Symptomatic Intracerebral Hemorrhage in Acute Ischemic Stroke After Thrombolysis With Intravenous Recombinant Tissue Plasminogen Activator

Yaghi, Shadi; Eisenberger, Andrew; Willey, Joshua Z.

doi:10.1001/jamaneurol.2014.1210

Cited by 162 publications

(111 citation statements)

References 30 publications

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“…The high proportion of HT in our sample diagnosed only at brain autopsy can be explained partially by the fact that control CT is performed only 24 h after thrombolysis [21]. Although the half-life of t-PA is only few minutes, there is a prolonged effect on the coagulation cascade [23,24].…”

Section: Discussionmentioning

confidence: 98%

Haemorrhagic transformation in ischaemic stroke is more frequent than clinically suspected – A neuropathological study

Szepesi

Csokonay

Murnyák

et al. 2016

Journal of the Neurological Sciences

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ObjectivesThe vast majority of literature on the frequency of the haemorrhagic transformation of ischaemic stroke is based on imaging studies. The purpose of the present study was to assess the added value of autopsy and neuropathological analysis in a neurology centre with emphasis on acute stroke care. MethodsWe retrospectively analysed the findings of 100 consecutive brain autopsies followed by detailed clinical correlation. ResultsThe clinical diagnosis was confirmed by neuropathology in every patient with intracerebral haemorrhage and with non-cerebrovascular neurological disorders (e.g. primary tumours, metastases, infections). At admission 64 patients (age 62 years, SD 6.5) were diagnosed with acute ischaemic stroke. In 10 of these patients (16%) haemorrhagic transformation was diagnosed clinically by a second CT. In 24 cases (38%) haemorrhagic transformation was detected only at autopsy. The distribution of haemorrhagic transformation in our material was the following: small petechiae in 26.5%, more confluent petechiae in 29.4%, ≤ 30% of the infarcted area with some mild space-occupying effect in 29.4% and > 30% of the infarcted area with significant space-occupying effect or clot remote from infarcted area in 14.7%. Most of the PH1-2 transformations developed in thrombolysed patients and all of the PH2 type transformations were diagnosed already clinically. ConclusionsWe demonstrated that haemorrhagic transformation is frequent and often undiscovered in vivo. Our findings underline the importance of post-mortem neuropathological examination also in the era of advanced imaging techniques and prove that autopsy is the ultimate yardstick of our diagnostic and therapeutic efforts. The high number of haemorrhagic transformations diagnosed only after death is an important novel finding with clinical implications.

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Section: Discussionmentioning

confidence: 98%

Haemorrhagic transformation in ischaemic stroke is more frequent than clinically suspected – A neuropathological study

Szepesi

Csokonay

Murnyák

et al. 2016

Journal of the Neurological Sciences

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“…e-Aminocaproic acid inhibits fibrinolysis by preventing the conversion of plasminogen to plasmin and increases fibrinogen levels that are reduced in patients with SICH. 53 Tranexamic acid is a newer analog of e-aminocaproic acid. 54 Much of our current knowledge on the efficacy and safety of both e-aminocaproic acid and tranexamic acid comes from studies involving patients with aneurysmal subarachnoid hemorrhage.…”

Section: Management Of Sich After R-tpamentioning

confidence: 99%

“…57 The usefulness of other agents including prothrombin complex concentrate (PCC), fibrinogen, fresh frozen plasma (FFP), and recombinant factor VII in postthrombolysis ICH is unknown. 8,53 Since FFP activates the coagulation cascade, potentially driving fibrin formation, it can theoretically counter the effect of r-tPA, which increases plasmin activity. However, FFP must be administered slowly and in large volumes to prevent transfusion-related reactions and fluid overload.…”

Section: Management Of Sich After R-tpamentioning

confidence: 99%

“…For example, in warfarin-related ICH, it can take a median of 30 hours for FFP to return the international normalized ratio to normal limits, and although the mechanism of coagulopathy differs in thrombolysis-associated ICH, the length of time needed for reversal is similar, with concern for continued hematoma expansion before correction of the coagulopathy can occur. 53,58 Prothrombin complex concentrate (PCC) offers a quick way to activate both the intrinsic and the extrinsic pathways of the coagulation cascade, leading to the downstream conversion of fibrinogen into fibrin, but because r-tPA reduces fibrinogen levels, coadministration of fibrinogen to patients receiving PCC may be necessary. Importantly, the use of PCC in patients with recent ischemic stroke is associated with a low risk (approximately 1%) of thrombotic events.…”

