Categories
Stroke

Is thrombolysis beneficial when time of stroke onset is unknown?

Efficacy and safety of thrombolytic therapy for stroke with unknown time of onset: a meta-analysis of observational studies.

Zhu RL, Xu J, Xie CJ, Hu Y, Wang K.

J Stroke Cerebrovasc Dis 2020 (Epub ahead of print).

Abstract

BACKGROUND:

Recombinant tissue plasminogen activator (rt-PA) is one of the most effective therapies available for patients with known-onset stroke (KOS). Whether rt-PA treatment would improve functional outcomes in patients with stroke with unknown time of onset (UTOS) is undetermined, we aimed to systematically assess the efficacy and safety of thrombolysis for UTOS patients in this meta-analysis.

METHODS:

A systematic literature search of Medline, Embase, and Cochrane Library was conducted. We considered the relevant data comparing thrombolyzed UTOS patients versus nonthrombolyzed UTOS patients or thrombolyzed UTOS patients versus thrombolyzed KOS patients. Treatment efficacy and safety were measured according to modified Rankin Scale scores of 0-2 (mRS 0-2), and the presence of spontaneous intracerebral hemorrhage (SICH) or mortality at 90 days respectively.

RESULTS:

A total of 11 studies with 2581 patients meeting the inclusion criteria were included in the meta-analysis. All the patients had an ischemic lesion that was assessed by imaging including computed tomography or magnetic resonance imaging. Among these studies, 6 compared the thrombolytic efficacy in thrombolyzed UTOS patients with that in nonthrombolyzed UTOS patients (mRS 0-2: odds ratio [OR] =1.76, 95% confidence interval [CI] 1.11-2.81, P = .02), and 8 studies compared thrombolyzed UTOS patients with thrombolyzed KOS patients (mRS 0-2: OR = 0.87, 95% CI 0.66-1.15, P = .33). The incidence of SICH and mortality at 90 days had no difference between thrombolyzed UTOS patients versus nonthrombolyzed UTOS patients and thrombolyzed UTOS patients versus thrombolyzed KOS patients (all P > .05).

CONCLUSIONS:

Data from observational studies suggest that thrombolysis for unknown time of onset stroke UTOS had significantly favorable outcomes at 90 days compared with nonthrombolyzed patients.

This paper is cited in the neurochecklist:

Thrombolysis: clinical use

By Marvin 101 – Own work, CC BY-SA 3.0, Link

Abstract link

Categories
Stroke

Is the bleeding risk of thrombolysis increased in those on dual antiplatelets?

Safety and efficacy of dual antiplatelet pretreatment in patients with ischemic stroke treated with IV thrombolysis: a systematic review and meta-analysis.

Malhotra K, Katsanos AH, Goyal N, et al.

Neurology 2020; 94:e657-e666.

Abstract

OBJECTIVE:

Conflicting data exist on the safety and efficacy of IV thrombolysis (IVT) in patients with acute ischemic stroke (AIS) receiving dual antiplatelet pretreatment (DAPP). The aim of the present systematic review and meta-analysis is to assess the safety and outcome of DAPP history among patients with AIS treated with IVT.

METHODS:

We performed a comprehensive literature review to identify studies that investigated the safety and efficacy of DAPP among patients with AIS treated with IVT.

RESULTS:

We identified 9 studies comprising 66,675 patients. In unadjusted analyses, DAPP was associated with a higher likelihood of pooled symptomatic intracranial hemorrhage (sICH; odds ratio [OR] 2.26; 95% confidence interval [CI] 1.39-3.67) and 3-month mortality (OR 1.47; 95% CI 1.25-1.73). DAPP was also related to higher odds of sICH according to Safe Implementation of Treatments in Stroke Monitoring Study (OR 2.71; 95% CI 2.05-3.59), European Cooperative Acute Stroke Study II (OR 2.23; 95% CI 1.46-3.40), and National Institute of Neurological Disorders and Stroke (OR 1.59, 95% CI 1.38-1.83) definitions. There was no association between DAPP and 3-month favorable functional outcome (FFO, modified Rankin Scale [mRS] score 0-1) and 3-month functional independence (FI; mRS score 0-2). In adjusted analyses, history of DAPP was not associated with pooled sICH (OR 2.03; 95% CI 0.75-5.52), 3-month mortality (OR 1.11; 95% CI 0.87-1.40), 3-month FFO (OR 0.92; 95% CI 0.77-1.09), and 3-month FI (OR 1.01; 95% CI 0.89-1.15).

