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Cardioembolic stroke on unaffected side during thrombolysis for acute ischemic stroke  [cached]
Garg Arun,Yaduvanshi Amitabh,Mohindra Kapil
Neurology India , 2010,
Abstract: Cardiac thrombus is not an established contraindication to thrombolysis with intravenous tissue plasminogen activator in acute ischemic stroke. Recurrent ischemic stroke involving an initially unaffected arterial territory during the course of thrombolysis in stroke has been reported, but remains exceptionally rare. We present a case that developed cardioembolic stroke on the previously unaffected side during thrombolysis for acute ischemic stroke.
First experience with intravenous thrombolysis in ischemic stroke in Serbia  [PDF]
Jovanovi? Dejana,Besla?-Bumba?irevi? Ljiljana,Kosti? Vladimir
Srpski Arhiv za Celokupno Lekarstvo , 2007, DOI: 10.2298/sarh0712621j
Abstract: Introduction Systemic thrombolytic therapy in the first three hours of acute ischemic stroke (IS) significantly improves its outcome. This therapy was approved for treatment in USA in 1997, and in most European countries in 2002. First intravenous thrombolysis of IS in Serbia was carried out in February 2006. Objective We present our preliminary experience with intravenous thrombolysis in treating patients with acute IS and compare it with the results of other clinical studies. Method All patients with IS treated with intravenous thrombolysis in our department were included in the study. The time of stroke onset, first neurological exam, time of CT exam and beginning of therapy were recorded. The early CT signs of ischemia were graded by the ASPECTS score. Neurological deficit was assessed with NIHSS score and functional outcome with modified Rankin Scale (mRS). Results During the eight-month period intravenous thrombolysis was given to 12 patients with acute IS, aged 18 to 66 years, of whom 75% were younger than 55 years. Median time from symptom onset to hospital door was 57.5 minutes, median time door-to-CT was 32.5 minutes, and the time from symptom onset to treatment was 155 minutes. Early CT signs of ischemia were present in 10 patients with median ASPECTS score 9. Median initial NIHSS score was 16.5 with its decline during the first 24 hours for at least 5 points in 58% of patients. Symptomatic intracerebral haemorrhage was present in one patient. After 30 days of follow-up 42% of patients had favourable outcome (mRS≤1). In only 2 patients the outcome was poor (mRS 4-5). One patient died with signs of cardiac failure. Conclusion Despite a small number of patients with short time of follow up, these results with thrombolysis in acute IS were found to be consistent with other authors’ reports. Uniqueness of our series of patients who received thrombolysis as compared to other studies was their very young age.
Abdominal wall hemorrhage after intravenous thrombolysis for acute ischemic stroke  [cached]
An Se-A,Kim Jinkwon,Kim Sang Heum,Kim Won Chan
BMC Neurology , 2013, DOI: 10.1186/1471-2377-13-6
Abstract: Background Thrombolysis is strongly recommended for patients with significant neurologic deficits secondary to acute ischemic stroke. Extracranial bleeding is a rare but major complication of thrombolysis. Case presentation A 78-year-old woman presented with acute ischemic stroke caused by occlusion of the basilar artery. Clinical recovery was observed after successful recanalization by intravenous thrombolysis and intraarterial thrombectomy. However, the patient complained of sudden abdominal pain following the intervention and a newly developed abdominal wall mass was found. CT scan and selective angiography confirmed active bleeding from the left epigastric artery into the abdominal muscle layer and the bleeding was successfully managed by selective embolization of the bleeding artery. Conclusions We report a rare case of abdominal wall hemorrhage after thrombolysis for acute ischemic stroke. The findings indicate that abdominal wall hemorrhage should be considered as a differential diagnosis in the presence of abdominal discomfort after thrombolysis for acute ischemic stroke.
Hemorrhagic transformation in ischemic stroke and its treatment during thrombolysis  [cached]
Maurizio Paciaroni,Luca Masotti,Valeria Caso
Reviews in Health Care , 2011, DOI: 10.7175/rhc.3921s99-107
Abstract: Haemorrhagic transformation (HT) of brain infarction or hemorrhagic infarction is a complication of acute ischemic stroke, especially in cardioembolic stroke, and represents the most feared complication of thrombolysis. HT is a multifocal secondary bleeding into brain infarcts with innumerable foci of capillary and venular extravasation either remaining as discrete petechiae or emerging to form confluent purpura. HT is evidenced as a parenchymal area of increased density within an area of low attenuation in a typical vascular distribution on non-contrasted CT scans and is subdivided into two major categories on the basis of standardised definition: haemorrhagic infarct (HI) and parenchymal haematoma (PH). PH has been associated to poor outcome in ischemic stroke patients. Thus, its prevention, early detection and adequate treatment represent key points in the management of acute stroke.
