Thrombolytic therapy in acute ischemic stroke patients with cardiac thrombus.

The authors describe the outcome of five patients with a cardiac thrombus selected among 183 patients with stroke (2.7 %) who were given IV tissue plasminogen activator (tPA). No early systemic or cerebral embolism occurred. Two patients made a complete recovery at 3 months. Two patients had a moderate outcome. One patient had late recurrent cerebral embolism and died. These data suggest that the presence of a cardiac thrombus is not associated with a high risk of recurrent embolism in patients with stroke who are given IV tPA.     

Thrombolytic therapy for acute ischemic stroke

The treatment of acute stroke changed dramatically since the publication of the NINDS trail for IV rt-PA for acute stroke. While this was not the first trial, it was the first positive trial. Subsequently there has been an explosion in acute treatment modalities since the NINDS trial showed that acute stroke treatment is feasible. The following chapter reviews the thrombolysis trials, the inclusion and exclusion criteria of intravenous and intra-arterial use of pharmacologic and mechanical thrombolysis in acute ischemic stroke. Also discussed are the new pharmacotherapies and mechanical devices that will hopefully expand the treatment window and make thrombolysis safer and more effective.     

Thrombolytic therapy in an adolescent ischemic stroke

We report the case of a 16-year-old Caucasian girl who developed acute onset of left hemiplegia, left hemisensory deficit, and dysarthria. After a negative computed tomographic scan of the brain, the patient was given intravenous recombinant tissue plasminogen activator according to established adult guidelines. The patient experienced a marked improvement within 24 hours. Stroke etiology was determined to be a paradoxical embolus via a patent foramen ovale associated with pelvic vein thrombosis. This case illustrates the importance of early recognition of stroke and the utility of thrombolytics in treating ischemic infarcts in the adolescent population.     

Thrombolytic therapy for acute ischemic stroke]

In this paper, results of the recent clinical trials were reviewed, and problems in treating patients with thrombolysis were discussed. Data generated from randomized controlled trials over the past few years have shown that acute intervention can improve neurological outcome in patients with ischemic stroke. Intravenous recombinant tissue plasminogen activator has become established as an acute treatment for stroke. Intra-arterial thrombolysis is a developing modality for the treatment of the acute stroke that shows promise in restoring cerebral arterial supply. However, thrombolysis have not approved yet in any forms in Japan. Under this circumstance, thrombolysis should be carried out in GCP-compatible clinical trials, so far. The overall results of a clinical trial cannot necessarily generalized to all patients in the trial and all similar future patients. A difference between settings of a clinical trial and of general practice should be also noted. Early recognition of stroke symptoms and immediate transfer to a suitable treatment facility should bring thrombolysis to a larger number of stroke victims. Finally, successful treatment is due in part to selecting patients who are not at increased risk for intracranial hemorrhage based on clinical and imaging features, and therefore rapid in-hospital triage protocols are mandatory.     

Thrombolytic therapy of acute ischemic stroke during pregnancy

The authors report eight pregnant women with acute ischemic stroke treated with thrombolysis (rt-PA [recombinant human tissue plasminogen activator] or urokinase). Seven women recovered. Two extracranial and two asymptomatic intracranial hemorrhages complicated treatment; one woman died of arterial dissection complicating angiography. Three patients had therapeutic abortions, two fetuses were miscarried, and two babies were delivered healthy. Although pregnant women may be treated safely with thrombolytics, risks and benefits to mother and fetus must be carefully weighed.     

Thrombolytic therapy in a patient with acute ischemic stroke caused by aortic dissection

The current medical literature indicates a poor outcome in patients with ischemic stroke in the presence of aortic dissection, especially in those who underwent thrombolytic therapy. We report a favorable outcome in a patient with acute stroke who received rt-PA and was later found to have Stanford type A aortic dissection.     

Thrombolytic therapy for acute ischemic stroke: 3 h and beyond

The current status of thrombolytic therapy approved by the US Food and Drug Administration is intravenous recombinant plasminogen activator given within 3 h of the onset of ischemic stroke. Intra-arterial therapy is possible for up to 6 h but is not Food and Drug Administration-approved for this purpose. Based on current radiologic methods (i.e., magnetic resonance imaging and perfusion computed tomography scans), it is being increasingly realized that the time window for effective thrombolytic therapy is variable, and salvageable tissue in the form of the ischemic penumbra may exist for longer periods of time and could therefore offer a greater time window based on these imaging studies. Development of an effective neuroprotective drug would greatly enhance the stability of the penumbra and offer further opportunities for extending the time window for reperfusion.     

