Combined intravenous and intra-arterial recombinant tissue plasminogen activator in acute ischemic stroke

Xuesaitong oral preparation as adjuvant therapy for treating acute cerebral infarction: A systematic review and meta-analysis of randomized controlled trials

ETHNOPHARMACOLOGICAL RELEVANCE

Cerebral infarction is the second leading cause of death and the third most common cause of disability. The use of anti-platelet aggregation drugs is prone to bleeding, liver and kidney damage, gastrointestinal reactions, and is not suitable for patients to take for a long time. Xuesaitong oral preparations (XSTOP), a traditional Chinese medicine formula, has shown therapeutic effect on treating cerebral infarction based on the clinical practice and pharmacological mechanism.

AIM OF THE STUDY

The study aims to evaluate the effectiveness and safety of XSTOP combined with conventional treatment (CT) in treatment of acute cerebral infarction (ACI), and to provide the reliable evidence for clinical application.

MATERIALS AND METHODS

We performed a literature search in Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, PubMed, EMBASE, Cochrane Library and Web of Science from their inceptions to August 2021. Systematic searches for randomized controlled trials (RCTs) of XSTOP in treatment of ACI. Odds ratio (OR) or mean difference (MD) with their 95% confidence interval was calculated between with and without XSTOP therapy. Cochrane risk of bias tool was used to evaluate the methodological quality of the included trials.

RESULTS

Eight RCTs involving 827 patients were included in this meta-analysis. By comparing XSTOP plus conventional treatment with conventional treatment alone, the meta-analysis gave the following results: (1) Total effective rate (OR = 4.53, 95% CI[2.85, 7.19], P < 0.0001); (2) National Institutes of Health Stroke Scale (NIHSS) score (MD = -3.22, 95% CI[-4.52, -1.92], P＜0.00001); (3) Plasma viscosity (PV) (MD = -0.74, 95%CI [-0.96, -0.51], P＜0.00001), hole blood high-cut viscosity (HBV) (MD = -0.63, 95%CI [-0.73, -0.53], P = 0.84), whole blood low-cut viscosity (LBV) (MD = -0.37, 95%CI [-0.56, -0.19], P = 0.96), fibrinogen (FIB) (MD = -23.78, 95%CI [-28.57, -18.99], P = 1.00), hematocrit (Hct) (MD = -2.76, 95%CI [-3.16, -2.36], P = 0.96); (4) China Stroke Scale (CSS) score (MD = -6.53, 95% CI[-9.07, -3.99], P＜0.00001); (5) No significant adverse reactions were reported; (6) The evidence was downgraded to "very low" quality, according to GRADE system.

CONCLUSION

XSTOP plus CT is conditional recommended to improve the total effective rate, NIHSS score, PV, CSS score, and no serious adverse reactions were noted. The GRADE assessment indicates that the overall certainty quality of evidence is very low. Further large-scale, well-designed and high-quality RCTs are needed to confirm the positive results. As all studies included were conducted in China. It is unclear if the findings of this meta-analysis could be generalized to other populations.

Translation, cross-cultural adaptation, and validation of the Los Angeles Prehospital Stroke Screen for use in Brazil

ABSTRACT Background: Stroke is one of the leading causes of death and neurological disability in the world. Several scales help professionals in the early recognition of the disease. However, none of these were developed in Brazil. Objectives: To translate the Los Angeles Prehospital Stroke Screen (LAPSS) into Brazilian Portuguese, and cross-culturally adapt and validate the scale in a representative sample of the Brazilian population. Methods: This study was carried out in two phases: the first consisted in the translation and cross-cultural validation of the LAPSS, and the second in a cross-sectional study with prospectively collected data in patients with suspected stroke treated in a Brazilian prehospital and referred to a stroke center. Statistical analysis was used to assess the sensitivity, specificity, and accuracy of the scale. Cohen's Kappa coefficient (κ) was used for psychometric assessment. Results: After translation and cross-cultural adaptation, the scale was applied to 86 patients. The scale presented a sensitivity of 83.8%, positive predictive value of 79.50%, specificity of 40.70%, negative predictive value of 47.80%, and accuracy of 77%. Cohen’s kappa coefficient was calculated using data from 26 (30.23%) patients and the results showed excellent inter-rater reliability in the majority of the items (52.96%). Conclusions: The scale was translated and cross-culturally adapted for use in Brazil. The scale presented high sensitivity and accuracy but low specificity, and the Cohen’s kappa demonstrated inter-rater reliability. The greatest difficulties occurred when the evaluation included subjective identifications. The scale excluded patients < 45 years old as stroke suspects.

Quatro anos de experiência no tratamento trombolítico do AVC Isquêmico na cidade de Porto Alegre

Embora o benefício do tratamento trombolítico no AVC isquêmico esteja bem demonstrado, o impacto na população geral de pacientes com AVC ainda é limitado, principalmente devido a estreita janela terapêutica. No Brasil, poucos centros estão estruturados para o uso do rtPA no AVC isquêmico agudo. Nós apresentamos os resultados de 4 anos de experiência em terapia trombolítica, com 173 pacientes tratados em 3 Unidades Vasculares implementadas em hospitais gerais no Sul do Brasil.

Acute Ischaemic Stroke: Management, Recent Advances and Controversies

Acute ischaemic stroke is a major cause of death and disability. It may become an enormous burden to the patients themselves, their families as well as the health care systems. Patients at risk of airway, breathing and circulatory compromise should receive prompt resuscitation. Vital parameters and neurological status should be closely monitored. Attentions to blood pressure, temperature and sugar profile are important. The significance of early and correct diagnosis and subsequent treatment cannot be over-emphasised. There have been tremendous recent advances in different treatment modalities in acute stroke management. Various recanalisation modalities include intravenous and/or intra-arterial thrombolysis, acute defibrinogenation, anti-platelet treatment and anticoagulation. Carotid endarterectomy and endovascular strategies are recommended in selected patients. Advanced neuro-imaging techniques and neuroprotectants are being evaluated. Multidisciplinary stroke teams have been shown to improve patient survival and functional outcome. Pre-defined algorithms and protocols should be in place to expedite smooth and effective delivery of stroke service. Future directions should be aimed at exploring safer recanalisation modalities and extending the limit of the current 3-hour treatment window for thrombolysis.

