The response variable was the rate of sICH per the definition of the National Institute of Neurological Disorders and Stroke Study. Clinical improvement was measured by the National Institutes of Health Stroke Scale (NIHSS) and defined as NIHSS 0 or 1 or an improvement of more than 4 points (within 7 days or at discharge). Rare event logistic regression was performed to analyse the OR of safety outcome. Results To optimise the interaction effect between tissue plasminogen activator (tPA) dosage (standard/lower) and patient subgroups, three subgroups based on the severity of stroke were identified: (1) NIHSS ≤4, (2) NIHSS between 5 and 14, and (3) NIHSS ≥15. The estimated difference of OR of having sICH was 2.71 (95% CI 0.80 to 7.69, p=0.10) for mild, 0.13 (95% CI 0.02 to 0.68, p=0.01) for moderate, and 0.65 (95% CI 0.19 to 2.55, p=0.52) for severe, respectively. In addition, patients who had moderate stroke treated with lower dose had comparable efficacy outcome (OR 1.23, 95% CI 0.71 to 2.13, p=0.45). Conclusion Our analysis demonstrated that in patients who had moderate stroke, lower doses of alteplase are associated with significant sICH reduction and non-inferior performance in efficacy, compared with those in the standard dose group. Trial registration number The TIMS-China was a national prospective stroke registry on thrombolytic therapy using intravenous tPA in patients who had acute ischaemic stroke. The results were initially published in 2012 without a clinical trial registration number. The Shanghai Stroke Service System was registered at www.clinicaltrial.gov (NCT02735226).
Collapse
Affiliation(s)
- Yi Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, Shanghai, China
| | - Ye Han
- Department of Business Administration, College of Business, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Haipeng Shen
- Faculty of Business and Economics, University of Hong Kong, Hong Kong, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Frank Ma
- Medical Research Center, DotHealth, Shanghai, China
| | - Hao Li
- Big data and AI dempartment, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, Shanghai, China
| |
Collapse
|
22
|
Affiliation(s)
- Patrick D Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
23
|
Wong YS, Sung SF, Wu CS, Hsu YC, Su YH, Hung LC, Ong CT. The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:257-263. [PMID: 32021109 PMCID: PMC6974114 DOI: 10.2147/dddt.s235388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022]
Abstract
Background Intravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1–2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT). Aim This study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Methods In this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0–5), moderate (6–14), severe (15–24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups. Results In patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose. Conclusion In severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.
Collapse
Affiliation(s)
- Yi-Sin Wong
- Department of Family Medicine, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Sheng-Feng Sung
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Chi-Shun Wu
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yung-Chu Hsu
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yu-Hsiang Su
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Ling-Chien Hung
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Cheung-Ter Ong
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| |
Collapse
|
24
|
Evaluation of sex differences in acid/base and electrolyte concentrations in acute large vessel stroke. Exp Neurol 2020; 323:113078. [DOI: 10.1016/j.expneurol.2019.113078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/26/2022]
|
25
|
Affiliation(s)
- Patrick D Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
26
|
Truc My Nguyen T, van de Stadt SI, Groot AE, Wermer MJ, den Hertog HM, Droste HM, van Zwet EW, van Schaik SM, Coutinho JM, Kruyt ND. Thrombolysis related symptomatic intracranial hemorrhage in estimated versus measured body weight. Int J Stroke 2019; 15:159-166. [PMID: 31092150 PMCID: PMC7045279 DOI: 10.1177/1747493019851285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In acute ischemic stroke, under- or overestimation of body weight can lead to dosing errors of recombinant tissue plasminogen activator with consequent reduced efficacy or increased risk of hemorrhagic complications. Measurement of body weight is more accurate than estimation of body weight but potentially leads to longer door-to-needle times. Our aim was to assess if weight modality (estimation of body weight versus measurement of body weight) is associated with (i) symptomatic intracranial hemorrhage rate, (ii) clinical outcome, and (iii) door-to-needle times. METHODS Consecutive patients treated with intravenous thrombolysis between 2009 and 2016 from 14 hospitals were included. Baseline characteristics and outcome parameters were retrieved from medical records. We defined symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study (ECASS)-III definition and clinical outcome was assessed with the modified Rankin Scale. The association of weight modality and outcome parameters was estimated with regression analyses. RESULTS A total of 4801 patients were included. Five hospitals used measurement of body weight (n = 1753), six hospitals used estimation of body weight (n = 2325), and three hospitals (n = 723) changed from estimation of body weight to measurement of body weight during the study period. In 2048 of the patients (43%), measurement of body weight was used and in 2753 (57%), estimation of body weight. In the measurement of body weight group, an inbuilt weighing bed was used in 1094 patients (53%) and a patient lift scale in 954 patients (47%). In the estimation of body weight group, policy regarding estimation was similar. Estimation of body weight was not associated with increased symptomatic intracranial hemorrhage risk (adjusted odds ratio = 1.16; 95% confidence interval 0.83-1.62) or favorable outcome (adjusted odds ratio = 0.99; 95% confidence interval 0.82-1.21), but it was significantly associated with longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed (adjusted B = 3.57; 95% confidence interval 1.33-5.80) and shorter door-to-needle times compared to measurement of body weight using a patient lift scale (-3.96; 95% confidence interval -6.38 to -1.53). CONCLUSION We did not find evidence that weight modality (estimation of body weight versus measurement of body weight) to determine recombinant tissue plasminogen activator dose in intravenous thrombolysis eligible patients is associated with symptomatic intracranial hemorrhage or clinical outcome. We did find that estimation of body weight leads to longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed and to shorter door-to-needle times compared to measurement of body weight using a patient lift scale.