Thrombolytic therapy in acute ischemic stroke in Asia: The first prospective evaluation

OBJECTIVE: Intravenous thrombolytic therapy has been widely recommended as a standard treatment for acute ischemic stroke in most clinical practice guidelines. However, the experience in Asia is still limited. We report the first prospective case series of thrombolytic therapy in a developing Asian country. PATIENTS AND METHODS: Consecutive patients with acute ischemic stroke who presented within 3 h of onset were screened under stroke fast track program. Those who were eligible were treated with intravenous recombinant tissue plasminogen activator (rt-PA). General and neurological examinations together with the National Institute of Health stroke scale (NHISS) and modified Rankin scale (MRS) were recorded prior to and after the treatment at 1 h, 24 h, on discharge and at 3 months. Hemorrhagic brain lesion and death within 3 months were also recorded. RESULTS: Thirty-four patients or 2.1% of patients with acute stroke received intravenous thrombolysis. The mean pretreatment NIHSS was 18.8 and the majority of patients had stroke in the middle cerebral artery territory. The mean door-to-needle time was 72.6 min (ranged 20-150 min). Major neurological improvement, defined as improving of the NIHSS >8 points or NIHSS of 0 points at 24 h, was observed in 17 patients (50%). Intracerebral hemorrhage was detected in four cases (11.8%), two of them were symptomatic (5.9%) and one was fatal. CONCLUSION: Intravenous thrombolysis can be given in patients with acute stroke in our population. Our cases were more severe than other studies. However, half of them experienced major neurological improvement. The risk of hemorrhagic brain lesion is not much higher than previously reported.     

Thrombolytic therapy in acute ischaemic stroke

BACKGROUND: The aim of this study was to assess the feasibility, clinical effect and safety of intravenous thrombolysis with tissue plasminogen activator in patients with acute ischaemic stroke treated in an acute stroke unit. METHODS: All patients admitted within 3 h after an acute ischaemic stroke were considered for thrombolysis. Twenty-four patients were treated. RESULTS: Ten patients demonstrated early clinical improvement compatible with a positive effect of thrombolysis. Five patients demonstrated a substantial but slow clinical improvement with an uncertain relationship to thrombolysis. Nine patients did not improve. One patient developed an intracerebral haematoma and 2 developed a haemorrhagic infarction without clinical deterioration. Five patients (21%) died within the first 3 months. At follow-up after 6 months, 10 patients (42%) had achieved independence [modified Rankin Scale (mRS) 0-2], 9 (33%) had an unfavourable outcome (mRS 3-5) and 5 patients (21%) had died. None of these 5 patients died due to a treatment complication. CONCLUSIONS: This study in a small patient population suggests that thrombolysis may be administered relatively safely in an acute stroke unit without intensive care facilities. The clinical effect and safety were similar to those which have been found in large randomised studies and clinical series.     

Early apixaban therapy after ischemic stroke in patients with atrial fibrillation

Journal of Neurology - The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. We aimed to objectively assess the rate of radiological hemorrhagic...     

Safety of induced hypertension therapy in patients with acute ischemic stroke

Introduction  The management of blood pressure in acute stroke is controversial. Small pilot studies have suggested that blood pressure augmentation improves short-term neurological function, but the rate of adverse events with induced hypertension (IH) therapy is unknown. Methods and Results  We reviewed 100 consecutive patients who underwent perfusion magnetic resonance imaging for acute ischemic stroke. IH therapy was employed in 46 patients and standard therapy (ST) in 54. The two groups had similar baseline characteristics, but more patients in the IH group had significant large-artery stenoses. The IH group achieved significantly higher mean arterial pressure (MAP) than the ST group within 3 days of initiation of therapy with a variety of vasopressor agents. Only 35% of patients in the IH group actually achieved the target MAP augmentation of 10–20% above baseline, however. All patients survived to discharge. Four patients experienced major adverse events in each group. Two patients in the IH group experienced intracerebral hemorrhage compared to none in the ST group. Two patients in the ST group experienced myocardial ischemia, compared to none in the IH group. The National Institutes of Health Stroke Scale during the hospitalization and place of discharge were similar in both groups. Patients in the IH group were more likely to be admitted to the intensive care unit and had a longer hospital stay by nearly 4 days compared to the ST group. Conclusion  These data demonstrate the relative safety of IH therapy in acute stroke patients. Given the greater use of resources, however, the role of IH in improving clinical outcomes requires a prospective, randomized trial.