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Zhang Y, Lv T, Nguyen TN, Wu S, Li Z, Bai X, Chen D, Zhao C, Lin W, Chen S, Sui Y. Intravenous Alteplase Versus Best Medical Therapy for Patients With Minor Stroke: A Systematic Review and Meta-Analysis. Stroke 2024; 55:883-892. [PMID: 38465591 DOI: 10.1161/strokeaha.123.045495] [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: 10/11/2023] [Accepted: 01/29/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The efficacy of thrombolysis (IVT) in minor stroke (National Institutes of Health Stroke Scale score, 0-5) remains inconclusive. The aim of this study is to compare the effectiveness and safety of IVT with best medical therapy (BMT) by means of a systematic review and meta-analysis of randomized controlled trials and observational studies. METHODS We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to IVT in minor stroke from inception until August 10, 2023. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days. The associations were calculated for the overall and preformulated subgroups by using the odds ratios (ORs). This study was registered with PROSPERO (CRD42023445856). RESULTS A total of 20 high-quality studies, comprised of 13 397 patients with acute minor ischemic stroke, were included. There were no significant differences observed in the modified Rankin Scale scores of 0 to 1 (OR, 1.10 [95% CI, 0.89-1.37]) and 0 to 2 (OR, 1.16 [95% CI, 0.95-1.43]), mortality rates (OR, 0.67 [95% CI, 0.39-1.15]), recurrent stroke (OR, 0.89 [95% CI, 0.57-1.38]), and recurrent ischemic stroke (OR, 1.09 [95% CI, 0.68-1.73]) between the IVT and BMT group. There were differences between the IVT group and the BMT group in terms of early neurological deterioration (OR, 1.81 [95% CI, 1.17-2.80]), symptomatic intracranial hemorrhage (OR, 7.48 [95% CI, 3.55-15.76]), and hemorrhagic transformation (OR, 4.73 [95% CI, 2.40-9.34]). Comparison of modified Rankin Scale score of 0 to 1 remained unchanged in subgroup patients with nondisabling deficits or compared with those using antiplatelets. CONCLUSIONS These findings indicate that IVT does not yield significant improvement in the functional prognosis of patients with acute minor ischemic stroke. Additionally, it is associated with an increased risk of symptomatic intracranial hemorrhage when compared with the BMT. Moreover, IVT may not have superiority over BMT in patients with nondisabling deficits or those using antiplatelets.
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Affiliation(s)
- Yang Zhang
- School of Public Health, China Medical University, Shenyang, China (Y.Z., X.B., D.C., Y.S.)
| | - Tian Lv
- Department of Neurology, Zhuji Affliated Hospital of WenZhou University, China (T.L.)
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine (T.N.N.)
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.W.)
| | - Zhi Li
- Department of Medical Oncology (Z.L.), The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xue Bai
- School of Public Health, China Medical University, Shenyang, China (Y.Z., X.B., D.C., Y.S.)
| | - Dan Chen
- School of Public Health, China Medical University, Shenyang, China (Y.Z., X.B., D.C., Y.S.)
| | - Chuansheng Zhao
- and Department of Neurology (C.Z., Y.S.), The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wanyi Lin
- Department of Neurology, Qingtian County Hospital, Lishui, China (W.L.)
| | - Shiqin Chen
- Department of Neurology, Second People's Hospital of Yuhuan, China (S.C.)
| | - Yi Sui
- School of Public Health, China Medical University, Shenyang, China (Y.Z., X.B., D.C., Y.S.)
- Department of Neurology and Neurointervention, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, China (Y.S.)