Collapse
Affiliation(s)
- T Truc My Nguyen
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Stephanie Iw van de Stadt
- Department of Neurology, University Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Adrien E Groot
- Department of Neurology, University Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Hanneke M Droste
- Department of Neurology, Isala hospital, Zwolle, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sander M van Schaik
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.,Zaans Medical Centre, Zaandam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, University Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| |
Collapse
|
27
|
Zivelonghi C, Tamburin S. Mechanical thrombectomy for acute ischemic stroke: the therapeutic window is larger but still "time is brain». FUNCTIONAL NEUROLOGY 2019; 33:5-6. [PMID: 29633691 DOI: 10.11138/fneur/2018.33.1.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
28
|
Ghandehari K, Shahedi S, Valipour Z, Sobhani MR, Salehian H, Nazemian S, Rezae M. Review Study: Intravenous Thrombolysis, Time Window, Dosage, and Off-Label. CASPIAN JOURNAL OF NEUROLOGICAL SCIENCES 2018. [DOI: 10.29252/cjns.4.15.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
29
|
Majidi S, Leon Guerrero CR, Burger KM, Sigounas D, Olan WJ, Qureshi AI. Fixed Dose IV rt-PA and Clinical Outcome in Ischemic Stroke Patients With Body Weight >100 kg: Pooled Data From 3 Randomized Clinical Trials. J Stroke Cerebrovasc Dis 2018; 27:2843-2848. [PMID: 30076113 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/27/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND AND PURPOSE The ASA/AHA guidelines recommend a fixed dose of 90 mg of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) for acute stroke patients weighing more than 100 kg. We aimed to determine if body weight >100 kg (and receiving <0.9 mg/kg dose) independently influence patient clinical outcomes following IV rt-PA treatment. METHODS We pooled data from IV rt-PA treatment arms from 3 randomized controlled clinical trials; NINDS IV rt-PA study, Interventional Management of Stroke 3 and ALIAS (part 1 and 2). Baseline characteristic, hospital course and 90-day mRS were compared between patients >100 kg and those ≤100 kg body weight. Multivariate logistic regression model was used to identify the independent effect of >100 kg body weight on favorable 90-day outcome (defined as mRS 0-2), the rate of symptomatic intracranial hemorrhage, and poor 90-day outcome (mRS 4-6). RESULTS Among 873 patients treated with IV rt-PA, a total of 105 (12%) subjects had body weight >100 kg. Compared with patients having ≤100 kg body weight, the rate of favorable outcome at 90 days was not significantly different among patients with >100 kg body weight (OR: 0.99; 95% CI: 0.91-1.01; p=0.91) , after adjusting for potential confounders. The ordinal analysis did not show any significant shift in the distribution of 90-day mRS score in patients with >100 kg body weight (OR, 0.93; 95% CI, 0.64-1.37; P = 0.74) CONCLUSIONS: There was no reduction in the rate of favorable outcome in patients with acute ischemic stroke with body weight >100 kg who received <0.9 mg/kg dose of IV rt-PA. Our results support the current recommendations in the ASA/AHA guidelines.
Collapse
Affiliation(s)
- Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai.
| | | | | | | | - Wayne J Olan
- George Washington University, Washington, District of Columbia.
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Institute, St Cloud, Minnesota.
| |
Collapse
|
30
|
Xu N, Chen Z, Zhao C, Xue T, Wu X, Sun X, Wang Z. Different doses of tenecteplase vs alteplase in thrombolysis therapy of acute ischemic stroke: evidence from randomized controlled trials. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:2071-2084. [PMID: 30013325 PMCID: PMC6038859 DOI: 10.2147/dddt.s170803] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Recent studies showed inconsistent results of tenecteplase vs alteplase for acute ischemic stroke (AIS) with safety and efficacy. Methods A meta-analysis was performed to explore the value of tenecteplase and alteplase in AIS treatment. Medline, Embase, and Cochrane Library from January 2001 to April 2018 were searched for randomized controlled trials (RCTs) with tenecteplase vs alteplase for AIS. Results The primary outcomes were early neurological improvement at 24 h and functional outcome at 3 months. We pooled 1,390 patients from four RCTs. Tenecteplase showed a significant early neurological improvement (P=0.035) compared with alteplase. In addition, tenecteplase showed a neutral effect on excellent outcome (P=0.309), good functional outcome (P=0.275), and recanalization (P=0.3). No significant differences in safety outcomes were demonstrated. In subgroup analysis, 0.25 mg/kg dose of tenecteplase showed a significantly increased early neurological improvement (P<0.001). In serious stroke at baseline (National Institutes of Health Stroke Scale [NIHSS] >12) subgroup, tenecteplase showed a dramatic early neurological improvement (P=0.002) and low risks of any intracranial hemorrhage (ICH) (P=0.027). Conclusion Tenecteplase provided better early neurological improvement than alteplase. The 0.25 mg/kg dose of tenecteplase subgroup specially showed better early neurological improvement and lower any ICH tendency than that of alteplase. In addition, in serious stroke at baseline subgroup, tenecteplase showed a lower risk of any ICH.
