Abstract:Background and purpose: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. Methods: The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-mont… Show more
“…14 Trials are underway to test the effectiveness of thrombectomy in patients with large-artery occlusion and NIHSS scores 0–5 (In Extremis/Minor Stroke Therapy Evaluation [MOSTE; NCT 03796468], Endovascular Therapy for low NIHSS Ischemic Strokes [ENDOLOW; NCT 04167527]). In addition, two recent multicentre observational studies suggest a potential beneficial effect of IVT 118 and bridging therapy 119 in acute ischaemic stroke patients with minor stroke (NIHSS-scores < 6) and large vessel occlusion.Expert consensus statement For patients with acute minor, non-disabling ischaemic stroke of < 4.5 h duration, and with large-vessel occlusion, 6 of 8 group members suggest intravenous thrombolysis with alteplase. One group member (WW) did not vote or comment on this chapter because he has been involved in the data monitoring committee of a trial related to this topic (TEMPO-2).…”
Section: Resultsmentioning
confidence: 99%
“…Quality of evidence: Very low Strength of recommendation: - NCT 04167527]). In addition, two recent multicentre observational studies suggest a potential beneficial effect of IVT 118 and bridging therapy 119 in acute ischaemic stroke patients with minor stroke (NIHSS-scores < 6) and large vessel occlusion.…”
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
“…14 Trials are underway to test the effectiveness of thrombectomy in patients with large-artery occlusion and NIHSS scores 0–5 (In Extremis/Minor Stroke Therapy Evaluation [MOSTE; NCT 03796468], Endovascular Therapy for low NIHSS Ischemic Strokes [ENDOLOW; NCT 04167527]). In addition, two recent multicentre observational studies suggest a potential beneficial effect of IVT 118 and bridging therapy 119 in acute ischaemic stroke patients with minor stroke (NIHSS-scores < 6) and large vessel occlusion.Expert consensus statement For patients with acute minor, non-disabling ischaemic stroke of < 4.5 h duration, and with large-vessel occlusion, 6 of 8 group members suggest intravenous thrombolysis with alteplase. One group member (WW) did not vote or comment on this chapter because he has been involved in the data monitoring committee of a trial related to this topic (TEMPO-2).…”
Section: Resultsmentioning
confidence: 99%
“…Quality of evidence: Very low Strength of recommendation: - NCT 04167527]). In addition, two recent multicentre observational studies suggest a potential beneficial effect of IVT 118 and bridging therapy 119 in acute ischaemic stroke patients with minor stroke (NIHSS-scores < 6) and large vessel occlusion.…”
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
“…non‐IVT‐treated iICAo) was not available. Although IVT likely is beneficial in acute minor strokes with intracranial occlusions [22], further studies are warranted specifically regarding minor strokes with iICAo. Note that in the observational ICARO (Internal Carotid ARtery Occlusion) study [23], which reported better outcomes in IVT as compared to non–IVT‐treated patients with ICA occlusion, the proportion of patients with iICAo is unknown, as occurrence of tandem ICA + MCA occlusions is not presented.…”
Background and purposeBetter understanding the incidence, predictors and mechanisms of early neurological deterioration (END) following intravenous thrombolysis (IVT) for acute stroke with mild symptoms and isolated internal carotid artery occlusion (iICAo) may inform therapeutic decisions.MethodsFrom a multicenter retrospective database, we extracted all patients with both National Institutes of Health Stroke Scale (NIHSS) score <6 and iICAo (i.e. not involving the Willis circle) on admission imaging, intended for IVT alone. END was defined as ≥4 NIHSS points increase within 24 h. END and no‐END patients were compared for (i) pre‐treatment clinical and imaging variables and (ii) occurrence of intracranial occlusion, carotid recanalization and parenchymal hemorrhage on follow‐up imaging.ResultsSeventy‐four patients were included, amongst whom 22 (30%) patients experienced END. Amongst pre‐treatment variables, suprabulbar carotid occlusion was the only admission predictor of END following stepwise variable selection (odds ratio = 4.0, 95% confidence interval: 1.3–12.2; P = 0.015). On follow‐up imaging, there was no instance of parenchymal hemorrhage, but an intracranial occlusion was now present in 76% vs. 0% of END and no‐END patients, respectively (P < 0.001), and there was a trend toward higher carotid recanalization rate in END patients (29% vs. 9%, P = 0.07). As compared to no‐END, END was strongly associated with a poor 3‐month outcome.ConclusionsEarly neurological deterioration is a frequent and highly deleterious event after IVT for minor stroke with iICAo, and is of thromboembolic origin in three out of four patients. The strong association with iICAo site—largely a function of underlying stroke etiology—may point to a different response of the thrombus to IVT. These findings suggest END may be preventable in this setting.
“…Importantly, the effect of IVT was independent of preceded mechanical thrombectomy (MT). 16 On the other hand, there are concerns regarding the utility of IVT in LVO patients scheduled to undergo MT. Potential disadvantages of bridging IVT with MT include increased risk of systemic or intracranial hemorrhage, orolingual angioedema, and distal embolization.…”
Section: Reperfusion Therapies For Acute Isch-emic Strokementioning
confidence: 99%
“…Although NIHSS scores >10 are consistent with LVO, cases with low NIHSS scores, even lower of 4, are not uncommon. 33,16 TCD may rapidly detect cases with LVO causing a minor stroke, a finding that might encourage tissue plasminogen activator (tPA) administration without further delays to reduce the likelihood of late clinical deterioration. 34 In such cases, LVO detection may also prompt some stroke experts to select tenecteplase as thrombolytic instead of alteplase, based on preliminary data showing higher recanalization rates with tenecteplase in comparison to alteplase.…”
Section: Tcd/tccd Applications In Acute Ischemic Stroke Diagnosismentioning
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