Low-dose intravenous tissue plasminogen activator for acute ischaemic stroke: an alternative or a new standard?

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.

Drip, Ship, and On-Demand Endovascular Therapy for Acute Ischemic Stroke

BACKGROUND

The "drip and ship" approach can facilitate an early initiation of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) at community hospitals. New endovascular treatment modalities, such as stent retrieval, have further improved the rate of safe and successful recanalization. We assessed the clinical outcomes of on-demand endovascular therapy in patients with AIS who were transported to a comprehensive stroke center under the "drip and ship" paradigm.

METHODS

This retrospective study evaluated prospectively registered patients with acute large vessel occlusions in the anterior circulation who underwent endovascular recanalization after IVT at our regional comprehensive stroke center between January 2011 and April 2014. Clinical outcomes and neuroradiological findings were compared between patients who received IVT at the center (direct visit, DV) and at a community hospital (drip and ship, DS).

RESULTS

Baseline characteristics such as age, initial National Institutes of Health Stroke Scale (NIHSS) score, and risk factors for stroke were similar, and most patients underwent endovascular therapy with a Solitaire stent (81.9% vs. 89.3% for DV and DS, respectively, P = 0.55). The average initial NIHSS score was 12.15 ± 4.1 (12.06 vs. 12.39 for DV and DS, respectively, P = 0.719). The proportions of long-term favorable outcomes (modified Rankin Scale score ≤ 2 at 90 days) and successful recanalization (Thrombolysis in Cerebral Ischemia score ≥ 2b) were not significantly different (P = 0.828 and 0.158, respectively). The mortality rates and occurrences of symptomatic intracerebral hemorrhage were not significantly different (P = 0.999 and 0.267, respectively).

CONCLUSIONS

The "drip and ship" approach with subsequent endovascular therapy is a feasible treatment concept for patients with acute large vessel occlusion in the anterior circulation that could help improve clinical outcomes in patients with AIS.

Efficacy and Safety of Mechanical Thrombectomy in Treating Acute Ischemic Stroke: A Meta Analysis

OBJECTIVES

Mechanical thrombectomy (MT) is a promising treatment for acute ischemic stroke (AIS). But the results of completed trials were contradictory. Hence, we performed a meta-analysis to evaluate the efficacy and safety of MT in treating AIS.

METHODS

Literatures were searched in the databases including Pubmed, Cochrane Library, Web of Science and Ovid-SP. The bias and quality of publications with randomized controlled trials (RCTs) were assessed with the Cochrane collaboration's tool for assessing risk of bias.

RESULTS

Totally 16 publications matched the inclusion criteria, including seven independent RCTs and 2043 AIS patients. The results showed that the recanalization rate and the modified Rankin score of 0-2 at 90 days after treatment were better in MT combining standard care group, but the mortality had no significant difference, even the incidence of intracerebral hemorrhage during follow-up period was worse, as compared with standard care group.

CONCLUSION

MT combining standard care would be an effective and promising treatment for AIS patients according to the present study.

Evolution of endovascular mechanical thrombectomy for acute ischemic stroke

Acute ischemic stroke (AIS) is a common medical problem associated with significant morbidity and mortality worldwide. A small proportion of AIS patients meet eligibility criteria for intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator, and its efficacy for large vessel occlusion is poor. Therefore, an increasing number of patients with AIS are being treated with endovascular mechanical thrombectomy when IVT is ineffective or contraindicated. Rapid advancement in catheter-based and endovascular device technology has led to significant improvements in rates of cerebral reperfusion with these devices. Stentrievers and modern aspiration catheters have now surpassed earlier generation devices in the degree and rapidity of revascularization. This progress has been achieved with no concurrent increase in risk of major complications or mortality, both when used alone or in combination with IVT. The initial randomized controlled trials comparing endovascular therapy to IVT for AIS failed to show superior outcomes with endovascular treatment, but key limitations of each trial may limit the significance of these results to current practice. While endovascular devices and operator experience continue to evolve, we are optimistic that this will be accompanied by improvements in patient outcomes. This review highlights the major endovascular devices used in current practice and the trials which have investigated their efficacy.

MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial

BACKGROUND

Endovascular or intra-arterial treatment (IAT) increases the likelihood of recanalization in patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion. However, a beneficial effect of IAT on functional recovery in patients with acute ischemic stroke remains unproven. The aim of this study is to assess the effect of IAT on functional outcome in patients with acute ischemic stroke. Additionally, we aim to assess the safety of IAT, and the effect on recanalization of different mechanical treatment modalities.

METHODS/DESIGN

A multicenter randomized clinical trial with blinded outcome assessment. The active comparison is IAT versus no IAT. IAT may consist of intra-arterial thrombolysis with alteplase or urokinase, mechanical treatment or both. Mechanical treatment refers to retraction, aspiration, sonolysis, or use of a retrievable stent (stent-retriever). Patients with a relevant intracranial proximal arterial occlusion of the anterior circulation, who can be treated within 6 hours after stroke onset, are eligible. Treatment effect will be estimated with ordinal logistic regression (shift analysis); 500 patients will be included in the trial for a power of 80% to detect a shift leading to a decrease in dependency in 10% of treated patients. The primary outcome is the score on the modified Rankin scale at 90 days. Secondary outcomes are the National Institutes of Health stroke scale score at 24 hours, vessel patency at 24 hours, infarct size on day 5, and the occurrence of major bleeding during the first 5 days.

