Thrombolysis Despite Recent Stroke

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultraearly repeated systemic thrombolysis in recurrent ischemic stroke - A multicentre case study

OBJECTIVE

We analysed outcomes of patients who received off-label repeated thrombolysis with recombinant tissue plasminogen activator for ischemic stroke recurrence within 10 days (ultraearly repeated thrombolysis, UERT).

METHOD

We identified patients receiving UERT from the prospective telestroke network of South-East Bavaria (TEMPiS) registry and by database search (Pubmed, Google scholar). Corresponding authors were contacted for further details. Baseline demographic data and clinical, laboratory, and imaging findings were analysed in a multicentric case study.

RESULTS

Sixteen patients receiving UERT were identified. The median time between first and second thrombolysis was 3.5 days. In patients with available data, second thrombolysis achieved an early clinical improvement (NIHSS reduction ≥4 points) in 12 of 14 (85.7%) and a favourable outcome (mRS 0-2 after 3 months) in 11 of 16 (68.8%) patients. Intracerebral haemorrhage (ICH) occurred in 4 patients (25.0%) with one fatal large parenchymatous haemorrhage (6.3%). Neither allergic reactions nor other immunoreactive events were observed.

CONCLUSIONS

In our analysis UERT led to early clinical improvement and a favourable clinical outcome in a high percentage of patients with ICH rates comparable to prior publications. UERT might be considered in patients with early recurrent stroke under careful risk-benefit assessment.

Recovery of Hypoxic Regions in a Rat Model of Microembolism

OBJECTIVES

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke. Despite successful recanalization, a limited subset of patients benefits from the new treatment. Human MRI studies have shown that during removal of the thrombus, a shower of microclots is released from the initial thrombus, possibly causing new ischemic lesions. The aim of the current study is to quantify tissue damage following microembolism.

MATERIALS AND METHODS

In a rat model, microembolism was generated by injection of a mixture of polystyrene fluorescent microspheres (15, 25 and 50 µm in diameter). The animals were killed at three time-points: day 1, 3 or 7. AMIRA and IMARIS software was used for 3D reconstruction of brain structure and damage, respectively.

CONCLUSIONS

Microembolism induces ischemia, hypoxia and infarction. Infarcted areas persist, but hypoxic regions recover over time suggesting that repair processes in the brain rescue the regions at risk.

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

BACKGROUND

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

OBJECTIVES

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

SUMMARY OF REVIEW

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

CONCLUSIONS

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

Safety and Efficacy of Repeated Thrombolysis with Alteplase in Early Recurrent Ischemic Stroke: A Systematic Review

BACKGROUND AND AIM

The current American Heart Association guidelines for the management of acute ischemic stroke advise against the use of intravenous (IV) alteplase in patients with recurrent stroke occurring within 90 days of their index event. Following these guidelines strictly, patients having early recurrent ischemic stroke would be unable to avail of this reperfusion strategy that has been proven to confer superior clinical outcomes. While some registry-based studies have demonstrated the safety of IV alteplase in this subgroup of patients, data on the repeated use of the drug are lacking. Thus, we aim to determine the safety and efficacy of repeated thrombolysis in patients with early recurrent ischemic strokes.

METHODS

The following electronic databases were searched for relevant studies: the Cochrane Central Register for Controlled Trials by The Cochrane Library, MEDLINE by PubMed, Health Research and Development Information Network, Scopus, and ClinicalTrials.gov. Data on symptomatic intracranial hemorrhage, 90-day clinical outcomes, systemic hemorrhage and allergic reactionswere synthesized.

RESULTS

Ten articles with 33 patients in total were included in our review. One patient developed symptomatic intracranial hemorrhage after the second reperfusion attempt and subsequently died from pneumonia. Another died from spontaneous rupture of previously unidentified infrarenal aortic aneurysm. Six of the 13 patients with available follow-up data had good clinical outcomes (Modified Rankin Score 0-2). There were no allergic reactions and other drug-related adverse events noted.

CONCLUSIONS

Repeated IV alteplase can be safe and efficacious in patients who have early recurrent ischemic stroke. Larger studies, trials, or registry-based data are needed to ascertain the encouraging findings of our review.

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

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

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background and Purpose—

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

Methods—

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

Results—

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

Conclusions—

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

Thrombolysis in recurrent stroke-beyond guidelines: a case report

Intravenous (IV) thrombolysis is approved and proven treatment for acute ischemic stroke in the window period of 4.5 hours. The therapeutic benefit is not extended to many patients with prior stroke and recurrent stroke as they are excluded in the protocol for thrombolysis. We report a case of successful IV thrombolysis in a young patient with recent prior stroke and recurrent stroke. A 35-year-old male presented in our emergency with recurrent stroke had a history of acute onset vertigo, headache, and vomiting. He was diagnosed to have posterior circulation stroke before 5 days on the basis of clinical history and neuroimaging. On the day of presentation to our hospital, he had developed new symptom of acute onset right hemiparesis with dysarthria. IV tissue plasminogen activator administered within 2 hours of onset of new symptoms resulted in significant improvement in spite of the recent prior stroke.