Collapse
Affiliation(s)
- Na Xu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ; .,State Key Laboratory of Medical Neurobiology, Institute of Brain Sciences and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, People's Republic of China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ;
| | - Chongshun Zhao
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ;
| | - Tao Xue
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ;
| | - Xin Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ;
| | - Xiaoou Sun
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ;
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China, ;
| |
Collapse
|
31
|
Chang JY, Park H, Jang SY, Jung S, Bae HJ, Kwon OK, Han MK. Early partial recanalization after intravenous thrombolysis leads to prediction of favorable outcome in cases of acute ischemic stroke with major vessel occlusion. J Clin Neurosci 2017; 46:30-36. [DOI: 10.1016/j.jocn.2017.08.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 08/15/2017] [Indexed: 11/16/2022]
|
32
|
Nam H, Kim E, Kim S, Kim Y, Kim J, Lee H, Nam C, Heo J. Prediction of thrombus resolution after intravenous thrombolysis assessed by CT-based thrombus imaging. Thromb Haemost 2017; 107:786-94. [DOI: 10.1160/th11-08-0585] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 01/05/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe degree of thrombus resolution directly indicates the effectiveness of a thrombolytic drug. We investigated the degree of thrombus resolution and factors associated with thrombus resolution after intravenous (IV) recombinant tissue plasminogen activator (rt-PA) using thin-section noncontrast computed tomography (NCT). Thin-section NCTs were performed before and immediately after IV rt-PA infusion in acute stroke patients. The thrombus volume and Hounsfield unit were measured using three-dimensional imaging software. Immediate recanalisation was assessed immediately after IV rt-PA infusion using CT angiography. During a three-year study period, 130 patients were prospectively enrolled. On baseline thin-section NCT, no thrombi were found in 30 patients (23%). Among the 100 patients with confirmed thrombus, the median volume decreased by 20% on the follow-up NCT. The thrombus was completely resolved in 8%. Of note, an increase in thrombus volume was observed in 20 patients. Independent predictors of thrombus resolution were total rt-PA dose, thrombus location in the M2 segment of the middle cerebral artery, and time from baseline to follow-up NCT. Thrombus resolution increased by 9% per each 10-mg increase in rt-PA (p = 0.045). Immediate complete recanalisation was achieved in 12% of patients. Total dose of rt-PA was independently associated with complete recanalisation [odds ratio [OR] 4.52, 95% confidence interval [CI] 1.345–15.184) and good functional outcome at three months (modified Rankin scale score <3, OR 2.34, 95% CI 1.104–4.962). In conclusion, rt-PA dose was associated with the degree of thrombus resolution, immediate complete recanalisation, and good outcome at three months. CT-based thrombus imaging may be helpful in determining thrombolysis effectiveness.
Collapse
|
33
|
Tan G, Wang H, Chen S, Chen D, Zhu L, Xu D, Zhang Y, Liu L. Efficacy and safety of low dose alteplase for intravenous thrombolysis in Asian stroke patients: a meta-analysis. Sci Rep 2017; 7:16076. [PMID: 29167555 PMCID: PMC5700077 DOI: 10.1038/s41598-017-16355-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/10/2017] [Indexed: 02/05/2023] Open
Abstract
Whether low dose alteplase is comparable to standard dose in efficacy and safety for intravenous thrombolysis (IVT) in Asian stroke patients remains unverified. PubMed, EMBASE, and Cochrane Library Database from the beginning to June 30, 2017 were searched. IVT efficacy was measured by favorable outcome (modified Rankin Scale scores of 0–1) at 3 months, and safety measured by mortality within 3 months and symptomatic intracerebral hemorrhage (SICH). Pooled estimates were conducted using fixed- or random-effects model depending on heterogeneity. For SICH, studies were pooled separately according to different definitions. Twelve studies involving 7,905 participants were included. No association was found between alteplase dose and favorable outcome (OR = 0.94, 95% CI 0.78–1.14, P = 0.5; heterogeneity: Phetero = 0.01, I2 = 57.3%) and mortality (OR = 0.87, 95% CI 0.74–1.02, P = 0.08; Phetero = 0.83, I2 = 0) using random- and fixed-effects models, respectively. Low dose alteplase was associated with lower SICH as defined by the National Institute of Neurological Disorders and Stroke study (OR = 0.79, 95% CI 0.64–0.99, P = 0.04; Phetero = 0.57, I2 = 0) using fixed-effects model. Subgroup and sensitivity analysis could change the results significantly. Current limited evidence was insufficient to support the speculation that low dose alteplase was comparable to standard dose in thrombolytic efficacy and safety in Asian stroke patients.