DISCUSSION

If IAT leads to a 10% absolute reduction in poor outcome after stroke, careful implementation of the intervention could save approximately 1% of all new stroke cases from death or disability annually.

TRIAL REGISTRATION

NTR1804 (7 May 2009)/ISRCTN10888758 (24 July 2012).

Endovascular stroke therapy

BACKGROUND

Following the development of intravenous thrombolysis as a successful treatment for ischaemic stroke, advances in neurointerventional radiology have facilitated endovascular approaches to treatment. This article reviews the available endovascular therapeutic options and their evidence-base.

SUMMARY

Initial studies demonstrated that endovascular treatment of ischaemic stroke with intra-arterial thrombolysis and/or the use of clot-retrieval, thrombus aspiration and stent-retriever devices produced early recanalisation and reperfusion and improved neurological outcome. More recent randomised trials, however, have failed to show translation of recanalisation into successful clinical outcome with 'time to treatment' proving crucial. In this rapidly evolving field, combined therapy incorporating intravenous and intra-arterial thrombolysis in combination with endovascular clot-retrieval has been developed and further studies are expected to yield better evidence to guide the optimal treatment of acute cerebral ischaemia.

Predictors of critical care needs after IV thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE

Intravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. However, rigorous evidence to support this practice is lacking. This study evaluates factors that predict ICU needs after IV thrombolysis.

METHODS

A retrospective chart review was performed for 153 patients who received intravenous tPA for acute ischemic stroke. Data on stroke risk factors, physiologic parameters on presentation, and stroke severity were collected. The timing and nature of an intensive care intervention, if needed, was recorded. Using multivariable logistic regression, we determined factors associated with requiring ICU care.

RESULTS

African American race (Odds Ratio [OR] 8.05, 95% Confidence Interval [CI] 2.65-24.48), systolic blood pressure, and National Institutes of Health Stroke Scale (NIHSS) (OR 1.20 per point increase, 95% CI 1.09-1.31) were predictors of utilization of ICU resources. Patients with an NIHSS≥10 had a 7.7 times higher risk of requiring ICU resources compared to patients who presented with an NIHSS<10 (p<0.001). Most patients with ICU needs developed them prior to the end of tPA infusion (81.0%, 95% CI 68.8-93.1). Only 7% of patients without ICU needs by the end of the tPA infusion went on to require ICU care later on. These patients were more likely to have diabetes mellitus and had significantly higher NIHSS compared to patients without further ICU needs (mean NIHSS 17.3, 95% CI 11.5-22.9 vs. 9.2, 95% CI 7.7-9.6).

CONCLUSION

Race, NIHSS, and systolic blood pressure predict ICU needs following tPA for acute ischemic stroke. We propose that patients without ICU needs by the end of the tPA infusion might be safely monitored in a non-ICU setting if NIHSS at presentation is low.

Predictive value of thrombus attenuation on thin-slice non-contrast CT for persistent occlusion after intravenous thrombolysis

BACKGROUND

In stroke erythrocyte-rich thrombi are more sensitive to intravenous thrombolysis with recombinant tissue plasminogen activator (IV-rtPA) and have higher density on non-contrast CT (NCCT). We investigated the relationship between thrombus density and recanalization and whether persistent occlusions can be predicted by Hounsfield unit (HU) measurements.

METHODS

In 88 IV-rtPA-treated patients with intracranial ICA or MCA occluding thrombus and follow-up imaging, thrombus and contralateral vessel attenuation measurements were performed on thin-slice NCCT. Mean absolute and relative HU were compared between patients with persistent occlusion (modified Thrombolysis in Cerebral Infarction system, grade 0/1/2a) and recanalization (grade 2b/3). Univariate and multivariate (adjusted for stroke subtype, clot burden score, occlusion site and time to thrombolysis) odds ratios for persistent occlusion were calculated. Additional prognostic value for persistent occlusion was estimated by adding HU measurements to the area under the curve (AUC) of known determinants and calculating optimal cut-off values.

RESULTS

Patients with persistent occlusion (n = 19) had significant lower mean HU (absolute 52.2 ± 9.5, relative 1.29 ± 0.20) compared to recanalization (absolute 63.1 ± 10.7, relative 1.54 ± 0.23, both p < 0.0001). Odds ratios for persistent occlusion were 3.1 (95% confidence interval, CI 1.6-6.0) univariate and 3.1 (95% CI 1.7-5.7) multivariate per 10 absolute HU decrease and 3.2 (95% CI 1.6-6.5) univariate and 4.1 (95% CI 1.8-9.1) multivariate per 0.20 relative HU decrease. Attenuation measurements significantly increased the AUC (0.67) of the known determinants to 0.84 (absolute HU) and 0.86 (relative HU). Cut-off values of <56.5 absolute HU and <1.38 relative HU showed optimal predictive values for persistent occlusion.

CONCLUSIONS

Thrombus density is related to recanalization rate. Lower absolute and relative HU are independently related to persistent occlusion and HU measurements significantly increase discriminative performances of known recanalization determinants.

Advances in revascularization for acute ischemic stroke treatment

Intravenous thrombolysis with recombinant tissue plasminogen activator is the established treatment for acute ischemic stroke patients presenting within 3 h after stroke onset. In a significant number of patients, however, intravenous thrombolysis with recombinant tissue plasminogen activator remains ineffective. New thrombolytic agents, such as reteplase, tenecteplase or desmoteplase, offer pharmacokinetic and dynamic advantages over recombinant tissue plasminogen activator and have been or are currently being tested for safety and efficacy in clinical trials. Endovascular revascularization is an evolving treatment option enabling mechanical clot disruption or extraction in combination with thrombolysis. Several new endovascular devices have been successfully tested for safety in acute ischemic stroke patients and are now being tested for efficacy in larger clinical trials. Continued innovation and refinement of endovascular technology and techniques is expected to increase technical success with a minimal procedure-related morbidity in the treatment of acute ischemic stroke.

