Very Mild Stroke Patients Benefit from Intravenous Tissue Plasminogen Activator Without Increase of Intracranial Hemorrhage

Hassan, Ameer E; Hassanzadeh, Bahareh; Tohidi, Vahid; Kirmani, Jawad F.

doi:10.1097/smj.0b013e3181d7814a

Cited by 30 publications

(22 citation statements)

References 24 publications

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“…1,2,19 While the definition of symptomatic ICH used in GWTG-Stroke is not identical to the National Institute of Neurological Disorders and Stroke criteria, 1,20 it is similar and reasonably comparable. In smaller series of mild stroke treated with IV rtPA (27-488 patients), the risk of symptomatic ICH varied from 0% to 5%, 10,[21][22][23][24][25][26][27][28] and similar to our results, no increased risk was found in those treated in the extended window.…”

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confidence: 90%

Outcomes in Mild Acute Ischemic Stroke Treated With Intravenous Thrombolysis

et al. 2015

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IMPORTANCE Mild strokes have been poorly represented in thrombolytic trials and only a few series have reported outcomes after treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) after mild stroke. OBJECTIVE To report treatment complications and short-term outcomes in patients with mild stroke who have received treatment with IV rtPA. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of patients treated in the emergency department of hospitals that use the Get With the Guidelines-Stroke registry, a prospectively collected quality improvement registry used by hospitals across the United States. Patients were those admitted between May 1, 2010, and October 1, 2012, with acute ischemic stroke within 4.5 hours from symptom onset and a baseline National Institutes of Health Stroke Scale score of 5 or less. Univariable and multivariable analyses were performed to identify factors independently associated with discharge outcomes and treatment complications. INTERVENTION Intravenous rtPA. MAIN OUTCOMES AND MEASURESTreatment complications included symptomatic intracranial hemorrhage, life-threatening or serious systemic hemorrhage, other serious complications, and undetermined complications. The short-term outcomes analyzed were in-hospital mortality, discharge to home, independent ambulation at discharge, and length of stay. RESULTS Among 33 995 patients who arrived within 4.5 hours of symptom onset and were treated with IV rtPA, 7621 (22.4%) had a National Institutes of Health Stroke Scale score of 5 or less and 5910 had complete data for analysis. Treatment complications were infrequent: symptomatic intracranial hemorrhage, 1.8%; life-threatening or serious systemic hemorrhage, 0.2%; other serious complications, 1.8%; and complications of undetermined cause, 2.4%. Mortality was low (1.3%), but at discharge 30.3% could not ambulate independently, 29.4% could not go directly home, and 73.0% had a length of stay of 3 days or longer. Worse short-term outcomes were seen in older patients, African American patients, diabetic patients, and those who arrived by ambulance, after hours, or with a higher National Institutes of Health Stroke Scale score. CONCLUSIONS AND RELEVANCEMany patients with ischemic stroke treated with IV rtPA have a mild stroke. Symptomatic intracranial hemorrhage is infrequent, but approximately 30% of these patients are unable to return directly home or ambulate independently at discharge. Additional studies are needed to identify strategies to improve the outcomes in patients with mild stroke who receive thrombolysis.

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confidence: 90%

Outcomes in Mild Acute Ischemic Stroke Treated With Intravenous Thrombolysis

et al. 2015

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“…125,126 Risk of hemorrhagic transformation in milder stroke patients is significantly lower than for more severe strokes, ranging from 0% to 2% in the literature. [127][128][129][130] However, these estimates were obtained from smaller studies and have wide CIs. Given that relatively few patients were enrolled in clinical trials of intravenous alteplase that included milder cases, the risk-to-benefit ratio for administration of intravenous alteplase in milder stroke cases is unknown and requires further study.…”

Section: 123mentioning

confidence: 99%

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

Demaerschalk¹,

Kleindorfer²,

Adeoye³

et al. 2016

Stroke

586

237

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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...

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“…Our results are therefore based on a representative cohort of patients with acute cerebral ischemia encountered in daily clinical practice. Most of previous cohorts describe the outcome of either treated (5,21) or not treated patients (22), used historical controls (23), or excluded patients with contraindications to rt-PA therapy (19), rendering comparison difficult.…”

Section: Discussionmentioning

confidence: 99%