Collapse
Affiliation(s)
- Ge Tan
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Haijiao Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Sihan Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Lina Zhu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Da Xu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Yu Zhang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China.
| |
Collapse
|
34
|
Baharoglu MI, Brand A, Koopman MM, Vermeulen M, Roos YB. Acute Management of Hemostasis in Patients With Neurological Injury. Transfus Med Rev 2017; 31:236-244. [DOI: 10.1016/j.tmrv.2017.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 01/28/2023]
|
35
|
Impact of Tissue Plasminogen Activator Dosing on Patients Weighing More Than 100 kg on 3-Month Outcomes in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1041-1046. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/03/2016] [Accepted: 12/21/2016] [Indexed: 11/23/2022] Open
|
36
|
Abraham SV, Thaha F, Krishnan SV, Shajan A, Balakrishnan JM, Palatty BU. The need for a population-based, dose optimization study for recombinant tissue plasminogen activator in acute ischemic stroke: A study from a tertiary care teaching hospital from South India. Ann Indian Acad Neurol 2017; 20:36-40. [PMID: 28298840 PMCID: PMC5341265 DOI: 10.4103/0972-2327.199911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context: The guideline recommended dose of intravenous (i.v) recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke is 0.9 mg/kg in the European and American populations. In Asiatic population, some studies have shown that a lower dose of i.v rt-PA is equally efficacious. Aims: To assess if there is a need for a dose optimization for i.v rt-PA study among Indians. Setting and Design: A prospective, observational database of acute stroke cases that presented to a tertiary care institute over a period of 1 year was made. Methods: The data procured using a prestructured elaborate pro forma. Based on the dose of rt-PA received, the individuals were divided into three groups; Group 1 (0.6–0.7 mg/kg), Group 2 (0.7–0.8 mg/kg), and Group 3 (0.8–0.9 mg/kg). Improvement was assessed in each group and between the thrombolysed and nonthrombolysed individuals. Statistical Analysis Used: The nonparametric Mann–Whitney U-test (Wilcoxon rank-sum test) was applied for assessing improvement of National Institutes of Health Stroke Scale score with significance level of α < 0.05 (P < 0.012) and compliance level at 95%. Results: Between the thrombolysed (n = 46) and nonthrombolysed (n = 113) group, there was a statistically significant neurological improvement in the thrombolysed group. Clinical improvement was noted in 75%, 85.7%, and 66.7% of individuals receiving rt-PA in Groups 1, 2, and 3, respectively. Four out of the five who developed a clinically significant intracranial hemorrhage were thrombolysed at a dose of 0.8–0.9 mg/kg rt-PA (Group 3). Conclusion: There is a need for a properly randomized, dose optimization study of i.v rt-PA in the Indian subcontinent.
Collapse
Affiliation(s)
- Siju V Abraham
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Fazil Thaha
- Department of Neurology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - S Vimal Krishnan
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Athulya Shajan
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | | | - Babu Urumese Palatty
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| |
Collapse
|
37
|
Abstract
Recent advancements in stem cell biology and neuromodulation have ushered in a battery of new neurorestorative therapies for ischemic stroke. While the understanding of stroke pathophysiology has matured, the ability to restore patients' quality of life remains inadequate. New therapeutic approaches, including cell transplantation and neurostimulation, focus on reestablishing the circuits disrupted by ischemia through multidimensional mechanisms to improve neuroplasticity and remodeling. The authors provide a broad overview of stroke pathophysiology and existing therapies to highlight the scientific and clinical implications of neurorestorative therapies for stroke.