Thrombolysis in acute ischemic stroke: where and when?
Giuseppe Micieli,Simona Marcheselli,Stefano Ottolini,Salvatore Badalamenti
Emergency Care Journal , 2007, DOI: 10.4081/ecj.2007.6.18
Abstract: The therapy of acute ischemic stroke remains an open challenge for the clinicians and is closely connected to the ready acknowledgment of symptoms, to the promptness of the instrumental diagnosis and consequently to the rapidity of the pharmacological intervention. Although several studies have validated the effectiveness and the safety profileof the intravenous fibrinolytic treatment, the number of patients who benefit of such therapeutic opportunity is still too little. This data is partially due to the delay within patients arrive to the hospital and to the doubts of the physicians on the possible collateral effects, but it is also related to logistic and organizational-managerial problematic of the patient with acute stroke.These last ones mainly derive from the deficiency on the national territory of dedicated structures (Stroke Unit), from the absence of operative connections between the 118-service and the Stroke Unit, from the delay of the neurologist calling in the emergency room that does not allow an adapted diagnostic evaluation of the ischemic event. The spread of the intravenous fibrinolysis must therefore necessarily pass through the creation of participation protocols between hospitals with stroke unit and primary aid, and between department of emergency/ urgency and staff of the stroke unit also previewing the creation of professional figures like those of the urgency neurologist that could have the full right of the management and the treatment of cerebral ischemic pathology.
Sex, Diastolic Blood Pressure, and Outcome after Thrombolysis for Ischemic Stroke  [PDF]
David Nathanson,Cesare Patrone,Thomas Nystr?m,Mia von Euler
Stroke Research and Treatment , 2014, DOI: 10.1155/2014/747458
Abstract: Background. The goal of this study was to identify differences in risk factors and functional outcome between the two sexes in patients treated with thrombolysis for ischemic stroke. Methods. This cohort study audited data from patients treated with thrombolysis for ischemic stroke during a 3-year period at S?dersjukhuset, Stockholm. Results. Of the 355 patients included in the study, 162 (45%) were women and 193 (54%) were men. Women were older with a median age of 76 years; median age for men was 69 years ( ). Diastolic blood pressure was lower for women compared to men ( ). At admission fewer women had a favorable modified Rankin Scale score compared to men (93.8% versus 99%, ). Three months after discharge functional status did not differ significantly between the two sexes. Diastolic blood pressure was associated to functional outcome only in men when sex specific odds ratios were calculated (OR, 5.7; 95% CI, 1.7–20). Conclusion. The study indicates that females appear to gain a relatively greater benefit from thrombolytic therapy than men due to a better functional recovery. A higher diastolic blood pressure increases the risk for a worse prospective functional status in men. 1. Introduction Stroke is the primary cause of severe acquired disability in adults with 500,000 new cases each year in Europe [1, 2]. Administration of recombinant tissue plasminogen activator (rtPA), alteplase (Actilyse), within 4.5?h after onset of stroke, is an efficient treatment in patients where an intracerebral hemorrhage and other contraindications have been excluded [3–6]. Overall, women and men have a similar incidence for ischemic cerebrovascular disease but women are more frequently hit by stroke later in life than men [7]. Several epidemiological studies have shown that women having more severe stroke symptoms at admission, a worse prognosis, are less likely to return home and to live independently [8, 9] and have an overall worse outcome after ischemic stroke than men [10, 11]. However, some studies show a similar outcome for men and women after stroke [12, 13] and there is evidence that women treated with tPA benefit at least as much as men [14–16]. Very recently a study from the prospective multinational Safe Implementation of Treatments in Stroke International Stroke Thrombolysis Register (SITS-ISTR) suggested a possible larger beneficial effect of intravenous tPA in women compared with men [17]. Several recent studies have shown the same risk of bleeding and positive treatment effects in patients above 80 years old even though this age group has an overall
Views of Emergency Physicians on Thrombolysis for Acute Ischemic Stroke
Bentley J. Bobrow, Bart M. Demaerschalk, Joseph P. Wood, Albert Villarin, Lani Clark and Anthony Jennings
Journal of Central Nervous System Disease , 2012,
Abstract: Background: The 3-hour window for treating stroke with intravenous tissue plasminogen activator (t-PA) requires well-organized, integrated efforts by emergency physicians and stroke neurologists. Objective: To evaluate attitudes and knowledge of emergency physicians about intravenous t-PA for acute ischemic stroke, particularly in primary stroke centers (PSCs) with stroke neurology teams. Methods: A 15-question pilot Internet survey administered by the Arizona College of Emergency Physicians. Results: Between March and August 2005, 100 emergency physicians responded: 71 in Arizona and 29 in Missouri. Forty-eight percent practiced at PSCs; 48% thought t-PA was effective, 20% did not, and 32% were uncertain. PSC or non-PSC location of practice did not influence endorsement (odds ratio, 0.96; 95% confidence interval, 0.27–1.64). Of those opposing t-PA, 87% cited risk of hemorrhage. Conclusions: Most emergency physicians did not endorse t-PA. Improved collaboration between emergency physicians and stroke neurologists is needed.
