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Outcomes in Mild Acute Ischemic Stroke Treated With Intravenous Thrombolysis A Retrospective Analysis of the Get With the Guidelines–Stroke Registry
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.
Source: JAMA Neurology - February 2, 2015 Category: Neurology Source Type: research

In-Hospital Stroke
There have been tremendous strides in standardization of the care for acute ischemic stroke since widespread use of thrombolytic therapy began almost 20 years ago. Efficacy is still limited by delayed presentation to the emergency department following stroke symptom onset, although this has also improved in that period with education of emergency medical services and the community at large. The real improvement lies in development of streamlined and standardized protocols for “code stroke,” so that thrombolysis rates of 20% are becoming typical and door-to-needle times are just as typically under 1 hour. These encourag...
Source: JAMA Neurology - May 4, 2015 Category: Neurology Source Type: research

Prehospital Thrombolysis for Stroke An Idea Whose Golden Hour Has Arrived
Soon after thrombolytic therapy was established as a therapy for ischemic stroke, our colleague Anthony Furlan, MD, famously circulated a cartoon of a computed tomographic (CT) scanner visible through the back doors of an ambulance, where a happy stroke physician had hung a bottle dripping tissue plasminogen activator (tPA) into the scanned patient’s arm. Because the time interval from stroke onset to initiation of thrombolysis after ischemic stroke is inversely related to the probability of disability-free recovery, prehospital initiation of thrombolytic therapy seemed a compelling and logical ambition, if one could rul...
Source: JAMA Neurology - November 17, 2014 Category: Neurology Source Type: research

Questions on Predicting Early Neurological Deterioration in Patients With Minor Stroke and Large-Vessel Occlusion —Reply
In Reply We thank Ospel and colleagues for their thoughtful comments on our article showing that more proximal occlusion and greater thrombus length predict early neurological deterioration of ischemic origin (ENDi) in patients with acute minor ischemic stroke with large-vessel occlusion treated with intravenous thrombolysis, with implications regarding how to best manage these patients. Although the precise pathophysiological links between more proximal occlusion, a longer thrombus, and ENDi are uncertain, we fully agree that a leading hypothesis is in situ thrombus extension leading to secondary hemodynamic compromise vi...
Source: JAMA Neurology - July 6, 2021 Category: Neurology Source Type: research

Dual Thrombolytic Therapy With Mutant Prourokinase and Small Bolus Alteplase for Ischemic Stroke
This randomized clinical trial of individuals with ischemic stroke assesses the safety and efficacy of treatment with a dual plasminogen activator vs usual treatment with intravenous alteplase.
Source: JAMA Neurology - May 22, 2023 Category: Neurology Source Type: research

Thrombolysis Works in Lacunar Infarct, Complicating Imaging Selection
A new, exploratory analysis of the Efficacy and Safety of MRI-Based Thrombolysis in Wake-up Stroke (WAKE-UP) trial by Barow and colleagues in this issue ofJAMA Neurology provides unique and compelling data suggesting that thrombolysis improves clinical outcomes after acute lacunar infarction. The European Union –commissioned, 500-patient, randomized, double-blind, placebo-controlled WAKE-UP trial of alteplase captured the magnetic resonance imaging (MRI) and magnetic resonance angiography of patients with acute ischemic stroke prior to thrombolysis. This allowed categorization of infarcts as lacunar vs n onlacunar, using...
Source: JAMA Neurology - March 25, 2019 Category: Neurology Source Type: research

Building Evidence on Safety of Thrombolysis for Patients Receiving Direct Oral Anticoagulants
Nearly 20% of patients with acute ischemic stroke (AIS) are undergoing direct oral anticoagulant (DOAC) treatment at the time of their stroke. Common indications for DOACs among these patients include stroke prevention from atrial fibrillation, treatment of venous and pulmonary thrombosis, and coronary and peripheral atherosclerotic disease. Novel indications for DOAC use are expected to emerge and may increase the proportion of patients with AIS who are undergoing treatment with DOACs. Current US and European acute stroke treatment guidelines recommend withholding intravenous thrombolysis (thrombolysis), a morbidity- and ...
Source: JAMA Neurology - January 3, 2023 Category: Neurology Source Type: research

Treatment of Poststroke Aphasia With Transcranial Direct Current Stimulation
Stroke remains a leading cause of human disability. Important gains have been realized in the setting of acute ischemic stroke, where thrombolytic and catheter-based reperfusion therapies can substantially improve long-term behavioral outcomes. However, most patients with a new stroke are not eligible for such therapies because of delays in diagnosis or hemorrhagic etiology, for example, and many who are treated nonetheless have substantial long-term disability. Additional classes of poststroke therapy are needed.
Source: JAMA Neurology - August 20, 2018 Category: Neurology Source Type: research

Left Atrial Enlargement Could Be Detected on Extended Computed Tomography Angiography —Reply
In Reply We agree with Popkirov that left atrial volume is a better marker of incident atrial fibrillation than atrial diameter; however, we did not have these data available at all of the sites participating in the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) trial. Recently completed and ongoing studies will help determine if our observation has a clinical role and may provide additional data on left atrial size and function. Once all of these data are available, guidelines committees will likely make recommendat...
Source: JAMA Neurology - November 11, 2019 Category: Neurology Source Type: research

Progress in Intravenous Thrombolytic Therapy for Acute Stroke
This review traces the development of intravenous thrombolysis to date, considers the shortcomings of alteplase, and examines alternative thrombolytic approaches currently in the pipeline, including the role of neuroimaging and the possibility of combination therapies.
Source: JAMA Neurology - June 1, 2015 Category: Neurology Source Type: research

Obesity, Oral Contraceptive Use, and Cerebral Venous Thrombosis
Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that primarily affects young adults. A unique risk factor profile and plurality of presenting features make it an elusive diagnosis unless a high index of suspicion is maintained. It comprises approximately 0.5% to 1% of all strokes, and widespread availability of magnetic resonance imaging has made recognition easier. The International Study on Cerebral Vein and Dural Sinus Thrombosis is the largest prospective, multinational, observational study of patients with CVT to date, including 624 consecutive patients with symptomatic CVT at 89 centers between May ...
Source: JAMA Neurology - March 15, 2016 Category: Neurology Source Type: research

Association Between Calcium Level and Hematoma Size and Expansion
Intracerebral hemorrhage (ICH) is a common and deadly type of stroke, with high rates of morbidity and mortality (40%-50% in most series). There are several well-described and validated risk factors and diseases that increase the risk of ICH, including race, hypertension, use of anticoagulants, amyloid angiopathy, renal insufficiency, thrombolytic therapy, and drug abuse. However, not all ICHs are associated with one of these risk factors. This suggests that there might be some other modifying factors involved.
Source: JAMA Neurology - September 6, 2016 Category: Neurology Source Type: research

Safety and Efficacy of Dabigatran vs Warfarin After CVT
This randomized clinical trial conducted in 9 countries compares the use of dabigatran with warfarin in stroke prevention among patients who just experienced cerebral venous thrombosis.
Source: JAMA Neurology - September 3, 2019 Category: Neurology Source Type: research