Multiple microemboli after disintegration of clot during thrombolysis for acute myocardial infarction.

586

237

Purpose-To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke. Methods-Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke 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.This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 24, 2015, and the American Heart Association Executive Committee on October 5, 2015. 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 online-only Data Supplement, which contains literature search strategies and Figures A, B, and C, is available with this article at http://circ. ahajournals.org/lookup/suppl/doi:10.1161/STR.0000000000000086/-/DC1.The American Heart Association requests that this document be cited as follows: Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE; on behalf of the American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific rational...

Section: Left-sided Heart Thrombusmentioning

confidence: 99%

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Demaerschalk¹,

Kleindorfer²,

Adeoye³

et al. 2016

586

237

“…Артериальная гипертензия 151 (66) 52 (70) 99 (64) Сахарный диабет 24 (10) 12 (16,2) 12 (7,8) Гиперлипидемия 48 (21) 14 (19) 34 (22) Курение сигарет 56 (24,5) 11 (15) 45 (29) ТИА или инсульт в анамнезе 45 (19,7) 13 (17,5) 32 (20,8) Прием аспирина 105 (46) 44 (59,5) 61 (39,6) Прием других антиагрегантов 22 (9,5) 6 (8) 16 (10) Прием антикоагулянтов 7 (3) 5 (6,7) 2 (1,3)…”

Section: данные анамнеза N (%)unclassified

“…Оценка по шкале NIH, медиана (МКР) 14 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) 14 (8-19) 14,5 (7-20) Время до начала лечения, среднее ± СО, минуты 170±38 162,7±32 173,3±40 РНН, n (%) 34 (15) 12 (16,2) 22 (14,3) Прогрессирование инсульта, n (%) 18 (8) 4 (5,4) 14 (9) СВМК, n (%) 10 (4,4) 3 (4) 7 (4,5) РПИИ, n (%) 6 (2,6) 5 (6,8) с РПИИ (83,3%) и, наоборот, частота развития РПИИ была значительно выше (таблица 1) у пациентов с подтверж-денной ФП (6,8%, 95% ДИ от 2,6 до 15,2%) по сравнению с пациентами без ФП в анамнезе (0,6%, 95% ДИ от 0 до 3,9%, отношение рисков [OP]=11,1, 95% ДИ от 1,27 до 96,7, р=0,0146), кроме того РПИИ составлял 5 (42%) из 12 случаев РНН у пациентов с ФП по сравнению только с 1 из 22 случаев РНН у пациентов без ФП (ОР=15,0; 95% ДИ от 1,49 до 151,3; р=0,0136). В логистической регрес-сии только наличие в анамнезе ФП было ассоциировано с развитием РПИИ (ОР=11,1; 95% ДИ от 1,27 до 96, 7, р=0,029).…”

Section: характеристики инсультаunclassified

“…Вторичная эмболия после проведения системного тромболизиса, в т. ч. развитие ишемического инсульта, считается редким его осложнением при острой ишемии миокарда [8][9][10][11][12][13][14], тромбозе искусственного клапана серд-ца [15][16][17][18] и массивной тромбоэмболии легочной арте-рии [19] и предположительно происходит в результате разрушения существующего внутрисердечного тромба или тромба на клапанах сердца. Наличие ранее сущест-вующего тромба в левом желудочке было документально подтверждено при проведении эхокардиографии до раз-вития ишемического инсульта как осложнения тром-болизиса при острой ишемии миокарда [10,13], причем после инсульта происходило уменьшение размера тромба или его исчезновение.…”