Intra-arterial thrombolysis in acute ischemic stroke: a review of pharmacologic approaches

Ischemic stroke is a major public health problem worldwide. The potential to cure stroke patients with intravenous thrombolytic therapy has evolved to the use of intra-arterial thrombolytic agents. Fewer than 200 patients have been enrolled in randomized trials of intra-arterial therapy. In this article the authors have reviewed the literature listed in MEDLINE and EMBase, and searched relevant articles to examine the role of fibrinolytic agents in acute interventional stroke therapy. Only English language articles reporting five or more patients were included. Outcomes were defined at 90 days. Good outcome was defined on the modified Rankin Scale. Symtpomatic hemorrhage was defined as hemorrhage in the setting of clinical deterioration in the first 24 to 48 h. The search identified 57 studies of which 44 reported usable data. Only three randomized trials were reported. Of a total of 1140 patients, most (73%) were treated open-label with urokinase (Abbokinase, Abbott Laboratories). The best outcomes were reported in case series and slightly worse outcomes were reported in clinical trials. Overall, it was not possible to distinguish whether one agent was superior to the others. There is a paucity of published evidence on intra-arterial therapy for acute ischemic stroke. Alteplase (Activase, Genentech Inc.) is currently the drug of choice simply because it is available and it is the current intravenous standard. Further trials and developments are anticipated.

Alteplase for acute ischemic stroke

Alteplase, an intravenously administered form of recombinant tissue plasminogen activator (rt-PA), remains the only US FDA-approved thrombolytic treatment for acute ischemic stroke within 3 h of symptom onset. Patients treated with intravenous rt-PA are at least 30% more likely to have minimal or no disability at 3 months compared with placebo. Despite an increased risk of symptomatic intracranial hemorrhage, rt-PA does not increase mortality. The benefit achieved with rt-PA is cost effective and sustained 1 year after treatment. Despite its clear benefit, rt-PA remains underutilized. Although the future of acute ischemic stroke treatment will most likely involve a multi-faceted treatment approach, the primary objective remains to establish recanalization of the involved vessel. For patients with acute ischemic stroke within the first 3 h of symptom onset, rt-PA remains the first step in accomplishing this goal.

Evolution of thrombectomy approaches and devices for acute stroke: a technical review

While intravenous administration of tissue plasminogen activator (tPA) remains the only FDA-approved treatment modality for acute ischemic stroke, many patients do not meet the criteria for intravenous tPA and are offered intra-arterial therapy. Rapid advances in devices and approaches have marked the evolution of thrombectomy over the past decade from rudimentary mechanical disruption, followed by intra-arterial thrombolytic infusions to increasingly effective thrombectomy devices. We review the critical advancements in thrombectomy technique that have evolved and the key anatomic and technical challenges they address, from first-generation Merci retrieval systems to second-generation Penumbra aspiration systems and third-generation stent retrievers, as well as nuances of their uses to maximize their effectiveness. We also highlight more recent advances that offer patients hope for more expedient vessel recanalization.

Thrombolytic therapy for acute ischaemic stroke: what can we do to improve outcomes?

Constant efforts are being made in the stroke community to aim for maximum benefit from thrombolytic therapy since the approval of intravenous recombinant tissue plasminogen activator (rt-PA; alteplase) for the management of acute ischaemic stroke. However, fear of symptomatic haemorrhage secondary to thrombolytic therapy has been a major concern for treating physicians. Certain imaging and clinical variables may help guide the clinician towards better treatment decision making. Aggressive management of some predictive variables that have been shown to be surrogate outcome measures has been related to better clinical outcomes. Achieving faster, safer and complete recanalization with evolving endovascular techniques is routinely practiced to achieve better clinical outcomes. Selection of an 'ideal candidate' for thrombolysis can maximize functional outcomes in these patients. Although speed and safety are the key factors in acute management of stroke patients, there must also be a systematic and organized pattern to assist the stroke physician in making decisions to select the 'ideal candidate' for treatment to maximize results.

Endovascular and neurosurgical management of acute ischemic stroke

Acute ischemic stroke is recognized as the third leading cause of death in the United States; improved treatments for management are important to reduce disability and death. The standard of care of acute stroke therapy has been reperfusion/recanalization of the occluded vessels using pharmacologic management, endovascular management, or a combination approach. Significant improvements have been made in the management with the use of endovascular therapy. This article reviews the literature on the endovascular and neurosurgical management of patients presenting with acute ischemic stroke and presents current evidence-based guidelines for endovascular or neurosurgical interventions outlined for management of ischemic stroke.

Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion

BACKGROUND AND PURPOSE

Patients who develop severe stroke symptoms due to acute internal carotid artery occlusion eventually in combination with a thromboembolic obstruction of the middle cerebral artery incur a major risk of developing extensive MCA infarction with a poor outcome. The purpose of this study was to evaluate the outcome for patients with tandem occlusions in the MCA and/or distal ICA, retrospectively, who had undergone stent implantation in the proximal segment of the ICA in addition to intra-arterial thrombolysis.

MATERIALS AND METHODS

Thirty-five patients with tandem occlusions of the MCA and/or distal ICA and acute occlusion of the proximal ICA underwent stent implantation for the proximal ICA occlusion and IAT for the tandem occlusion. Clinical outcome measures were assessed on admission and at discharge by using the National Institutes of Health Stroke Scale as well as 3 months after treatment by using the modified Rankin Scale.