Intra-arterial thrombolysis in acute ischemic stroke: A single center experience  [cached]
Huded Vikram,Dhomne Sachin,Shrivastava Manish,Saraf Rashmi
Neurology India , 2009,
Abstract: Intra-arterial thrombolysis (IAT) is a treatment modality in patients with acute large vessel occlusive ischemic stroke. To our knowledge, this is probably the first reported study of intra-arterial thrombolysis in acute ischemic stroke from India. Of the 17 patients treated who recieved IAT, successful recanalization was achieved in nine patients, Thrombolysis in Myocardial Infarction (TIMI) score of 2 or 3. At 90-day follow-up, eight patients achieved modified Rankin Scale (mRS) score of < 2.
Combination therapy with normobaric oxygen (NBO) plus thrombolysis in experimental ischemic stroke
Norio Fujiwara, Yoshihiro Murata, Ken Arai, Yasuhiro Egi, Jie Lu, Ona Wu, Aneesh B Singhal, Eng H Lo
BMC Neuroscience , 2009, DOI: 10.1186/1471-2202-10-79
Abstract: Upon clot injection, cerebral perfusion in the MCA territory dropped below 20% of pre-ischemic baselines. Both tPA-treated groups showed effective thrombolysis (perfusion restored to nearly 100%) and smaller infarct volumes (379 ± 57 mm3 saline controls; 309 ± 58 mm3 NBO; 201 ± 78 mm3 tPA; 138 ± 30 mm3 tPA plus NBO), showing that tPA-induced reperfusion salvages ischemic tissue and that NBO does not significantly alter this neuroprotective effect. NBO had no significant effect on hemorrhagic conversion, brain swelling, or mortality.NBO can be safely co-administered with tPA. The efficacy of tPA thrombolysis is not affected and there is no induction of brain hemorrhage or edema. These experimental results require clinical confirmation.Intravenous tissue plasminogen activator (tPA) remains the only acute stroke therapy that is approved by the FDA and established to improve clinical outcome [1,2]. However, the use of this thrombolytic agent has been limited by the need to deliver treatment within a narrow therapeutic time window, presently 3 hours, and the excess risk of brain hemorrhage and edema ('reperfusion injury') if treatment is started at delayed time points after stroke [1,2]. It is important to develop strategies that can safely extend the therapeutic time window for tPA and thereby increase the utilization of this effective treatment.A key factor that increases the risks for brain edema and hemorrhage, and reduces the efficacy of tPA, is the development of substantial cellular necrosis prior to treatment. Preventing early cell death may allow relatively delayed thrombolysis with tPA, without compromising safety. Several animal [3-16] and human [17-19] studies have documented that normobaric oxygen therapy (NBO) therapy is neuroprotective in acute ischemic stroke. Imaging studies indicate that NBO slows down and transiently arrests the process of ischemic cell death[6,14,18,19]. Since it is simple to administer, noninvasive, inexpensive, widely available, and
Predictors of Critical Care Needs after IV Thrombolysis for Acute Ischemic Stroke  [PDF]
Roland Faigle, Anjail Sharrief, Elisabeth B. Marsh, Rafael H. Llinas, Victor C. Urrutia
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0088652
Abstract: 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.
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