Early Intravenous Thrombolysis for Acute Ischemic Stroke in a Community-Based Approach

Grond, Martin; Stenzel, Christoph; Schmülling, Susanne; Rudolf, Jobst; Neveling, M.; Lechleuthner, A.; Schneweis, Susanne; Heiss, Wolf‐Dieter

doi:10.1161/01.str.29.8.1544

Cited by 221 publications

(168 citation statements)

References 27 publications

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“…We found no difference in the occurrence of SICH and early in-hospital mortality between the sub-3 h and 3-4.5 h groups. We observed a similar incidence of SICH (5.7%) and early in-hospital mortality (9.7%) in thrombolysis up to 4.5 h as were reported in the NINDS study [1] and other t-PA registries [7,[12][13][14][15][16][17][18][19], where most patients were treated within 3 h. In the ATLANTIS trial [4], 7.0% of the t-PA treated patients in the 3-5 h time window had a SICH, compared to 5.3% in our cohort.…”

Section: Discussionsupporting

confidence: 84%

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Uyttenboogaart

Vroomen

Stewart

et al. 2007

Journal of the Neurological Sciences

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Background: The administration of tissue plasminogen activator (t-PA) has been proven effective for ischemic stroke within 3 h after onset. A pooled-analysis of six trials showed that intravenous t-PA still improves outcome when given between 3 to 4.5 h after stroke onset. On the basis of this pooled analysis, t-PA was also routinely offered to our patients between 3-4.5 h. We report the safety and clinical features of this group together with the features of the group given t-PA within 3 h. Methods: Prospectively patient characteristics, stroke severity, stroke subtype, incidence of symptomatic intracerebral hemorrhage (SICH), in-hospital mortality, and 3-months modified Rankin Scale scores (mRS) were registered. Data was analyzed separately for patients treated within 3 h (early group) and those treated between 3-4.5 h (late group). Results: Among 176 patients who underwent intravenous thrombolysis, 101 were treated in the early group and 75 in the late group. Six (5.9%; 95% CI 2.8%-12.3%) patients in the early group and 4 (5.3%; 95% CI 2.2%-12.9%) in the late group developed SICH (p = 1.0). In the early group 13 (12.9%; 95% CI 7.7%-20.8%) patients died within 7 days after admission, compared to 5 (6.7%; 95% CI 3.0%-14.7%) in the late group (p = 0.179). In the early group 44 (43.6%; 95% CI 43.3%-53.3%) were independent (mRS ≤ 2) at three months, compared to 36 (48.0%; 95% CI 37.0%-59.1%) in the late group (p = 0.559). Conclusion: Our data show no trend of decreased safety of thrombolysis beyond 3 h. Due to a small sample size a harmful effect cannot be excluded but seems unlikely.

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Section: Discussionsupporting

confidence: 84%

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Uyttenboogaart

Vroomen

Stewart

et al. 2007

Journal of the Neurological Sciences

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“…Only 9% to 22% of the patients receive intravenous thrombolysis. 19,17 In the present series 16.8% received intra-arterial thrombolysis. We must consider how to further increase the number of patients treated.…”

Section: Discussionmentioning

confidence: 57%

“…12,14,[17][18][19][20][21] It has also been shown that educational programs for both the public and physicians increase the number of patients arriving at the hospitals within the time limits for thrombolysis. 22 In US stroke centers, up to 59% of the patients who presented within 24 hours of symptom onset arrived within 3 hours.…”

Section: Discussionmentioning

confidence: 99%

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Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis

Nedeltchev

Arnold

Brekenfeld

et al. 2003

Stroke

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Background and Purpose-Thrombolysis for treatment of acute ischemic stroke should be administered as fast as possible after symptom onset. The aim of this study was to examine, in our tertiary care center, the time intervals preceding intra-arterial thrombolysis in order to accelerate and optimize the management of acute strokes. Methods-Between January 1, 2000, and April 30, 2002, 597 patients with acute stroke were admitted to our stroke center.One hundred forty-eight patients underwent diagnostic arteriography, and 100 (16.8%) received intra-arterial thrombolysis. For all patients, we prospectively recorded and analyzed the time of symptom onset, admission, CT and/or MRI scan, diagnostic arteriography, and, if performed, intra-arterial thrombolysis. Results-The mean time to arrival in the emergency department was 99 minutes for patients who were admitted directly (Bern patients), 127 minutes for those who were referred from community hospitals without a CT scanner (non-Bern/ϪCT patients), and 210 minutes for patients from hospitals with imaging facilities (non-Bern/ϩCT patients).The mean delay from symptom onset to treatment was 234 minutes for Bern patients, 269 minutes for non-Bern/ϪCT patients, and 302 minutes for non-Bern/ϩCT patients. The patients from the last group needed longer to receive intra-arterial thrombolysis than did patients who were admitted directly (Pϭ0.002) or who were transferred from a hospital without a CT scanner (Pϭ0.03). Conclusions-This prospective study indicates that direct referral without prior imaging at community hospitals shortens the time until intra-arterial thrombolysis. In addition, our in-hospital delay preceding intra-arterial thrombolysis is longer than the delays reported for intravenous thrombolysis and indicates potential for improvement.

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“…However, a post-hoc analysis concluded that patients treated within 3 hours appeared to benefit from rt-PA treatment. In fact, community studies have confirmed the safety and usefulness of the drug in routine clinical practice when administered within the first 3 hours after stroke symptom onset (2,30,74). Recently finished is the multinational Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) which was designed to evaluate the safety and efficacy of IV rt-PA under routine clinical use when administered within 3 hours of symptom onset in acute ischemic stroke patients.…”

Section: Pharmacology Of Restoration Of Cerebral Perfusionmentioning

confidence: 99%

Stroke pathophysiology: management challenges and new treatment advances

Jordán

Ikuta

García-García

et al. 2007

J. Physiol. Biochem.

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J. JORDÁN, I. IKUTA, J. GARCÍA-GARCÍA, S. CALLEJA and T. SEGURA. Stroke pathophysiology: Management challenges and new treatment advances (minireview). J. Physiol. Biochem., 63 (3), 261-278, 2007. Stroke is the second leading cause of death and the first cause of lost disabilityadjusted years in developed countries. During the past decade, new developments in thrombolytic therapy have led to the implementation of emergency intervention protocols for the treatment of ischemic stroke, replacing the widespread sense of therapeutic nihilism in the past. Treatment with rtPA has shown to be effective within the first 3 hours following stroke onset and the FDA and the European Medical Agency (EMEA) have approved its use. Acknowledging the urgency and intricacies of stroke, Stroke Units allow the monitoring of physiological parameters in the acute phase of stroke and are considered an important management tool that can significantly improve the quality of care provided to the patient. The concept of neuroprotective therapy for acute ischemic stroke to salvage tissue at risk and improve functional outcome is based on sound scientific principles and extensive preclinical animal studies demonstrating efficacy. However, most neuroprotective drugs in clinical trials have failed, possibly due to inadequate preclinical testing or flawed clinical development programs. Several new treatment strategies are under development and are being tested. This review is directed at understanding the management of acute ischemic stroke pathophysiology. We address the management challenges and new treatment advances by integrating the knowledge of possible pharmacological targets for acute ischemic stroke. We hope to shed new light upon the controversy surrounding the management of acute ischemic stroke in an attempt to elucidate why failed clinical trials continue to occur despite promising neuroprotective preclinical studies.

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Early Intravenous Thrombolysis for Acute Ischemic Stroke in a Community-Based Approach

Abstract: Thrombolysis with rtPA was effectively applied in routine management of stroke patients in a community-based approach with acceptable efforts and without additional costs. Under these circumstances, outcome and complication rates were comparable to those of multicenter trials.

Cited by 221 publications

References 27 publications

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis

Stroke pathophysiology: management challenges and new treatment advances

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