Predictors of Thrombolysis Administration in Mild Stroke

Asdaghi, Negar; Wang, Kefeng; Ciliberti-Vargas, Maria A; Gutierrez, Carolina M; Koch, Sebastian; Gardener, Hannah; Dong, Chuanhui; Rose, David Z.; Garcia, Enid; Burgin, W. Scott; Zevallos, Juan Carlos; Rundek, Tatjana; Sacco, Ralph L.; Romano, José G.

doi:10.1161/strokeaha.117.019341

Cited by 29 publications

(9 citation statements)

References 25 publications

(17 reference statements)

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“…8 Additionally, prior observational cohorts not undergoing thrombolysis may have included more severely affected patients, given recent trends toward increased use of alteplase for patients with minor stroke in clinical practice. 4,5 An increase in sICH was associated with alteplase in this population (risk difference, 3.3%; 95% CI, 0.8%-7.4%) without an associated increase in mortality. In a nationwide US registry, among 5910 patients with NIHSS scores of 0 to 5 treated with alteplase in routine practice, a 1.8% (95% CI, 1.5%-2.2%) absolute risk of sICH was observed.…”

Section: Discussionmentioning

confidence: 81%

“…Clinical use of alteplase for ischemic stroke with low National Institutes of Health Stroke Scale (NIHSS) scores has increased in recent years, presumably based on concern for this substantial poststroke disability. 4,5 Although alteplase is the standard of care for patients with ischemic stroke and disabling deficits regardless of severity judged by NIHSS scores, 6,7 the optimal management of patients with not clearly disabling deficits is unclear. Most major trials of alteplase (NINDS Parts 1 and 2; ECASS 1, 2, and 3; Atlantis Parts A and B; and EPITHET) explicitly excluded varying subsets of patients with the mildest deficits (see eTable 1 in Supplement 1 for exclusion criteria).…”

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confidence: 99%

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Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits

Investigators

2018

JAMA

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IMPORTANCE More than half of patients with acute ischemic stroke have minor neurologic deficits (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) at presentation. Although prior major trials of alteplase included patients with low NIHSS scores, few without clearly disabling deficits were enrolled. OBJECTIVE To evaluate the efficacy and safety of alteplase in patients with NIHSS scores of 0 to 5 whose deficits are not clearly disabling. DESIGN, SETTING, AND PARTICIPANTS The PRISMS trial was designed as a 948-patient, phase 3b, double-blind, double-placebo, multicenter randomized clinical trial of alteplase compared with aspirin for emergent stroke at 75 stroke hospital networks in the United States. Patients with acute ischemic stroke whose deficits were scored as 0 to 5 on the NIHSS and judged not clearly disabling and in whom study treatment could be initiated within 3 hours of onset were eligible and enrolled from May 30, 2014, to December 20, 2016, with final follow-up on March 22, 2017. INTERVENTIONS Participants were randomized to receive intravenous alteplase at the standard dose (0.9 mg/kg) with oral placebo (n = 156) or oral aspirin, 325 mg, with intravenous placebo (n = 157). MAIN OUTCOMES AND MEASURES The primary outcome was the difference in favorable functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days via Cochran-Mantel-Haenszel test stratified by pretreatment NIHSS score, age, and time from onset to treatment. Because of early termination of the trial, prior to unblinding or interim analyses, the plan was revised to examine the risk difference of the primary outcome by a linear model adjusted for the same factors. The primary safety end point was symptomatic intracranial hemorrhage (sICH) within 36 hours of intravenous study treatment. RESULTS Among 313 patients enrolled at 53 stroke networks (mean age, 62 [SD, 13] years; 144 [46%] women; median NIHSS score, 2 [interquartile range {IQR}, 1-3]; median time to treatment, 2.7 hours [IQR, 2.1-2.9]), 281 (89.8%) completed the trial. At 90 days, 122 patients (78.2%) in the alteplase group vs 128 (81.5%) in the aspirin group achieved a favorable outcome (adjusted risk difference, −1.1%; 95% CI, −9.4% to 7.3%). Five alteplase-treated patients (3.2%) vs 0 aspirin-treated patients had sICH (risk difference, 3.3%; 95% CI, 0.8%-7.4%). CONCLUSIONS AND RELEVANCE Among patients with minor nondisabling acute ischemic stroke, treatment with alteplase vs aspirin did not increase the likelihood of favorable functional outcome at 90 days. However, the very early study termination precludes any definitive conclusions, and additional research may be warranted.

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Section: Discussionmentioning

confidence: 81%

mentioning

confidence: 99%

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits

Investigators

2018

JAMA

Self Cite

284

251

View full text Add to dashboard Cite

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“…The physicians' fears of risk of intracranial hemorrhage among other side effects of thrombolytic therapy may play a role in clinical decision to treat patients which affects the DTN [37]. Khathami et al [38] claimed that the main reasons for emergency physicians who do not recommend tPA use were that they found the said treatment lacking efficacy or effectiveness.…”

Section: Barriers On Timely Administration Of Tpamentioning

confidence: 99%

Timely Administration of Thrombolytic Therapy in Acute Ischemic Stroke: An Ethnographic Study

Catangui¹,

Baua²,

Pizarro³

et al. 2020

Int J Nurs Clin Pract

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“…The 2019 guidelines for AIS thus recommended that minor disabling AIS patients could be treated with alteplase [ 5 ]. Treatment with alteplase in minor stroke has increased in recent years to reduce potential post-stroke disability [ 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

Minor Non-Disabling Stroke Patients with Large Vessel Severe Stenosis or Occlusion Might Benefit from Thrombolysis

et al. 2021

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Background: The benefit of alteplase in minor non-disabling acute ischemic stroke (AIS) is unknown. We aimed to explore the clinical efficacy of alteplase-treatment in minor non-disabling stroke in clinical practice. Methods: We used a prospectively collected database of AIS patients who were being assessed for thrombolysis with alteplase. Minor non-disabling AIS was identified as patients with baseline National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 and a score 0 or 1 on each baseline NIHSS score item (items 1a to 1c being 0). Results: A total of 461 patients with minor non-disabling AIS were included and among them 240 (52.1%) patients were treated with alteplase and 113 (24.5%) patients had severe stenosis/occlusion of large vessels. No significant association of 90-day excellent outcome was found with alteplase-treatment (77.1% vs. 80.5%, p 1 = 0.425; OR 0.911, 95% CI 0.428 to 1.940; p 2 = 0.808). However, among patients with severe stenosis/occlusion of large vessels, alteplase-treatment was independently associated with excellent outcome (74.4% vs. 45.7%, p 1 = 0.005; OR 4.709, 95% CI 1.391 to 11.962; p 2 = 0.010). Conclusion: Although alteplase-treatment did not result in an excellent outcome in general minor non-disabling stroke patients, it may work in those specific patients who had severe stenosis/occlusion of large vessels.

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Predictors of Thrombolysis Administration in Mild Stroke

Cited by 29 publications

References 25 publications

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits

Timely Administration of Thrombolytic Therapy in Acute Ischemic Stroke: An Ethnographic Study

Minor Non-Disabling Stroke Patients with Large Vessel Severe Stenosis or Occlusion Might Benefit from Thrombolysis

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