Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence

AbstractPurpose of ReviewRecent evidence has shown an overwhelming benefit of mechanical thrombectomy for acute anterior circulation large vessel occlusion (LVO). Whether there is any additional benefit of IV tPA treatment prior to thrombectomy over thrombectomy alone is unproven in randomized trials. In this review, we summarize the available evidence for and against pre-thrombectomy treatment with IV tPA.Recent FindingsIn clinical trials demonstrating efficacy of thrombectomy, the majority of included patients were eligible for (and treated with) IV tPA. Systemic thrombolysis prior to thrombectomy is fraught with potential disadvantages: delay in thrombectomy, increased risk of systemic hemorrhagic complications and angioedema, and limitation of endovascular treatment options in patients who require more vigorous antithrombotic treatment (for instance due to stent placement). Two randomized clinical trials comparing outcomes of patients treated with IV tPA + thrombectomy versus thrombectomy alone have recently reported their outcomes. The DIRECT-MT investigators found no difference in functional outcomes or mortality among patients pre-treated with IV tPA prior to thrombectomy, while the SKIP investigators found similar rates of good functional outcome and mortality between treatment groups--although they failed to demonstrate non-inferiority. The limitations of these trials are reviewed here.  Therefore, much of our understanding relies on indirect comparisons between...
Source: Current Treatment Options in Neurology - Category: Neurology Source Type: research

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This study aimed to investigate the prognostic value of PNR and PWR in acute ischemic stroke patients treated with EVT. METHODS: Poor functional outcome was defined as Modified Rankin Scale (mRS) of 3-6 at 3 months, Symptomatic intracranial hemorrhage (sICH) was diagnosed based on CT scan and classified according to the criterial of Heidelberg Bleeding Classification. Binary logistical regression was used to analyze the relationship of PWR, PNR with functional outcome and symptomatic intracranial hemorrhage (sICH). RESULTS: Patients with good prognosis had higher PNR and PWR value (29 vs. 24, P=0.002) (22 vs. 19, P...
Source: Neurological Research - Category: Neurology Tags: Neurol Res Source Type: research
Conclusion: tPA treatment is frequently used as first-line therapy for acute ischemic stroke. Therefore, physicians should be aware of the potential for the SCEH in patients presenting with hemiparesis, as tPA administration may increase cervical hematoma leading to clinical deterioration. With this case, we intended to warn about SCEH as a rare but possible entity, since its early recognition and prompt clinical intervention may improve neurological outcomes. PMID: 32637210 [PubMed]
Source: Surgical Neurology International - Category: Neurosurgery Tags: Surg Neurol Int Source Type: research
Authors: Kruska M, Fastner C, Scheitz JF, Kolb A, Rutsch M, Papavassiliu T, Borggrefe M, Alonso A, Akin I, Szabo K, Baumann S Abstract Routine determination of troponin levels is recommended for all patients with acute ischemic stroke. In 20-55% of these patients the troponin levels are elevated, which may be caused by ischemic as well as non-ischemic myocardial damage and particularly neurocardiogenic myocardial damage. In patients with acute ischemic stroke, the prevalence of previously unknown coronary heart disease is reported to be up to 27% and is prognostically relevant for these patients; however, relevant ...
Source: Herz - Category: Cardiology Tags: Herz Source Type: research
Authors: Deltour S, Pautas E Abstract Primary and secondary prevention of stroke is often a challenge in elderly patients due to the increase in both thrombotic and hemorrhagic risks with age. In some cases, there is sufficient data in the elderly population to allow recommendations or anticoagulation decisions to be made, such as for the indication of anticoagulation to prevent stroke related to atrial fibrillation (AF) or the choice of oral anticoagulant therapy in this situation. In other situations, the less robust data leave some questions; this is the case for the delay to initiate an oral anticoagulant thera...
Source: Revue Neurologique - Category: Neurology Tags: Rev Neurol (Paris) Source Type: research
ConclusionsNon-HHT PAVMs occur more commonly in females, are most commonly simple and single, and have lower lobe predominance and a high rate of neurologic complications. Potential predisposing risk factors were identified in about 40% of the cases. Clinicians should be aware of the risk of PAVM development in patients with history of chest trauma, congenital heart disease, lung infection/abscess, and thoracic surgery.
Source: Lung - Category: Respiratory Medicine Source Type: research
ConclusionPatients with ESUS have IPH in the carotid artery ipsilateral to the ischemic stroke in 25.8% of cases. Carotid artery vessel wall MRI should be considered as part of the standard work-up in patients with ESUS.
Source: Clinical Neuroradiology - Category: Neurology Source Type: research
CONCLUSIONS The efficacy of MT and IVT was comparable in AMIS patients with LVO. While MT had a higher incidence of systemic complications, its short- and long-term effects were equivalent to IVT. PMID: 32628645 [PubMed - as supplied by publisher]
Source: Medical Science Monitor - Category: Research Tags: Med Sci Monit Source Type: research
AbstractTo determine the correlation of uric acid (UA) with hemorrhagic transformation (HT) and poor short-term functional outcomes in anterior circulation acute ischemic stroke (AIS) patients after endovascular thrombectomy (EVT). A retrospective analysis was conducted for anterior circulation AIS patients who underwent EVT at our hospital from 2015 to 2019. HT within 72  h was documented according to the European Cooperative Acute Stroke Study II Classification. Baseline demographic, clinical and laboratory data were compared between the HT and non-HT groups, and between patients with favorable and unfavorable outco...
Source: Metabolic Brain Disease - Category: Neurology Source Type: research
We present a case of stroke in a 62-year-old COVID-19-positive patient, with multiple vascular risk factors. The patient arrived 1 h after onset of symptoms, was treated with recombinant tissue plasminogen activator (rtPA) with improvement of neurologic deficits, and later developed right foot arterial ischemia (recanalized by balloon catheter angioplasty) and left arm superficial venous thrombosis. A control computed tomography (CT) scan 7 days after onset showed hemorrhagic transformation of ischemic lesion without mass effect. However, respiratory and neurologic conditions improved so that the patient was discharged to ...
Source: Cerebrovascular Diseases - Category: Neurology Source Type: research
Abstract Blood-brain barrier (BBB) integrity injury within the thrombolytic time window is becoming a critical target to reduce haemorrhage transformation (HT). We have previously reported that BBB damage was initially damaged in non-infarcted striatum after acute ischaemia stroke. However, the underlying mechanism is not clear. Since acute ischaemic stroke could induce a significant increase of dopamine release in striatum, in current study, our aim is to investigate the role of dopamine receptor signal pathway in BBB integrity injury after acute ischaemia using rat middle cerebral artery occlusion model. Our dat...
Source: J Cell Mol Med - Category: Molecular Biology Authors: Tags: J Cell Mol Med Source Type: research
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