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Cui Y, Li XQ, Chen HS. Dual antiplatelet instead of intravenous thrombolysis for minor nondisabling acute ischemic stroke: A perspective from China. J Transl Int Med 2024; 12:1-4. [PMID: 38525443 PMCID: PMC10956727 DOI: 10.2478/jtim-2023-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, Province, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, Province, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, Province, China
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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Chen HS, Cui Y, Zhou ZH, Zhang H, Wang LX, Wang WZ, Shen LY, Guo LY, Wang EQ, Wang RX, Han J, Dong YL, Li J, Lin YZ, Yang QC, Zhang L, Li JY, Wang J, Xia L, Ma GB, Lu J, Jiang CH, Huang SM, Wan LS, Piao XY, Li Z, Li YS, Yang KH, Wang DL, Nguyen TN. Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial. JAMA 2023; 329:2135-2144. [PMID: 37367978 PMCID: PMC10300686 DOI: 10.1001/jama.2023.7827] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/22/2023] [Indexed: 06/28/2023]
Abstract
Importance Intravenous thrombolysis is increasingly used in patients with minor stroke, but its benefit in patients with minor nondisabling stroke is unknown. Objective To investigate whether dual antiplatelet therapy (DAPT) is noninferior to intravenous thrombolysis among patients with minor nondisabling acute ischemic stroke. Design, Setting, and Participants This multicenter, open-label, blinded end point, noninferiority randomized clinical trial included 760 patients with acute minor nondisabling stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤5, with ≤1 point on the NIHSS in several key single-item scores; scale range, 0-42). The trial was conducted at 38 hospitals in China from October 2018 through April 2022. The final follow-up was on July 18, 2022. Interventions Eligible patients were randomized within 4.5 hours of symptom onset to the DAPT group (n = 393), who received 300 mg of clopidogrel on the first day followed by 75 mg daily for 12 (±2) days, 100 mg of aspirin on the first day followed by 100 mg daily for 12 (±2) days, and guideline-based antiplatelet treatment until 90 days, or the alteplase group (n = 367), who received intravenous alteplase (0.9 mg/kg; maximum dose, 90 mg) followed by guideline-based antiplatelet treatment beginning 24 hours after receipt of alteplase. Main Outcomes and Measures The primary end point was excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 (range, 0-6), at 90 days. The noninferiority of DAPT to alteplase was defined on the basis of a lower boundary of the 1-sided 97.5% CI of the risk difference greater than or equal to -4.5% (noninferiority margin) based on a full analysis set, which included all randomized participants with at least 1 efficacy evaluation, regardless of treatment group. The 90-day end points were assessed in a blinded manner. A safety end point was symptomatic intracerebral hemorrhage up to 90 days. Results Among 760 eligible randomized patients (median [IQR] age, 64 [57-71] years; 223 [31.0%] women; median [IQR] NIHSS score, 2 [1-3]), 719 (94.6%) completed the trial. At 90 days, 93.8% of patients (346/369) in the DAPT group and 91.4% (320/350) in the alteplase group had an excellent functional outcome (risk difference, 2.3% [95% CI, -1.5% to 6.2%]; crude relative risk, 1.38 [95% CI, 0.81-2.32]). The unadjusted lower limit of the 1-sided 97.5% CI was -1.5%, which is larger than the -4.5% noninferiority margin (P for noninferiority <.001). Symptomatic intracerebral hemorrhage at 90 days occurred in 1 of 371 participants (0.3%) in the DAPT group and 3 of 351 (0.9%) in the alteplase group. Conclusions and Relevance Among patients with minor nondisabling acute ischemic stroke presenting within 4.5 hours of symptom onset, DAPT was noninferior to intravenous alteplase with regard to excellent functional outcome at 90 days. Trial Registration ClinicalTrials.gov Identifier: NCT03661411.
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Affiliation(s)
- Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Zhong-He Zhou
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Hong Zhang
- Department of Neurology, Liaoning Health Industry Group Fukuang General Hospital, Fushun, China
| | - Li-Xia Wang
- Department of Neurology, Tieling Central Hospital, Tieling, China
| | - Wei-Zhong Wang
- Department of Neurology, Dandong Central Hospital, Dandong, China
| | - Li-Ying Shen
- Department of Neurology, Tieling County Central Hospital, Tieling, China
| | - Li-Yan Guo
- Department of Neurology, Fushun Second Hospital, Fushun, China
| | - Er-Qiang Wang
- Department of Neurology, The Fuqing Affiliated Hospital of Fujian Medical University, Fuqing, China
| | - Rui-Xian Wang
- Department of Neurology, The Tianjin Beichen Traditional Chinese Medicine Hospital, Tianjin, China
| | - Jing Han
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Yu-Ling Dong
- Department of Neurology, Chaoyang Second Hospital, Chaoyang, China
| | - Jing Li
- Department of Neurology, Donggang Central Hospital, Donggang, China
| | - Yong-Zhong Lin
- Department of Neurology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qing-Cheng Yang
- Department of Neurology, Anyang People‘s Hospital, Anyang, China
| | - Li Zhang
- Department of Neurology, Suizhong Central Hospital, Suizhong, China
| | - Jing-Yu Li
- Department of Neurology, Chinese People’s Liberation Army 967 Hospital, Dalian, China
| | - Jin Wang
- Department of Neurology, Huludao Central Hospital, Huludao, China
| | - Lei Xia
- Department of Neurology, Zhoukou Central Hospital, Zhoukou, China
| | - Guang-Bin Ma
- Department of Neurology, Haicheng Traditional Chinese Medicine Hospital, Haicheng, China
| | - Jiang Lu
- Department of Neurology, The Dalinghe Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Chang-Hao Jiang
- Department of Neurology, Lvshunkou Traditional Chinese Medicine Hospital, Lvshunkou, China
| | - Shu-Man Huang
- Department of Neurology, Dawa District People‘s Hospital, Panjin, China
| | - Li-Shu Wan
- Department of Neurology, Dandong First Hospital, Dandong, China
| | - Xiang-Yu Piao
- Department of Neurology, The Zhongshan Affiliated Hospital of Dalian University, Dalian, China
| | - Zhuo Li
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Yan-Song Li
- Department of Neurology, Army Hospital of Northern Theatre Command, Shenyang, China
| | - Kui-Hua Yang
- Department of Neurology, Liaoyang Second People’s Hospital, Liaoyang, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Thanh N. Nguyen
- Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
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Situmeang RFV, Pangestu A, Stevano R, Tannu Y, Herlambang J, Putri C. Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023. [DOI: 10.1186/s41983-023-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Abstract
Background
Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.