Section: Management Of Sich After R-tpamentioning

confidence: 99%

“…Importantly, the use of PCC in patients with recent ischemic stroke is associated with a low risk (approximately 1%) of thrombotic events. 53,59 Although guidelines exist for blood pressure and surgical management of spontaneous ICH, they are lacking for postthrombolysis ICH. Given the lack of data in postthrombolysis ICH, we think it is reasonable to follow current guidelines for spontaneous ICH, which suggest a target blood pressure of 160/90 mm Hg and that the acute lowering of SBP to 140 mm Hg in patients presenting with a SBP of 150 to 220 mm Hg is probably safe 60 ( Table 3).…”

Section: Management Of Sich After R-tpamentioning

confidence: 99%

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Management of Postthrombolysis Hemorrhagic and Orolingual Angioedema Complications

O’Carroll

Aguilar

2015

The Neurohospitalist

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Intravenous recombinant tissue plasminogen activator was first approved for the treatment of acute ischemic stroke in the United States in 1996. Thrombolytic therapy has been proven to be effective in acute ischemic stroke treatment and shown to improve long-term functional outcomes. Its use is associated with an increased risk of symptomatic intracerebral hemorrhage as well as orolingual angioedema. Our goal is to outline the management strategies for these postthrombolysis complications.

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Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke

Zi¹,

Qiu²,

Li³

et al. 2021

JAMA

403

426

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IMPORTANCEFor patients with large vessel occlusion strokes, it is unknown whether endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment (standard treatment) can achieve similar functional outcomes. OBJECTIVE To investigate whether endovascular thrombectomy alone is noninferior to intravenous alteplase followed by endovascular thrombectomy for achieving functional independence at 90 days among patients with large vessel occlusion stroke.DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, noninferiority trial conducted at 33 stroke centers in China. Patients (n = 234) were 18 years or older with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from symptoms onset and eligible for intravenous thrombolysis. Enrollment took place from May 20, 2018, to May 2, 2020. Patients were enrolled and followed up for 90 days (final follow-up was July 22, 2020).INTERVENTIONS A total of 116 patients were randomized to the endovascular thrombectomy alone group and 118 patients to combined intravenous thrombolysis and endovascular thrombectomy group. MAIN OUTCOMES AND MEASURESThe primary end point was the proportion of patients achieving functional independence at 90 days (defined as score 0-2 on the modified Rankin Scale; range, 0 [no symptoms] to 6 [death]). The noninferiority margin was −10%. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. RESULTSThe trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization. All 234 patients who were randomized (mean age, 68 years; 102 women [43.6%]) completed the trial. At the 90-day follow-up, 63 patients (54.3%) in the endovascular thrombectomy alone group vs 55 (46.6%) in the combined treatment group achieved functional independence at the 90-day follow-up (difference, 7.7%, 1-sided 97.5% CI, −5.1% to ϱ)P for noninferiority = .003). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% vs 6.8%; difference, −0.8%; 95% CI, −7.1% to 5.6%) and 90-day mortality (17.2% vs 17.8%; difference, −0.5%; 95% CI, −10.3% to 9.2%).CONCLUSIONS AND RELEVANCE Among patients with ischemic stroke due to proximal anterior circulation occlusion within 4.5 hours from onset, endovascular treatment alone, compared with intravenous alteplase plus endovascular treatment, met the prespecified statistical threshold for noninferiority for the outcome of 90-day functional independence. These findings should be interpreted in the context of the clinical acceptability of the selected noninferiority threshold.

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Symptomatic Intracerebral Hemorrhage in Acute Ischemic Stroke After Thrombolysis With Intravenous Recombinant Tissue Plasminogen Activator

Cited by 162 publications

References 30 publications

Haemorrhagic transformation in ischaemic stroke is more frequent than clinically suspected – A neuropathological study

Haemorrhagic transformation in ischaemic stroke is more frequent than clinically suspected – A neuropathological study

Management of Postthrombolysis Hemorrhagic and Orolingual Angioedema Complications

Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke

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