RESULTS

The median NIHSS score on admission was 12 (range, 6-22). All patients had patent flow into the M1 and ICA after carotid artery stent placement and IAT. After the procedure, 19 patients (54.3%) were TICI grade III; 7 (20.0%), TICI grade IIb; and 9 (25.7%), TICI grade IIa. Symptomatic intracerebral hemorrhage occurred in 1 patient (2.9%). The overall mortality rate was 11.4% (4/35). At 3-month follow-up, the median NIHSS score was 4 (range, 1-17). NIHSS score at admission and TICI grade were all found to be independently associated with an unfavorable outcome at 3 months.

CONCLUSIONS

Initial stroke severity, degree of successful revascularization, and the side of ischemia were found to independently predict the functional outcome at 3 months after treatment.

Guidelines for acute ischemic stroke treatment: part II: stroke treatment

The second part of these Guidelines covers the topics of antiplatelet, anticoagulant, and statin therapy in acute ischemic stroke, reperfusion therapy, and classification of Stroke Centers. Information on the classes and levels of evidence used in this guideline is provided in Part I. A translated version of the Guidelines is available from the Brazilian Stroke Society website (www.sbdcv.com.br).

Combined full-dose IV and endovascular thrombolysis in acute ischaemic stroke

BACKGROUND

There is an increasing trend to treating proximal vessel occlusions with intravenous-inter-arterial (IV-IA) thrombolysis. The best dose of IV tissue plasminogen activator (tPA) remains undetermined. We compared the combination of full-dose IV recombinant tissue plasminogen activator (rtPA) and IA thrombolytic therapy to IA therapy.

METHODS

Between 2002 and 2009, we reviewed our computed tomographic angiography database for patients who received full-dose intravenous rtPA and endovascular therapy or endovascular therapy alone for acute ischaemic stroke treatment. Details of demographics, risk factors, endovascular procedure, and symptomatic intracranial haemorrhage were noted. Modified Rankin Scale ≤2 at three-months was used as good outcome. Recanalization was defined as Thrombolysis in Myocardial Ischaemia 2-3 flow on angiography.

RESULTS

Among 157 patients, 104 patients received IV-IA treatment and 53 patients underwent direct IA therapy. There was a higher recanalization rate with IV-IA therapy compared with IA alone (71% vs. 60%, P < 0·21) which was driven by early recanalization after IV rtPA. Mortality and independent outcome were comparable between the two groups. Symptomatic intracranial haemorrhage occurred in 8% of patients (12% in the IA group, 7% in the IV-IA group) but was more frequent as the intensity of intervention increased from device alone to thrombolytic drug alone to device plus thrombolytic drug(s). Recanalization was a strong predictor of reduced mortality risk ratio (RR) 0·48 confidence interval95 0·27-0·84) and favourable outcome (RR 2·14 confidence interval95 1·3-3·5).

CONCLUSIONS

Combined IV-IA therapy with full-dose intravenous rtPA was safe and results in good recanalization rates without excess symptomatic intracranial haemorrhage. Testing of full-dose IV tPA followed by endovascular treatment in the IMS3 trial is justified.

Safety of full-dose intravenous recombinant tissue plasminogen activator followed by multimodal endovascular therapy for acute ischemic stroke

BACKGROUND AND PURPOSE

The optimal management of stroke patients who fail treatment with intravenous recombinant tissue plasminogen activator (rt-PA) remains unknown. A study was undertaken to establish whether treatment with a standard intravenous t-PA dose (0.9 mg/kg) followed by multimodal endovascular therapy would have a similar safety profile to reduced dose (0.6 mg/kg) bridging therapy.

METHODS

A retrospective analysis was performed of a prospectively collected database. All patients treated with full-dose t-PA and endovascular therapy were included. The primary safety endpoints included ECASS-III symptomatic intracranial hemorrhage (sICH) and ECASS parenchymal hematomas (PH). Secondary safety endpoints included severe systemic bleeding and 90-day mortality. Clinical efficacy endpoints included rates of recanalization (TICI 2-3), ambulation at hospital discharge and 90-day independent outcomes (mRS 0-2).

RESULTS

106 consecutive patients (mean age 69 ± 17 years; mean baseline NIH Stroke Scale 17.8 ± 4.8; 55% women; occlusion sites: MCA-M1 60.4%; MCA-M2 6.6%; ICA-T 19.8%; tandem cervical ICA+MCA-M1 7.5%; basilar artery 5.7%) were identified over a 10-year period. The sICH rate was 8.5% and the PH-1, PH-2 and subarachnoid hemorrhage rates were 2.8%, 8.5% and 2.8%, respectively. There were two (1.9%) severe groin hematomas. The recanalization rate was 66%. At hospital discharge, 41.4% of the patients were ambulatory. The rate of independent functional outcomes at 90 days was 24%; however, this sample is biased since nearly all deaths were captured but detailed 90-day functional outcomes were missing in 27 patients. The 90-day death rate was 32.4%.

CONCLUSION

Combined treatment with full-dose intravenous rt-PA followed by multimodal endovascular therapy seems to be associated with similar rates of sICH to that of bridging therapy with reduced rt-PA dosage.

