IV vs. IA TPA in Acute Ischemic Stroke with CT Angiographic Evidence of Major Vessel Occlusion: A Feasibility Study

Sen, Souvik; Huang, David; Akhavan, Omid; Wilson, Susan E.; Verro, Piero; Solander, Sten

doi:10.1007/s12028-009-9204-1

Cited by 28 publications

(37 citation statements)

References 23 publications

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“…Of the 11 RCTs retrieved for detailed assessment, 4 were excluded owing to confounding (IV fibrinolysis in the control group in 2 trials, 11,12 IA fibrinolysis in the control group in 2 trials 13,14 ), and 2 were excluded for no mRS scores (or nearest equivalent) in the outcome assessment ( Figure 1). 15,16 Our final analysis included 5 RCTs, [17][18][19][20][21] comprising 395 individuals, with 224 (57%) participants randomly assigned to the active treatment group and 171 (43%) to the control group.…”

Section: Resultsmentioning

confidence: 99%

“…There are only 2 small RCTs with 34 participants comparing IA and IV fibrinolysis to date, and the results are inconclusive. 11,12 The results from the prospective observational registries comparing IA and IV efficacy were conflicting. 30,31 In the study of ischemic stroke with hyperdense middle cerebral artery sign on computed tomography, IA fibrinolysis was more beneficial than IV fibrinolysis, even though IA fibrinolysis was started later.…”

Section: Discussionmentioning

confidence: 99%

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Efficacy of Intra-Arterial Fibrinolysis for Acute Ischemic Stroke

Lee

Hong

Saver

2010

Stroke

142

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Background and Purpose-Although intra-arterial (IA) fibrinolysis for acute ischemic stroke has been clinically available for many years, it is not a therapy approved by the US Food and Drug Administration. Single, randomized, clinical trials (RCTs) have suggested beneficial effects, but no single RCT has demonstrated that IA fibrinolysis yields increases in both good (modified Rankin Scale score 0 to 2) and excellent (modified Rankin Scale score 0 to 1) outcomes when compared with the control group. Relatively few participants and inadequate statistical power in single RCTs may have contributed to this difficulty. Method-We performed a systematic literature search to identified RCTs of IA fibrinolysis in acute ischemic stroke.Multiple outcomes were analyzed, with emphasis on good and excellent outcomes at 90 days or at trial end point. Results-The systematic search identified 5 RCTs with 395 participants comparing IA fibrinolysis and control. IA fibrinolysis was associated with increased good (odds ratioϭ2.05; 95% CI, 1.33 to 3.14; Pϭ0.001) and excellent (odds ratioϭ2.14; 95% CI, 1.31 to 3.51; Pϭ0.003) outcomes. For additional end points, IA fibrinolysis was associated with increased frequencies of minimal neurologic deficit (National Institutes of Health Stroke Scale score 0 to 1), minimal impairment of activities of daily living (Barthel Index 90 to 100 or 95 to 100), and recanalization. IA fibrinolysis was associated with increased radiological and symptomatic intracerebral hemorrhage. However, there was no difference in mortality between groups. Conclusions-Formal meta-analysis suggests that IA fibrinolysis substantially increases recanalization rates and good and excellent clinical outcomes in acute ischemic stroke. Increased hemorrhage frequencies are not associated with any increase in mortality. (Stroke. 2010;41:932-937.)

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Efficacy of Intra-Arterial Fibrinolysis for Acute Ischemic Stroke

Lee

Hong

Saver

2010

Stroke

142

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“…Favorable outcomes (mRS score 0-2) were seen in 29 (53%) of 55 intra-arterial cases and 13 (23%) of 57 intravenous cases (P=0.001). In addition, a small feasibility study by Sen et al 549 randomized consecutive patients with proximal arterial occlusions on CTA scan within 3 hours of stroke symptom onset to standard intravenous rtPA (0.9 mg/kg) versus intra-arterial rtPA (up to 22 mg over 2 hours). Median NIHSS scores were 17 and 16 and mean ages were 71 and 66 years for the intravenous and intraarterial arms, respectively.…”

Section: Intra-arterial Fibrinolysismentioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

Stroke

5,372

1,801

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Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

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“…[18][19][20][21][22][23][24][25][26][27][28][29] Among these, a single trial of seven patients not presenting mRS outcome data was excluded. [18] Another trial that included an intravascular therapeutic procedure in both arms was also excluded. [19] Nine trials were suitable for meta-analysis (Table 1).…”

Section: Resultsmentioning

confidence: 99%

Intra-arterial treatment for acute ischemic stroke: a meta-analysis

Lakhan¹,

Walther²,

Morganstein³

et al. 2017

int arch med

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Objective: To assess the potential benefit of treating patients with acute ischemic stroke using intra-arterial methods. Methods:A meta-analysis of published randomized controlled trials that compared standard therapy with intravenous tissue plasminogen activator (IVtPA) for thrombolysis to intra-arterial therapies in patients with acute stroke was performed. All studies reported were analyzed as one group and studies documenting patients with large vessel obstruction were analyzed as a second group. The standardized mean difference (SMD) and the odds ratio (OR) of the dichotomized outcomes of Modified Rankin Scale (mRS) of these trials was calculated.

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IV vs. IA TPA in Acute Ischemic Stroke with CT Angiographic Evidence of Major Vessel Occlusion: A Feasibility Study

Cited by 28 publications

References 23 publications

Efficacy of Intra-Arterial Fibrinolysis for Acute Ischemic Stroke

Efficacy of Intra-Arterial Fibrinolysis for Acute Ischemic Stroke

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Intra-arterial treatment for acute ischemic stroke: a meta-analysis

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