CONCLUSIONS:

After adjustment for potential confounders, dual antiplatelet pretreatment appears not to be associated with higher risk of adverse outcomes in patients with acute ischeamic stroke treated with intravenous thrombolysis.

This paper is cited in the neurochecklist:

Thrombolysis: complications

By TleonardiOwn work, CC BY 3.0, Link

Abstract link

Categories
Stroke

Is thrombolysis effective in spinal stroke?

Acute ischemic myelopathy treated with intravenous thrombolysis: four new cases and literature review.

Jankovic J, Rey Bataillard V, Mercier N, Bonvin C, Michel P.

Int J Stroke 2019; 14:893-897.

Abstract

BACKGROUND:

Intravenous thrombolysis is a well-established treatment of ischemic stroke within 4.5 h. However, its effectiveness in acute ischemic myelopathy is unknown.

PURPOSE:

We describe a series of four acute ischemic myelopathy patients treated with intravenous thrombolysis within 4.5 h and review the current literature to explore this treatment feasibility, potential safety, and efficacy.

METHODS:

We reviewed all routinely collected clinical, radiological, and follow-up data of patients with a final acute ischemic myelopathy diagnosis who received acute intravenous thrombolysis in our stroke network. We also reviewed thrombolyzed acute ischemic myelopathy patients in the literature.

RESULTS:

Four patients (three women) aged 57 to 83 years presented with acute uni- or bilateral extremity paresis, considered initially as cerebral strokes in two of them. After excluding contraindications by brain imaging in three, spinal computed tomography in one and confirmation of acute ischemic myelopathy on spinal magnetic resonance imaging in one patient, intravenous thrombolysis was administered at 135, 190, 240, and 245 min accordingly. Subacute diffusion-weighted imaging-magnetic resonance imaging confirmed acute ischemic myelopathy in all but one patient. Favorable outcome was achieved in two patients rapidly and in three patients at three-month follow-up. We identified seven other thrombolyzed acute ischemic myelopathy patients in the literature, who showed variable recovery and no hemorrhagic complications.

CONCLUSIONS:

With appropriate acute imaging, intravenous thrombolysis after acute ischemic myelopathy is feasible and potentially safe within 4.5 h. Given the potential of benefit of thrombolysis in acute ischemic myelopathy, this treatment warrants further efficacy and safety studies.

This paper is cited in the neurochecklist:

Spinal cord infarction (SCI): management

Spinal Cord 7. SpinalFlames09 on Flickr. https://www.flickr.com/photos/greenflames09/116396795

Abstract link

Categories
Stroke

Do seizures at stroke onset increase the risks of thrombolysis?

TRISP Collaborators. Intravenous thrombolysis for suspected ischemic stroke with seizure at onset.

Polymeris AA, Curtze S, Erdur H, et al; TRISP collaborators
Ann Neurol 2019; 86:770-779.

Abstract

OBJECTIVE:

Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke.

METHODS:

In this multicenter, IVT-registry-based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3-month mortality, and 3-month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses.

RESULTS:

Among 10,074 IVT-treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non-SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio [OR]unadjusted = 1.53 [95% confidence interval (CI) = 0.74-3.14], ORadjusted = 0.52 [95% CI = 0.13-2.16], ORmatched = 0.68 [95% CI = 0.15-3.03], ORweighted = 0.95 [95% CI = 0.39-2.32]), mortality (ORunadjusted = 1.49 [95% CI = 1.00-2.24], ORadjusted = 0.98 [95% CI = 0.5-1.92], ORmatched = 1.13 [95% CI = 0.55-2.33], ORweighted = 1.17 [95% CI = 0.73-1.88]), and functional outcome (mRS ≥ 3/ordinal mRS: ORunadjusted = 1.33 [95% CI = 0.96-1.84]/1.35 [95% CI = 1.01-1.81], ORadjusted = 0.78 [95% CI = 0.45-1.32]/0.78 [95% CI = 0.52-1.16], ORmatched = 0.75 [95% CI = 0.43-1.32]/0.45 [95% CI = 0.10-2.06], ORweighted = 0.87 [95% CI = 0.57-1.34]/1.00 [95% CI = 0.66-1.52]). These results were consistent regardless of whether patients had an eventual diagnosis of ischemic stroke (89/146) or stroke mimic (57/146 SaO patients).

INTERPRETATION:

Seizure at stroke onset was not an independent predictor of poor prognosis. Withholding intravenous thrombolysis from patients with assumed ischemic stroke presenting with seizure at onset seems unjustified.