[Treatment of arterial and venous brain ischemia. Experts' recommendations: stroke management in the intensive care unit]

With thrombolysis, intravenous alteplase (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by a 60-minute infusion, is recommended within 4.5 hours of onset of ischemic stroke. When indicated, intravenous thrombolysis must be initiated as soon as possible. It is possible to use intravenous alteplase in patients with seizures at stroke onset, if the neurological deficit is related to acute cerebral ischemia. Intravenous alteplase can be discussed for use on a case-by-case basis, according to risk of bleeding, in selected patients under 18 years and over 80 years of age, although for the current European recommendations this would be an off-label use. In hospitals with a stroke unit, intravenous thrombolysis is prescribed by a neurologist (current French labelling) or a physician having the French certification for neurovascular diseases (outside the current French labelling). The patient must be monitored in the stroke unit or in case of multiple organ failure in an intensive and critical care unit. In hospitals without a stroke unit, thrombolysis must be decided by the neurologist from the corresponding stroke unit via telemedicine. It is recommended to perform brain imaging 24 hours after thromboysis. Intra-arterial thrombolysis can be contemplated on a case-by-case basis after multidisciplinary discussion within a 6-hour time window for patients with acute middle cerebral artery or carotid occlusions, and within a larger time window for patients with basilar artery occlusion, because of their very poor spontaneous prognosis. Mechanical thrombectomy can also be contemplated in the same situations. With antiplatelet agents, it is recommended that patients receive aspirin (160 mg-325 mg) within 48 hours of ischemic stroke onset. When thrombolysis is performed or contemplated, it is recommended to delay the initiation of aspirin or other antithrombotic drugs for 24 hours. The use of antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended. Urgent anticoagulation using heparin, low-molecular-weight heparins or danaparoid with the goal to treat ischemic stroke patients is not recommended. Secondary prevention by anticoagulation can be used, immediately or within the first days, after minor ischemic stroke or TIA in patients with a high risk for cardioembolism, if uncontrolled hypertension is absent. In patients with large infarcts and a high risk for cardioembolism, the timing for initiating anticoagulation must be decided on a case-by-case basis. In patients with anticoagulation who had an ischemic stroke, the decision to temporarily stop or maintain anticoagulation must be made on a case-by-case basis, depending on thromboembolic risk, level of anticoagulation at stroke onset and estimated risk of hemorrhagic transformation. It is not recommended to use neuroprotective agents in ischemic stroke patients. Patients with cerebral venous thrombosis must be treated with therapeutic doses of heparin, even in case of concomitant intracranial hemorrhage related to cerebral venous thrombosis. If the patient's status worsens despite adequate anticoagulation, thrombolysis may be used in selected cases. The optimal administration route (local or intravenous), thrombolytic agent (urokinase or alteplase) and dose are unknown. There is currently no recommendation with regard to local thrombolytic therapy in patients with dural sinus thrombosis. Urgent blood transfusions are recommended to reduce hemoglobin S to <30% in patients with sickle cell disease and acute ischemic stroke.

Endovascular treatment strategies for acute ischemic stroke

The limitations of intravenous thrombolysis therapy have paved the way for the development of novel endovascular technologies for use in the setting of acute stroke. These technologies range from direct intraarterial thrombolysis to various thrombus disruption or retrieval devices to angioplasty and stenting. The tools in the armamentarium of the neuroendovascular interventionalist enable fast, effective revascularization to be offered to a wider population of patients that may otherwise have few therapeutic options available to them. In this paper, we review the current state-of-the-art in neuroendovascular intervention for acute ischemic stroke. Particular emphasis is placed on delineating the indications and outcomes for use of these various technologies.

Impact of tissue plasminogen activator on the neurovascular unit: from clinical data to experimental evidence

About 15 million strokes occur each year worldwide. As the number one cause of morbidity and acquired disability, stroke is a major drain on public health-care funding, due to long hospital stays followed by ongoing support in the community or nursing-home care. Although during the last 10 years we have witnessed a remarkable progress in the understanding of the pathophysiology of ischemic stroke, reperfusion induced by recombinant tissue-type plasminogen activator (tPA-Actilyse) remains the only approved acute treatment by the health authorities. The objective of the present review is to provide an overview of our present knowledge about the impact of tPA on the neurovascular unit during acute ischemic stroke.

Simultaneous combined intravenous recombinant tissue plasminogen activator and endovascular therapy for hyperacute middle cerebral artery m1 occlusion

We investigated the efficacy and safety of combined intravenous (IV) recombinant tissue plasminogen activator (rtPA) and simultaneous endovascular therapy (ET) for hyperacute middle cerebral artery (MCA) M1 occlusion. Between October 2005 and April 2007, in the combined group, 22 patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, were treated with IV rtPA and simultaneous ET was initiated as soon as possible. The other patients were treated with IV rtPA alone (IV group A: n = 11). Between May 2007 and November 2008, all patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, underwent thrombolysis by IV rtPA alone (IV group B: n = 24). The improvement of the National Institutes of Health Stroke Scale score at 24 hours was highest in the combined group (10 ± 4.1). In contrast, it was 5.1 ± 4.7 in the IV group A (P = 0.017) and 5.6 ± 5.6 in IV group B (P = 0.006). In the combined group, successful recanalization was observed in 18 of 22 patients with one symptomatic intracranial hemorrhage. The rate of mRS0-2 at three months was highest in the combined group, 36% in the IV group A and 33% in the IV group B (P = 0.008).Simultaneous treatment with IV rtPA and ET improved the clinical outcome of MCA M1 occlusion without a significant increase of adverse effects in our study.

Fibrinolysis and Beyond: Bridging the Gap between Local and Systemic Clot Removal

Recanalization methods in ischemic stroke have been progressively expanded over the past years. In addition the continuous development of specialized mechanical devices for thrombectomy a broad spectrum of new drugs has been tested: Both options, novel drugs as well as new devices, can be employed independently of each other, but in most cases a combination of the two with the standard treatment of intravenous fibrinolysis is applied. Until recently, a large number of case series have been performed to investigate the effects of various drugs and interventions, but only a few trials have been conducted to determine the optimal conditions for combining both procedures. This review surveys the different systemic and endovascular vessel reopening practices and their major bridging techniques.