Methods
This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.
Results
One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).
Conclusions
Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.
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Zhang D, Li X, Jia N, Chen W, Hu Y. Bibliometric and visual analysis of cerebral revascularization from 1999 to 2022. Front Neurosci 2023; 16:1088448. [PMID: 36699511 PMCID: PMC9868924 DOI: 10.3389/fnins.2022.1088448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background Cerebral revascularization is a neurosurgical procedure used to restore the cerebral collateral circulation channel. This study examines the countries, institutions, authors, journals, keywords, and references related to the disease in the field of cerebral revascularization from 1999 to 2022 from a bibliometrics perspective, evaluates the changes of knowledge structure clustering and identifies the new hot spots and new research directions in this field. Methods The Web of Science Core Collection (WOSCC) database and the PICOS retrieval method were used to conduct a comprehensive search for articles and reviews pertaining to cerebral revascularization. The final filtered data were bibliometrically and visually drawn using Microsoft office 365, CiteSpace (v.6.1.R2), and VOSviewer (v.1.6.18). Results From 1999 to 2022, a total of 854 articles pertaining to cerebral revascularization, which originated from 46 nations, 482 institutions, and 686 researchers, were extracted from the WOSCC database, and the number of publications in this field of study was rising. The United States held the highest proportion in the ranking analysis of countries, institutions, authors, and journals. By analyzing co-citations, the scientific organization of this field and the development status of frontier fields were realized. Cerebral revascularization, moyamoya disease, extracranial intracranial bypass, and occlusion are the current research focal points in the field of cerebral revascularization. Hyperperfusion and vascular disorder may also become a new study focus in this discipline in the near future. Conclusion Using the method of bibliometrics, this study analyzed and reviewed the articles in the field of cerebral revascularization, which enabled scholars to better comprehend the dynamic process in this field and provided a foundation for future in-depth research.
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Affiliation(s)
- Ding Zhang
- Guangxi University of Chinese Medicine, Nanning, China
| | - Xiaoqian Li
- Weinan Vocational and Technical College Nursing College, Weinan, China
| | - Ni Jia
- Department of Encephalopathy, The First Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Xi’an, China
| | - Wei Chen
- Department of Encephalopathy, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Yueqiang Hu
- Department of Encephalopathy, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China,*Correspondence: Yueqiang Hu,
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Ferrari J, Reynolds A, Knoflach M, Sykora M. Acute Ischemic Stroke With Mild Symptoms-To Thrombolyse or Not to Thrombolyse? Front Neurol 2021; 12:760813. [PMID: 34867745 PMCID: PMC8637329 DOI: 10.3389/fneur.2021.760813] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/15/2021] [Indexed: 12/01/2022] Open
Abstract
Management of stroke with minor symptoms may represent a therapeutical dilemma as the hemorrhage risk of acute thrombolytic therapy may eventually outweigh the stroke severity. However, around 30% of patients presenting with minor stroke symptoms are ultimately left with disability. The objective of this review is to evaluate the current literature and evidence regarding the management of minor stroke, with a particular emphasis on the role of IV thrombolysis. Definition of minor stroke, pre-hospital recognition of minor stroke and stroke of unknown onset are discussed together with neuroimaging aspects and existing evidence for IV thrombolysis in minor strokes. Though current guidelines advise against the use of thrombolysis in those without clearly disabling symptoms due to a paucity of evidence, advanced imaging techniques may be able to identify those likely to benefit. Further research on this topic is ongoing.
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Affiliation(s)
- Julia Ferrari
- Department of Neurology, St John's Hospital, Vienna, Austria
| | - Audrey Reynolds
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marek Sykora
- Department of Neurology, St John's Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria
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