Collapse
Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
38
|
Synchronous cardiocerebral infarction in the era of endovascular therapy: which to treat first? J Thromb Thrombolysis 2017; 44:104-111. [DOI: 10.1007/s11239-017-1484-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
39
|
Dong Y, Cao W, Cheng X, Fang K, Wu F, Yang L, Xie Y, Dong Q. Low-dose intravenous tissue plasminogen activator for acute ischaemic stroke: an alternative or a new standard? Stroke Vasc Neurol 2016; 1:115-121. [PMID: 28959472 PMCID: PMC5435201 DOI: 10.1136/svn-2016-000033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 08/26/2016] [Accepted: 08/31/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND With the recent publication of a large clinical trial on the use of a lower dose of intravenous (IV) tissue plasminogen activator (tPA) for acute ischaemic stroke (AIS), the concept of using a different dose has been debated. We intend to review the literature on using a lower dose of IV tPA and gain a better understanding of the impact of different IV doses on the treatment of patients with AIS. METHODS A comprehensive literature search of the related topics in PubMed, EMBASE, Web of Science and MEDLINE was carried out. Key words used include low dose IV tPA, thrombolysis, Alteplace and tPA for AIS. Findings were tabulated according to the size of the cohort studied, outcome, adverse event and level of evidence. The results of all studies using lower doses were analysed for efficacy and adverse events. RESULTS From 1992 to 2016, there were 23 trials that included 10 950 patients published on the use of lower doses of IV tPA for AIS. Doses ranged from 0.5, 0.6, 0.75 to 0.85 mg/kg. Most were observational, retrospective and registry studies. One was a prospective open-label randomised controlled trial. 13 trials combined lower doses of IV tPA with a glycoprotein IIb/IIIa inhibitor or thrombectomy. Patients treated with lower doses of IV tPA showed a trend of lower rate of symptomatic intracranial haemorrhage and mortality at 3 months but slightly more disability. CONCLUSIONS Lower doses of IV tPA showed less haemorrhagic events but were not more effective compared with the standard dose. The optimal low dose of IV tPA remains unclear. Patients with AIS with a high risk of developing sypmtomatic intracranial haemorrhage might benefit from lower dose IV tPA, such as 0.6 mg/kg.
Collapse
Affiliation(s)
- Yi Dong
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Wenjie Cao
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Xin Cheng
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Kun Fang
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Fei Wu
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Lumeng Yang
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Yanan Xie
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| | - Qiang Dong
- The Department of Neurology, Huashan Hospital, Fudan University, Shanghai, Shanghai, China
| |
Collapse
|
40
|
Holodinsky JK, Yu AYX, Assis ZA, Al Sultan AS, Menon BK, Demchuk AM, Goyal M, Hill MD. History, Evolution, and Importance of Emergency Endovascular Treatment of Acute Ischemic Stroke. Curr Neurol Neurosci Rep 2016; 16:42. [PMID: 27021771 DOI: 10.1007/s11910-016-0646-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
More than 800,000 people in North America suffer a stroke each year, with ischemic stroke making up the majority of these cases. The outcomes of ischemic stroke range from complete functional and cognitive recovery to severe disability and death; outcome is strongly associated with timely reperfusion treatment. Historically, ischemic stroke has been treated with intravenous thrombolytic agents with moderate success. However, five recently published positive trials have established the efficacy of endovascular treatment in acute ischemic stroke. In this review, we will discuss the history of stroke treatments moving from various intravenous thrombolytic drugs to intra-arterial thrombolysis, early mechanical thrombectomy devices, and finally modern endovascular devices. Early endovascular therapy failures, recent successes, and implications for current ischemic stroke management and future research directions are discussed.
Collapse
Affiliation(s)
- Jessalyn K Holodinsky
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
| | - Amy Y X Yu
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zarina A Assis
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abdulaziz S Al Sultan
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
41
|
Abstract
In the pivotal clinical trials of intravenous tissue plasminogen activator (TPA) therapy, a low rate of early arterial recanalization was suspected because only a few stroke patients may have had early dramatic clinical improvement. Tissue plasminogen activator activity can be enhanced with ultrasound, including 2 MHz transcranial Doppler (TCD). Transcranial Doppler identifies residual blood flow signals around thrombi, and, by delivering mechanical pressure waves, exposes more thrombus surface to circulating TPA. For the first time in clinical medicine, the international multicenter CLOTBUST trial showed that ultrasound enhances the thrombolytic activity of a drug in humans, thereby confirming multidisciplinary experimental research conducted worldwide for the past 30 years. In the CLOTBUST trial, the dramatic clinical recovery from stroke coupled with complete recanalization within 2 h after TPA bolus occurred in 25% of patients treated with TPA+TCD compared with 8% who received TPA alone ( P = 0·02). Complete clearance of a thrombus and dramatic recovery of brain functions during treatment are feasible goals for ultrasound-enhanced thrombolysis that can lead to sustained recovery. An early boost in brain perfusion seen in the target CLOTBUST group resulted in a trend of 13% more patients achieving favorable outcome at 3 months. To further enhance the ability of TPA to break up thrombi, current ongoing clinical trials include phase II studies of 2 MHz TCD with ultrasound contrast agents or (microbubbles): TCD+TPA+Levovist; TCD+TPA+MRX nano-platform (C3F8). Intra-arterial TPA delivery can be enhanced with 1·7–2·1 MHz pulsed wave ultrasound (EKOS catheter, IMS trial). Dose escalation studies of microbubbles, ultrasound exposure, and the development of an operator-independent ultrasound device are underway.