Current recommendations for endovascular interventions in the treatment of ischemic stroke

Ischemic stroke remains one of the leading cause of adult death and disability in the United States. Reperfusion of the occluded vessel is the standard of care in the setting of acute ischemic stroke according to established guidelines. Since the introduction of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) in the late 1990s, significant advances have been made in methods to deliver thrombolytic agents and in devices for mechanical recanalization of occluded vessels. Furthermore, improvements in patient selection contribute to achievement of good clinical outcomes after endovascular therapy. This article summarizes findings from recent clinical trials and presents evidence-based guidelines for endovascular interventions in the treatment of ischemic stroke.

Multimodal therapy for patients with acute ischemic stroke : outcomes and related prognostic factors

OBJECTIVE

The objectives of this study were to analyze the recanalization rates and outcomes of multimodal therapy that consisted of sequential intravenous (IV)/intra-arterial (IA) thrombolysis, mechanical thrombolysis including mechanical clot disruption using microcatheters and microwires, balloon angioplasty, and stenting for acute ischemic stroke, and to evaluate the prognostic factors related to the outcome.

METHODS

Fifty patients who were admitted to the hospital within 8 hours from ischemic symptom onset were retrospectively analyzed. Initial IV thrombolysis and subsequent cerebral angiography were performed in all patients. If successful recanalization was not achieved by IV thrombolysis, additional IA thrombolysis with mechanical thrombolysis, including balloon angioplasty and stenting, were performed. The outcomes were assessed by the National Institute of Health Stroke Scale (NIHSS) change and modified Rankin scale (mRS) and prognostic factors were analyzed.

RESULTS

Successful recanalization was achieved in 42 (84%) of 50 patients, which consisted of 8 patients after IV thrombolysis, 19 patients after IA thrombolysis with mechanical clot disruption, and 15 patients after balloon angioplasty or stenting. Symptomatic hemorrhage occurred in 4 (8%) patients. Good outcomes were achieved in 76% and 70% of patients upon discharge, and 93% and 84% of patients after 3 months according to the NIHSS change and mRS. The initial clinical status, recanalization achievement, and presence of symptomatic hemorrhage were statistically related to the outcomes.

CONCLUSION

Multimodal therapy may be an effective and safe treatment modality for acute ischemic stroke. Balloon angioplasty and stenting is effective for acute thrombolysis, and produce higher recanalization rates with better outcomes.

Safety and efficacy of alteplase in the treatment of acute ischemic stroke

After publication of the results of the National Institute of Neurological Disorders and Stroke study, the application of intravenous thrombolysis for ischemic stroke was launched and has now been in use for more than 10 years. The approval of this drug represented only the first step of the therapeutic approach to this pathology. Despite proven efficacy, concerns remain regarding the safety of recombinant tissue-type plasminogen activator for acute ischemic stroke used in routine clinical practice. As a result, a small proportion of patients are currently treated with thrombolytic drugs. Several factors explain this situation: a limited therapeutic window, insufficient public knowledge of the warning signs for stroke, the small number of centers able to administer thrombolysis on a 24-hour basis and an excessive fear of hemorrhagic complications. The aim of this review is to explore the clinical efficacy of treatment with alteplase and consider the hemorrhagic risks.

Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials

Reperfusion remains the mainstay of acute ischemic stroke treatment. Endovascular therapy has become a promising alternative for patients who are ineligible for or have failed intravenous (IV) thrombolysis. The conviction that recanalization of properly selected patients is essential for the achievement of good clinical outcomes has led to the rapid and widespread growth in the adoption of endovascular stroke therapies. However, comparisons of the recent reperfusion studies have brought into question the strength of the association between revascularization and improved clinical outcome. Despite higher rates of recanalization, the mechanical thrombectomy studies have demonstrated substantially lower rates of good outcomes compared with IV and/or intra-arterial thrombolytic trials. However, such analyses disregard important differences in clot location and burden, baseline stroke severity, time from stroke onset to treatment, and patient selection in these studies. Many clinical trials are testing novel devices and drugs as well as the paradigm of physiology-based stroke imaging as a treatment-selection tool. The objective of this article is to provide a comprehensive review of the relevant past, current, and upcoming data on endovascular stroke therapy with a special focus on the prospective studies and randomized clinical trials.

Intra-arterial stroke therapy: an assessment of demand and available work force

Intra-arterial therapy is currently applicable to a small subset of patients with ischemic stroke, but it will likely have an expanding role as new devices are introduced. This review evaluates the demand for such therapy and the physician work force available to provide such therapy in the United States. The available literature was reviewed to assess how many patients might need intra-arterial therapy annually and how many skilled neurointerventionalists are available to provide intra-arterial therapy for acute stroke. The number of acute ischemic strokes in the United States that will be amenable to intra-arterial therapy can only be crudely estimated, but it is certainly less than 126,000 per year and will quite likely be no more than 20,000 cases per year. The future demand for intra-arterial reperfusion techniques may change, but the number of patients who require intra-arterial thrombolysis is currently quite low. The overall number of neurointerventionists is currently adequate, though there might be local shortages.

Methodology of the Interventional Management of Stroke III Trial

RATIONALE

The Interventional Management of Stroke (IMS) I and II pilot trials demonstrated that the combined intravenous (i.v.) and intraarterial (i.a.) approach to recanalization may be more effective than standard i.v. rt-PA (Activase) alone for moderate-to-large National Institutes of Health Stroke Scale (NIHSS>or=10) strokes, and with a similar safety profile.