This paper is cited in the neurochecklist:

Thrombolysis: clinical use

Abstract link

By Bruce C. V. Campbell, Geoffrey A. Donnan and Stephen M. Davis.Uploaded by Mikael Häggström – (2014). “Vessel Occlusion, Penumbra, and Reperfusion – Translating Theory to Practice”. Frontiers in Neurology 5. DOI:10.3389/fneur.2014.00194. ISSN 1664-2295.(CC-BY-4.0), CC BY 4.0, Link
Categories
Neurochecklists updates

20 recently updated practical neurology checklists

Neurochecklists is a comprehensive and practical neurology database

Handy and fully referenced, it is in a constant state of review and renewal

Below are just 21 of our recently updated neurology checklists

***

Cervical artery dissection: clinical features 

Epilepsy: blood and CSF features 

Huntington’s disease: clinical features 

Leber hereditary optic neuropathy: management 

Parkinson’s disease tremor

***

Behcet’s disease: clinical features

MND C9orf72 variant

Thrombectomy 

Neuropathy: toxic and drug-induced 

Narcolepsy: clinical features

***

Epicrania fugax

West Nile virus: clinical features 

Thrombolysis: complications 

Migraine: CGRP monoclonal antibodies

Lambert Eaton myasthenic syndrome: clinical features

***

Alzheimer’s disease

Pes cavus

Immune checkpoint inhibitor toxicity: management

Adrenoleukodystrophy: phenotypes

Myotonic dystrophy type 2: management

***

Categories
Neurochecklists updates

30 recently revised and updated practical neurology checklists

Neurochecklists is proud of being comprehensive and practical.

But more than that, we take pride in keeping each checklist updated.

To do this, we keep a keen eye on all relevant developments in the literature.

And below are just a few of the checklists that we have recently revised.

They all reflect findings from the latest neurology publications.

***

Anti Ma2 syndrome

Cerebral aneurysms rupture risk factors

Cerebral vein thrombosis

CGRP monoclonal antibodies

CJD

Dural AV fistula management

Giant cell arteritis treatment

Gluten sensitivity neurology

IIH clinical features

King-Denborough syndrome

Levetiracetam

Migraine acute treatment

MND c9orf72

Multiple sclerosis clinical features

Narcolepsy

Normal pressure hydrocephalus

Ocular myasthenia gravis

Oculopharyngeal muscular dystrophy

Ocrelizumab

Parkinson’s disease risk factors

Post stroke recrudescence

PSP variants

Psychogenic seizures

Rapid onset dystonia-parkinsonism

Retinal migraine

Seizure manifestations

Stiff person syndrome

Subacute combined degeneration

Suprascapular neuropathy

Thrombolysis

***

Categories
Stroke

Does thrombolysis add any value to stroke thrombectomy?

IV thrombolysis prior to mechanical thrombectomy in large vessel occlusions.

Katsanos AH, Malhotra K, Goyal N, et al.

Ann Neurol 2019; 86:395-406

Abstract

Objective:

The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT;IVT followed by MT), compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusions (LVO).

Methods:

We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post-hoc analyses from RCTs that provided data on the outcomes of AIS patients with LVO stratified by the IVT treatment status prior to MT.

Results:

We identified 38 eligible observational studies (11,798 LVO patients, mean age 68 years, 56% treated with BT). In unadjusted analyses BT was associated with a higher likelihood of three-month functional independence (OR=1.52,95%CI:1.32-1.76), three-month functional improvement (cOR for 1-point decrease in mRS-score=1.52,95%CI:1.18-1.97), early neurological improvement (OR=1.21,95%CI:1.83-1.76), successful recanalization (OR=1.22,95%CI:1.02-1.46) and successful recanalization with less than two device passes (OR=2.28,95%CI:1.43-3.64) compared to dMT. BT was also related to a lower likelihood of three-month mortality (OR=0.64, 95%CI: 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of three-month functional independence (adjusted OR=1.55, 95%CI:1.26-1.91) and a lower odds of three-month mortality (adjusted OR=0.80,95%CI:0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR=1.24,95%CI:0.89-1.74) or symptomatic ICH (adjusted OR=0.87,95%CI:0.61-1.25).

Conclusion:

Bridging therapy appears to be associated with improved functional independence without evidence for safety concerns, compared to direct mechanical thrombectomy, for acute ischaemic stroke patients with large vessel occlusion.