Collapse
|
42
|
Huang X, MacIsaac R, Thompson JLP, Levin B, Buchsbaum R, Haley EC, Levi C, Campbell B, Bladin C, Parsons M, Muir KW. Tenecteplase versus alteplase in stroke thrombolysis: An individual patient data meta-analysis of randomized controlled trials. Int J Stroke 2016; 11:534-43. [DOI: 10.1177/1747493016641112] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 01/17/2016] [Indexed: 11/16/2022]
Abstract
Background Tenecteplase, a modified plasminogen activator with higher fibrin specificity and longer half-life, may have advantages over alteplase in acute ischemic stroke thrombolysis. Aims We undertook an individual patient data meta-analysis of randomized controlled trials that compared alteplase with tenecteplase in acute stroke. Methods Eligible studies were identified by a MEDLINE search, and individual patient data were acquired. We compared clinical outcomes including modified Rankin Scale at three months, early neurological improvement at 24 h, intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality at three months between all dose tiers of tenecteplase and alteplase. Results Three relevant studies (Haley et al., Parsons et al., and ATTEST) included 291 patients and investigated three doses of tenecteplase (0.1, 0.25, 0.4 mg/kg). There were no differences between any dose of tenecteplase and alteplase for either efficacy or safety end points. Tenecteplase 0.25 mg/kg had the greatest odds to achieve early neurological improvement (OR [95%CI] 3.3 [1.5, 7.2], p = 0.093), excellent functional outcome (modified Rankin Scale 0–1) at three months (OR [95%CI] 1.9 [0.8, 4.4], p = 0.28), with reduced odds of intracerebral hemorrhage (OR [95%CI] 0.6 [0.2, 1.8], P = 0.43) compared with alteplase. Only 19 patients were treated with tenecteplase 0.4 mg/kg, which showed increased odds of symptomatic intracerebral hemorrhage compared with alteplase (OR [95% CI] 6.2 [0.7, 56.3]). Conclusions While no significant differences between tenecteplase and alteplase were found, point estimates suggest potentially greater efficacy of 0.25 and 0.1 mg/kg doses with no difference in symptomatic intracerebral hemorrhage, and potentially higher symptomatic intracerebral hemorrhage risk with the 0.4 mg/kg dose. Further investigation of 0.25 mg/kg tenecteplase is warranted.
Collapse
Affiliation(s)
- Xuya Huang
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Bruce Levin
- Department of Biostatistics, Columbia University, New York, USA
| | | | - E Clarke Haley
- Department of Neurology, University of Virginia, Charlottesville, USA
| | - Christopher Levi
- Department of Neurology, University of Newcastle, Newcastle, Australia
| | - Bruce Campbell
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Christopher Bladin
- The Department of Neurosciences, Monash University, Melbourne, Australia
| | - Mark Parsons
- Department of Neurology, University of Newcastle, Newcastle, Australia
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| |
Collapse
|
43
|
Sun Z, Yue Y, Leung C, Chan M, Gelb A. Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review. Br J Anaesth 2016; 116:328-38. [DOI: 10.1093/bja/aev452] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
|
44
|
Intravenous Thrombolysis. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
|
45
|
Liu MD, Ning WD, Wang RC, Chen W, Yang Y, Lin Y, Hu DH, Lau WB, Qu Y. Low-Dose Versus Standard-Dose Tissue Plasminogen Activator in Acute Ischemic Stroke in Asian Populations: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e2412. [PMID: 26717400 PMCID: PMC5291641 DOI: 10.1097/md.0000000000002412] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Recent studies have investigated the most efficacious dose of intravenous tissue plasminogen activator (IV-tPA) for acute ischemic stroke (AIS) patients. There remains no definitive consensus concerning the superior efficacious IV-tPA dose (standard- vs. low-dose), prompting us to perform a meta-analysis comparing the efficacy and safety profile of standard- versus low-dose IV-tPA.We identified relevant studies pertaining to the specific aim of our meta-analysis by searching PubMed and EMBASE (January 1990-September 2015) Either a fixed- or random-effects model was employed (dependent upon data heterogeneity) to analyze the efficacy and safety outcome.Ten cohort studies involving 4389 sum patients were included in the meta-analysis. By using the random-effects model, the meta-analysis indicated no statistically significant difference in favorable functional outcome (modified Rankin scale 0-1) at 3 months (heterogeneity: χ = 17.45, P = 0.04, I = 48%; OR: 0.88 [95% CI: 0.71-1.11]; P = 0.28) and incidence of symptomatic intracranial hemorrhage (SICH) (heterogeneity: χ = 14.41, P = 0.11, I = 38%; OR: 1.19 [95% CI: 0.76 to 1.87]; P = 0.45) between the standard- and low-dose groups. The fixed-effects model demonstrated no significant difference in mortality within 3 months (heterogeneity: χ = 6.73, P = 0.57, I = 0%; OR: 0.91 [95% CI: 0.73-1.12]; P = 0.37) between the standard- and low-dose groups.Low-dose IV-tPA is comparable to standard-dose IV-tPA in both efficacy (favorable functional outcome) and safety (SICH and mortality). Confirmation of these findings through randomized trials is warranted.