AIMS

The primary objective of this NIH-funded, Phase III, randomized, multicenter, open-label clinical trial is to determine whether a combined i.v./i.a. approach to recanalization is superior to standard i.v. rt-PA alone when initiated within 3 h of acute ischemic stroke onset. The IMS III trial will develop and maintain a network of interventional centers to test the safety, feasibility, and potential efficacy of new FDA-approved catheter devices as part of a combined i.v./i.a. approach to recanalization as the IMS III study progresses. A secondary objective of the IMS III trial is to determine the cost-effectiveness of the combined i.v./i.a. approach as compared with standard i.v. rt-PA. Trial enrollment began in July of 2006.

DESIGN

A projected 900 subjects with moderate-to-large (NIHSS>or=10) ischemic strokes between ages 18 and 80 will be enrolled over the next 5 years at 40-plus centers in the United States and Canada. Patients must have i.v. treatment initiated within 3 h of stroke onset in both arms. Subjects will be randomized in a 2 : 1 ratio with more subjects enrolled in the combined i.v./i.a. group. The i.v. rt-PA alone group will receive the standard full dose [0.9 mg/kg, 90 mg maximum (10% as bolus)] of rt-PA intravenously over an hour. The combined i.v./i.a. group will receive a lower dose of i.v. rt-PA ( approximately 0.6 mg/kg, 60 mg maximum) over 40 min, followed by immediate angiography. If a treatable thrombus is not demonstrated, no i.a. therapy will be administered. If an appropriate thrombus is identified, treatment will continue with either the Concentric Merci thrombus-removal device, infusion of rt-PA and delivery of low-intensity ultrasound at the site of the occlusion via the EKOS Micro-Infusion Catheter, or infusion of rt-PA via a standard microcatheter. If i.a. rt-Pa therapy is the chosen strategy, a maximum of 22 mg of i.a. rt-PA may be given. The choice of i.a. strategy will be made by the treating neurointerventionalist. The i.a. treatment must begin within 5 h and be completed within 7 h of stroke onset.

STUDY OUTCOMES

The primary outcome measure is a favorable clinical outcome, defined as a modified Rankin Scale Score of 0-2 at 3 months. The primary safety measure is mortality at 3 months and symptomatic ICH within the 24 h of randomization.

Comparison of combined venous and arterial thrombolysis with primary arterial therapy using recombinant tissue plasminogen activator in acute ischemic stroke

OBJECTIVE

We sought to compare the safety and efficacy of combined intravenous (IV) and intra-arterial (IA) thrombolysis with primary IA therapy using tissue plasminogen activator for acute ischemic stroke presenting within 6 hours of symptom onset.

METHODS

We performed quasirandomization of a single institution's prospectively collected stroke database, comparing IV/IA (0.6 mg/kg IV < or = 60 mg, followed by 0.3 mg/kg IA < or = 30 mg) versus primary IA. Outcome measures include 90-day modified Rankin scale score, mortality, symptomatic intracerebral hemorrhage, and recanalization rates. Statistical analysis was performed using bivariate and propensity score methods.

RESULTS

Of 1057 patients, 41 patients were treated with IV/IA, and 55 with IA. There was significant difference in time to treatment (mean of 151 minutes for the combined group and 261 minutes for the IA, P < .0001) and arterial tissue plasminogen activator dose (17.5 mg for IV/IA v 22.8 mg for IA only, P = .05). Propensity score matching yielded 25 patients in each group. Symptomatic intracerebral hemorrhage rate was 12% in each group. Mortality was 20% in the IV/IA group versus 16% in the IA group (relative risk 1.3 [0.4-4.1], P = .7). More patients in IV/IA group had modified Rankin scale score less than or equal to 2 (odds ratio 1.6 [0.5-5.8], P = .3). Recanalization was 64% with IV/IA versus 48% with IA (odds ratio 1.9 [0.5-7.0], P = .3).

CONCLUSION

This study demonstrates that both combined IV/IA and primary IA recombinant tissue plasminogen activator therapy is feasible and safe in the treatment of acute ischemic stroke. Combined IV/IA therapy may be associated with an improvement in clinical outcome without a significant increase in the risk of symptomatic intracerebral hemorrhage and mortality compared with IA therapy.

Simultaneous treatment with intravenous recombinant tissue plasminogen activator and endovascular therapy for acute ischemic stroke within 3 hours of onset

BACKGROUND AND PURPOSE

Because intravenous (IV) recombinant tissue plasminogen activator (rtPA) does not always lead to a good outcome in a considerable proportion of patients, combined IV rtPA and rescue endovascular therapy (ET) have been performed in several recent studies. However, rescue therapy after completion of IV rtPA often results in late ineffective recanalization. We examined the efficacy and safety of combined IV rtPA and simultaneous ET as primary rather than rescue therapy for hyperacute middle cerebral artery (MCA) occlusion.

MATERIALS AND METHODS

A total of 29 patients eligible for IV rtPA, who were diagnosed as having MCA (M1 or M2) occlusion within 3 hours of onset, underwent thrombolysis. In the combined group, patients were treated by IV rtPA (0.6 mg/kg for 60 minutes) and simultaneous ET (intra-arterial rtPA, mechanical thrombus disruption with microguidewire, and balloon angioplasty) initiated as soon as possible. In the IV group, patients were treated by IV rtPA only.

RESULTS

The improvement of the National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was 11 +/- 4.8 in the combined group versus 5 +/- 4.3 in the IV group (P < .001). In the combined group, successful recanalization was observed in 14 (88%) of 16 patients with no symptomatic intracranial hemorrhage, and 10 (63%) of 16 patients had favorable outcomes (modified Rankin Scale [mRS] 0, 1) at 3 months.

CONCLUSIONS

Aggressive combined therapy with IV rtPA and simultaneous ET markedly improved the clinical outcome of hyperacute MCA occlusion without significant adverse effect. Additional randomized study is needed to confirm our results.