This reference is cited in the neurochecklist:

Thrombectomy

By Marvin 101 – Own work, CC BY-SA 3.0, Link

Abstract link

Categories
Stroke

Is thrombolysis effective 9 hours after stroke?

Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke.

Ma H, Campbell BCV, Parsons MW, et al; EXTEND Investigators.

N Engl J Med 2019; 380:1795-1803.

Abstract

BACKGROUND:

The time to initiate intravenous thrombolysis for acute ischemic stroke is generally limited to within 4.5 hours after the onset of symptoms. Some trials have suggested that the treatment window may be extended in patients who are shown to have ischemic but not yet infarcted brain tissue on imaging.

METHODS:

We conducted a multicenter, randomized, placebo-controlled trial involving patients with ischemic stroke who had hypoperfused but salvageable regions of brain detected on automated perfusion imaging. The patients were randomly assigned to receive intravenous alteplase or placebo between 4.5 and 9.0 hours after the onset of stroke or on awakening with stroke (if within 9 hours from the midpoint of sleep). The primary outcome was a score of 0 or 1 on the modified Rankin scale, on which scores range from 0 (no symptoms) to 6 (death), at 90 days. The risk ratio for the primary outcome was adjusted for age and clinical severity at baseline.

RESULTS:

After 225 of the planned 310 patients had been enrolled, the trial was terminated because of a loss of equipoise after the publication of positive results from a previous trial. A total of 113 patients were randomly assigned to the alteplase group and 112 to the placebo group. The primary outcome occurred in 40 patients (35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group (adjusted risk ratio, 1.44; 95% confidence interval [CI], 1.01 to 2.06; P = 0.04). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted risk ratio, 7.22; 95% CI, 0.97 to 53.5; P = 0.05). A secondary ordinal analysis of the distribution of scores on the modified Rankin scale did not show a significant between-group difference in functional improvement at 90 days.

CONCLUSIONS:

Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group.

This paper is cited in the neurochecklist:

Thrombolysis: clinical use

By Dr. Johannes Sobotta(Life time: -1945) – http://babel.hathitrust.org/cgi/pt?id=ien.35558004773517;view=1up;seq=5, Public Domain, Link

Abstract link

Categories
Stroke

How beneficial is thrombolysis before thrombectomy for stroke?

Comparison of outcomes after mechanical thrombectomy alone or combined with intravenous thrombolysis and mechanical thrombectomy for patients with acute ischemic stroke due to large vessel occlusion.

Choi JH, Im SH, Lee KJ, Koo JS, Kim BS, Shin YS.

World Neurosurg 2018; 114:e165-e172.

Abstract

BACKGROUND:

Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) provides additional benefits remains controversial. We aimed to compare clinical and radiologic outcomes between IVT+MT and MT alone groups.

METHODS:

We retrospectively reviewed the clinical and radiological features of patients from the prospectively collected database who sustained anterior circulation stroke due to large vessel occlusion (LVO) and were treated with MT within 8 hours of symptom onset. We compared rates of successful reperfusion, functional independence and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) as clinical endpoints between the 2 groups.

RESULTS:

The 81 patients included in this study included 38 (46.9%) in the MT alone group (mean age, 72.6 ± 14.1 years; 17 males [44.7%]) and 43 in the IVT+MT group (mean age, 68.9 ± 12.8 years; 29 males [67.4%]). There were no significant differences in patient baseline characteristics between the 2 groups except for a male predominance in the IVT+MT group. The mean interval from onset to groin puncture (221.6 ± 110.5 minutes vs. 204.7 ± 63.7 minutes; P = 0.472) and the rate of successful reperfusion rate (thrombolysis in cerebral infarction 2b/3, 60.5% vs. 58.1%; P = 0.827) did not differ significantly between the MT and IVT+MT groups. The rate of favorable functional outcome, as determined by a modified Rankin Scale score 0-2 (36.8% vs. 51.2%; P = 0.263) and mortality at 90 days (18.4% vs. 9.3%; P = 0.332), and the rate of sICH (5.3% vs. 4.6%; P = 1.000) were also not significantly different between the 2 groups.

CONCLUSIONS:

This study suggests that previous intravenous thrombolysis might not facilitate successful reperfusion and favorable functional outcomes in patients with anterior circulation stroke treated with mechanical thrombectomy. Mechanical thrombectomy alone can be a safe and effective treatment modality in patients who are ineligible for intravenous thrombolysis for various reasons.

This paper is cited in the neurochecklist:

Thrombectomy

Abstract link

By Neilbarman at English Wikipedia, CC BY-SA 3.0, Link