Collapse
Affiliation(s)
- Meng-Dong Liu
- From the Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, P.R. China (M-DL, D-HH); Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, P.R. China (WC, R-CW, YY); Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, P.R. China (W-DN, YQ); Department of Scientific Research, Fourth Military Medical University, Xi'an, P.R. China (YL); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (W-BL)
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Cheng NT, Kim AS. Intravenous Thrombolysis for Acute Ischemic Stroke Within 3 Hours Versus Between 3 and 4.5 Hours of Symptom Onset. Neurohospitalist 2015; 5:101-9. [PMID: 26288668 DOI: 10.1177/1941874415583116] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Data from randomized clinical trials have supported the safety and efficacy of intravenous tissue-type plasminogen activator (IV tPA) for acute ischemic stroke when administered within 3 hours of symptom onset, and regulatory approvals for this indication have been in place for almost 20 years. However, recent clinical trials have provided evidence that IV tPA may be safe and effective in selected patients up to 4.5 hours after symptom onset, thereby increasing the proportion of patients that may be eligible for treatment. Although professional organizations in the United States and many regulatory agencies internationally have supported this expanded time window for IV tPA, the US Food and Drug Administration has declined to approve this expanded indication and so this use of IV tPA has remained off-label in the United States. Here we review the current evidence for IV tPA in the standard and the expanded time windows and the data on current clinical practice in the United States as it relates to IV tPA treatment for acute stroke within 3 to 4.5 hours of symptom onset.
Collapse
Affiliation(s)
- Natalie T Cheng
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Anthony S Kim
- Department of Neurology, University of California, San Francisco, CA, USA
| |
Collapse
|
47
|
Anderson CS, Woodward M, Arima H, Chen X, Lindley RI, Wang X, Chalmers J. Statistical analysis plan for evaluating low- vs. standard-dose alteplase in the ENhanced Control of Hypertension and Thrombolysis strokE stuDy (ENCHANTED). Int J Stroke 2015; 10:1313-5. [PMID: 26283139 PMCID: PMC5324659 DOI: 10.1111/ijs.12602] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/22/2015] [Indexed: 12/01/2022]
Abstract
Background The ENhanced Control of Hypertension And Thrombolysis strokE stuDy trial is a 2 × 2 quasi‐factorial active‐comparison, prospective, randomized, open, blinded endpoint clinical trial that is evaluating in thrombolysis‐eligible acute ischemic stroke patients whether: (1) low‐dose (0·6 mg/kg body weight) intravenous alteplase has noninferior efficacy and lower risk of symptomatic intracerebral hemorrhage compared with standard‐dose (0·9 mg/kg body weight) intravenous alteplase; and (2) early intensive blood pressure lowering (systolic target 130–140 mmHg) has superior efficacy and lower risk of any intracerebral hemorrhage compared with guideline‐recommended blood pressure control (systolic target <180 mmHg). Objective To outline in detail the predetermined statistical analysis plan for the ‘alteplase dose arm’ of the study. Methods All data collected by participating researchers will be reviewed and formally assessed. Information pertaining to the baseline characteristics of patients, their process of care, and the delivery of treatments will be classified, and for each item, appropriate descriptive statistical analyses are planned with appropriate comparisons made between randomized groups. For the trial outcomes, the most appropriate statistical comparisons to be made between groups are planned and described. Results A statistical analysis plan was developed for the results of the alteplase dose arm of the study that is transparent, available to the public, verifiable, and predetermined before completion of data collection. Conclusions We have developed a predetermined statistical analysis plan for the ENhanced Control of Hypertension And Thrombolysis strokE stuDy alteplase dose arm which is to be followed to avoid analysis bias arising from prior knowledge of the study findings.
Collapse
Affiliation(s)
- Craig S Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Hisatomi Arima
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia.,Centre for Epidemiologic Research in Asia, Shiga University of Medical Sciences, Shiga University, Shiga, Japan
| | - Xiaoying Chen
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Richard I Lindley
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Xia Wang
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - John Chalmers
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | | |
Collapse
|
48
|
Jacquin GJ, van Adel BA. Treatment of acute ischemic stroke: from fibrinolysis to neurointervention. J Thromb Haemost 2015; 13 Suppl 1:S290-6. [PMID: 26149038 DOI: 10.1111/jth.12971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Thrombolytic therapy with intravenous recombinant tissue plasminogen activator is well established as a beneficial treatment for patients presenting with acute ischemic stroke (AIS). The odds of a favorable clinical outcome (living independently) increase as the time between stroke onset and treatment with IV thrombolysis decreases. However, many patients present with a large clot burden that seldom responds to systemic fibrinolysis. Alternative options include new and emerging endovascular therapies that have recently proven effectiveness at restoring cerebral blood flow to the ischemic brain parenchyma. This review article will briefly outline some of the key evidence for intravenous thrombolysis as well as endovascular therapy for AIS.