Section: ■ обсуждениеunclassified

See 1 more Smart Citation

Early Recurrent Ischemic Stroke Complicating Intravenous Thrombolysis for Stroke

Awadh

MacDougall²,

Santosh³

et al. 2010

Background and Purpose— Mechanisms of early neurologic deterioration after treatment with intravenous, recombinant, tissue-type plasminogen activator (IV rt-PA) include symptomatic intracerebral hemorrhage (SICH) and early recurrent ischemic stroke. We observed a number of cases of acute deterioration due to recurrent ischemic events. Methods— We undertook a single-center, retrospective analysis of consecutive acute stroke patients treated with IV rt-PA between January 2006 and December 2008 to define the incidence of early neurologic deterioration (≥4-point drop on the National Institutes of Health Stroke Scale within 72 hours) and its mechanism. Deterioration was attributed to SICH when associated with a PH1 or PH2 hemorrhage on postdeterioration computed tomography scans, to recurrent ischemic stroke when there was clinical and radiologic evidence of a new territorial infarction or new vessel occlusion, and otherwise to evolution of the incident stroke. Results— Of 228 consecutive IV rt-PA–treated patients, 34 (15%) developed early neurologic deterioration, 18 (8%) secondary to incident strokes 10 (4.4%) due to SICH, and 6 (2.6%) due to early recurrent ischemic events, which were significantly associated with atrial fibrillation (present in 5 of 6 patients; 4 paroxysmal, 1 permanent). In 4 patients, sudden clinical deterioration developed during or shortly after IV rt-PA infusion, and in 2, deterioration developed 3 days later. All died 2 days to 2 weeks later. The single case without atrial fibrillation had a recurrent, contralateral, middle cerebral artery stroke during IV rt-PA infusion and multiple high-signal emboli detected by transcranial Doppler. Early recurrent ischemic stroke accounted for 5 of 12 (42%) cases of early neurologic deterioration in patients with atrial fibrillation. Conclusion— In this single-center series, the incidence of early recurrent ischemic stroke after IV rt-PA was 2.6% and was associated with previous atrial fibrillation.

“…Thromboembolic complications have been observed in 1.5% of patients receiving systemic thrombolysis for acute myocardial infarction, who were believed to have a preexisting clot. 51 Very few data are available to evaluate the risk to benefit ratio of thrombolysis in stroke patients with cardiac thrombus. One study reported 5 patients with a cardiac thrombus who were given intravenous alteplase for stroke.…”

Section: Cardiac Embolusmentioning

confidence: 99%

Intravenous Alteplase for Stroke

Keyser

Gdovinová

Uyttenboogaart

et al. 2007

150

Background and Purpose-Because of the risk of hemorrhage, especially in the brain, thrombolytic therapy with intravenous alteplase is restricted by guidelines, and only a small number of selected patients are being treated. Findings from metaanalyses, post hoc analyses of the randomized trials, and postlicensing experience suggest that more subjects, who otherwise have a poor predicted outcome without treatment, might benefit from intravenous alteplase. Summary of Review-There is a strong indication that treatment may still be beneficial beyond 3 hours up until 4.5 hours.The risk of symptomatic intracerebral hemorrhage is not increased in patients aged 80 years or older. Excluding patients with severe stroke or with early ischemic changes in more than one third of the middle cerebral artery territory on baseline CT scan is probably not necessary when treatment is started Ͻ3 hours of symptom onset. Patients with minor or improving symptoms can also benefit. Intravenous thrombolysis appears appropriate as first line therapy for posterior circulation stroke. Alteplase can be given to patients with cervical artery dissection, seizure at onset and evidence of acute ischemia on brain imaging, and after carefully weighing risk and benefit in pregnancy and during menstruation. There are anecdotal reports on its use in children, patients with recent myocardial infarction, cardiac embolus, intracranial aneurysm or arteriovenous malformation, prior stroke and recent surgery. There appears to be a substantially increased risk of symptomatic cerebral hemorrhage in hyperglycemic stroke patients. The combined intravenous and intraarterial approach to recanalization appears safe and is currently under investigation in a randomized trial. Conclusions-This document does not intend to change the guidelines but reviews the literature on the use of intravenous alteplase for stroke beyond guidelines and in particular conditions.