Collapse
Affiliation(s)
- G J Jacquin
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - B A van Adel
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Diagnostic Imaging, Department of Radiology, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
49
|
García-Pastor A, Díaz-Otero F, Funes-Molina C, Benito-Conde B, Grandes-Velasco S, Sobrino-García P, Vázquez-Alén P, Fernández-Bullido Y, Villanueva-Osorio JA, Gil-Núñez A. Tissue plasminogen activator for acute ischemic stroke: calculation of dose based on estimated patient weight can increase the risk of cerebral bleeding. J Thromb Thrombolysis 2015; 40:347-52. [DOI: 10.1007/s11239-015-1232-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
50
|
Huang Y, Sharma VK, Robinson T, Lindley RI, Chen X, Kim JS, Lavados P, Olavarría V, Arima H, Fuentes S, Nguyen HT, Lee TH, Parsons MW, Levi C, Demchuk AM, Bath PMW, Broderick JP, Donnan GA, Martins S, Pontes-Neto OM, Silva F, Pandian J, Ricci S, Stapf C, Woodward M, Wang J, Chalmers J, Anderson CS. Rationale, Design, and Progress of the ENhanced Control of Hypertension ANd Thrombolysis Stroke Study (ENCHANTED) Trial: An International Multicenter 2 × 2 Quasi-Factorial Randomized Controlled Trial of Low- vs. Standard-Dose rt-PA and Early Intensive vs. Guideline-Recommended Blood Pressure Lowering in Patients with Acute Ischaemic Stroke Eligible for Thrombolysis Treatment. Int J Stroke 2015; 10:778-88. [DOI: 10.1111/ijs.12486] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/08/2015] [Indexed: 11/27/2022]
Abstract
Rationale Controversy exists over the optimal dose of intravenous (iv) recombinant tissue plasminogen activator (rt-PA) and degree of blood pressure (BP) control in acute ischaemic stroke (AIS). Asian studies suggest low-dose (0·6 mg/kg) is more efficacious than standard-dose (0·9 mg/kg) iv rt-PA, and guidelines recommend reducing systolic BP to <185 mmHg before and <180 mmHg after use of iv rt-PA, despite observational studies indicating better outcomes at much lower (<140 mmHg) systolic BP levels in this patient group. Aims The study aims to assess in thrombolysis-eligible AIS patients whether: (i) low-dose (0·6 mg/kg body weight; maximum 60 mg) iv rt-PA has non-inferior efficacy and lower risk of symptomatic intracerebral haemorrhage (sICH) compared to standard-dose (0·9 mg/kg body weight; maximum 90 mg) iv rt-PA; and (ii) early intensive BP lowering (systolic target 130–140 mmHg) has superior efficacy and lower risk of any ICH compared to guideline-recommended BP control (systolic target < 180 mmHg). Design The ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED) trial is an independent, 2 × 2 quasi-factorial, active-comparison, prospective, randomized, open blinded endpoint (PROBE), clinical trial that is evaluating Arm [A] ‘rt-PA dose’ and/or Arm [B] ‘BP control’, using central Internet randomization and data collection in patients fulfilling local criteria for thrombolysis and clinician uncertainty over the study treatments. The treatment arms will be analyzed separately. Study outcomes The primary study outcome in both trial Arms is death or disability according to the modified Rankin scale (mRS, scores 2–6) assessed at 90 days. Secondary outcomes include sICH, any ICH, a shift (‘improvement’) in function across mRS scores, separately on death and disability, early neurological deterioration, recurrent major vascular events, health-related quality of life, length of hospital stay, need for permanent residential care, and health care costs. Results Following launch of the trial in February 2012, the study has recruited more than 2500 patients across a global network of approximately 100 sites in 15 countries. The required sample sizes are 3300 for Arm [A] and 2300 for Arm [B], which will provide >90% power to detect non-inferiority of low-dose iv rt-PA and superiority of intensive BP lowering on the primary clinical outcome, respectively. Conclusions Low-dose iv rt-PA and early intensive BP lowering could provide more affordable and safer use of thrombolysis treatment for patients with AIS worldwide.
Collapse
Affiliation(s)
- Yining Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Vijay K. Sharma
- Division of Neurology, Department of Medicine, National University Hospital and YLL School of Medicine, National University of Singapore, Singapore
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Unit, University of Leicester University, Leicester, UK
| | - Richard I. Lindley
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Jong Sung Kim
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Pablo Lavados
- Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
- Universidad de Chile, Santiago, Chile
| | - Verónica Olavarría
- Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Hisatomi Arima
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Sully Fuentes
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | | | - Tsong-Hai Lee
- Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Mark W. Parsons
- John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Christopher Levi
- John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Philip M. W. Bath
- Stroke trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Geoffrey A. Donnan
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio grande do Sul, Rio Grande do Sul, Brazil
| | - Octavio M. Pontes-Neto
- Stroke Service — Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto School of Medicine, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | | | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, India
| | - Stefano Ricci
- Direttore, UO Neurologia, USL Umbria 1, Sedi di Città di Castello e Branca, Italy
| | - Christian Stapf
- Department of Neurology, APHP — Hôpital Lariboisière and DHU NeuroVasc Paris — Sorbonne, Univ Paris Diderot — Sorbonne Paris Cité, Paris, France
| | - Mark Woodward
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Jiguang Wang
- The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao-tong University School of Medicine, Shanghai, China
| | - John Chalmers
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | | |
Collapse
|