Marilou Ching

Is acute reperfusion therapy safe in acute ischemic stroke patients who harbor unruptured intracranial aneurysm

Background Intracranial aneurysms are currently considered as contraindication for intravenous thrombolysis in acute ischemic stroke, very likely due to a possible increase in the risk of bleeding from aneurysm rupture; however, there is limited data available on whether intravenous thrombolysis is safe for acute ischemic stroke patients with pre-existing intracranial aneurysms. Aims and/or hypothesis To find out the safety of intravenous thrombolysis in acute ischemic stroke patients who harbor unruptured intracranial aneurysms. Methods We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with intravenous thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with unruptured intracranial aneurysm present on cerebrovascular images prior to acute reperfusion therapy were identified. Post-thrombolysis brain imaging was reviewed to evaluate for any intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysm. Results A total of 637 patients received intravenous thrombolysis for acute ischemic stroke in our center during an 8.3-year period. Thirty-three (5.2%) were found to have at least one intracranial aneurysms. Twenty-three (70%) of those received only intravenous thrombolysis, and 10 patients received combination of intravenous and intra-arterial throm-bolysis. The size of the largest aneurysm was 10 mm in maximum diameter (range: 2-10 mm). The mean size of aneurysms was 4.8 mm. No symptomatic intracranial hemorrhage occurred among the 23 patients receiving only intravenous thrombolysis. Out of those who received a combination of intravenous and intra-arterial thrombolysis, one developed symptomatic intracranial hemorrhage in the location of acute infarct, distant to the aneurysm location. Conclusion Our findings suggest that neither intravenous thrombolysis nor combination of intravenous and intra-arterial thrombolysis increases the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for intravenous throm-bolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.

Safety of intravenous thrombolysis for acute ischemic stroke in patients with preexisting intracranial neoplasms: a case series

Intracranial neoplasms are currently considered a contraindication for intravenous (IV) thrombolysis in acute ischemic stroke (AIS) patients (1,2). Minimal data are available on the safety of IV thrombolysis for AIS in patients with preexisting intracranial neoplasm. We sought to determine the safety of IV recombitant tissue plasminogen activator (rtPA) in such patients through a retrospective hospital-based study. We retrospectively reviewed the medical records of patients who received IV rtPA for AIS from January 2006 to April 2014 at our tertiary academic medical center. All patients were treated based on the standard protocol adopted from the American Heart Association/ American Stroke Association within 4.5 h of AIS onset (2). Patients who received intra-arterial (IA) thrombolysis after IV rtPA were included. A subset of patients with definite intracranial neoplasms from this cohort was identified. Follow-up computed tomography (CT) or magnetic resonance imaging (MRI) within 24 to 36 h of IV rtPA administration and medical records were reviewed to determine the number of patients with symptomatic intracranial hemorrhage (sICH) in this subset. sICH was defined as intracranial hemorrhage (ICH) with an increase in National Institutes of Health Stroke Scale of at least 4 points (3). In addition, hemorrhage within the neoplasm was evaluated. Six hundred thirty-seven patients received full dose IV rtPA for AIS within the study period. Preexisting intracranial neoplasms were found in 13 of the 637 patients reviewed (2%). The demographics of the patients are outlined in Table 1. None of the 13 patients developed sICH or hemorrhage into the tumor after thrombolysis. To the best of our knowledge, our study is the largest on the safety of IV rtPA for AIS in patients with preexisting intracranial neoplasms. This study is also the first report, to our knowledge, of patients with intracranial neoplasm who received IV rtPA followed by IA thrombolysis with mechanical thrombectomy devices. Our study should be interpreted in light of several limitations. It is a single-center study with a low number of cases; in addition, we have no malignant neoplasm in our cohort and no generally valid conclusion can be drawn about the safety of IV thrombolysis in all grades of intracranial neoplasm. Our finding suggests that IV rtPA administration for AIS does not increase the risk of hemorrhage within the neoplasm in patients with preexisting benign intracranial neoplasm. Their listing in exclusion criteria for rtPA should be reconsidered to assure appropriate use of IV rtPA in this group of patients. We hope our study will encourage other centers to look into their data and study this further, so as to determine the actual risk of hemorrhage with rtPA in patients with intracranial neoplasms.

Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience

BACKGROUND Current American Stroke Association guidelines recommend initiating intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) within 60min of patient arrival, given the benefits of IVT for AIS are time dependent. This study aimed to identify the delaying factors in door-to-needle time (DTN) in the emergency department of one of the largest comprehensive stroke centers in New York State. We also recommended measures to reduce the delays. METHODS We retrospectively reviewed the medical charts of all AIS patients who received IVT in our emergency department patients between April 1, 2012 and December 31, 2015 to identify those with a DTN time of >60min. We categorized the factors causing the delay into different groups. For each group, we recommended measures to reduce the treatment delays. RESULTS A total of 487 patients received IVT for AIS during the 3.7-year period. Of these, 96 patients (20.4%) met our DTN time delay criteria. Delays for obtaining stroke imaging and hypertension control were the most common factors. Thirty eight patients (39.5%) had delay in obtaining CT-based stroke imaging. Twenty-two patients (22.9%) required control of elevated blood pressure prior to IVT. Other causes for delay in DTN time included delay in stroke triage and paging (11.4%), fluctuating neurological symptoms (7.2%), uncertainty about diagnosis (12.5%), delays associated with obtaining consent (9.3%), and uncertainty about the time of symptom onset (5.2%). CONCLUSION Important and common causes of delay in IVT for AIS were identified in a review of charts at our comprehensive stroke center. The authors recommend strategies to achieve faster DTN time for each of the delaying factor categories including faster acquisition and interpretation of stroke imaging, more effective triage protocols and faster blood pressure control for AIS patients who are eligible for IVT.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with Thrombocytopenia

OBJECTIVE To determine the safety of intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) who had a platelet count <100,000 /mm3. METHODS We reviewed the charts of all patients who received IV rtPA for AIS during a 9.6-year period at our stroke center. Those with platelets <100,000/mm3 were identified. Head computed tomography scans performed in 24-36 hours postthrombolysis were reviewed to evaluate the rate of symptomatic intracranial hemorrhage (sICH). RESULTS A total of 835 patients received IV rtPA for AIS during this period. A total of 5 patients were identified to have a platelet count <100,000/mm3. One of them (20%) developed sICH post-IV tPA administration .The mean platelet count of those 5 patients was 63,000 ± 19,000/mm3. To the best of our knowledge, only 21 thrombocytopenic patients have been reported to receive IV rtPA for AIS in the medical literature. Combining our 5 cases with 21 patients previously reported, we have 26 AIS patients who had a platelet count <100,000/mm3 and received IV rtPA, with 2 of them developing sICH (7.7 %). Comparing the rate of sICH among this group with the patients with normal platelet count in our cohort, there was no statistically significant difference (7.7% versus 6.04%, P value = .73). CONCLUSION IV rtPA for AIS might be safe in patients with platelet count <100,000/mm3 and it is reasonable not to delay IV rtPA administration while waiting for the platelet count result, unless there is strong suspicion for abnormal platelet count.

Prior Asymptomatic Parenchymal Hemorrhage Does Not Increase the Risk for Intracranial Hemorrhage after Intravenous Thrombolysis.

Background: The NINDS trial demonstrated the efficacy of intravenous (IV) recombinant tissue plasminogen activator (rtPA) in improving the neurologic outcome in patients presenting with acute ischemic strokes. Patients who had a prior history of intracranial hemorrhage (ICH) were excluded from this trial, possibly due to a hypothetical increase in the subsequent bleeding risk. Thus, there is little data available, whether against or in favor of, the use of IV rtPA in patients with prior ICH. We aim to aid in determining the safety of IV rtPA in such patients through a retrospective hospital-based single center study. Methods: We reviewed the brain imaging of all patients who received IV rtPA at our comprehensive stroke center from January 2006 to April 2014 for evidence of prior ICH at the time of IV rtPA administration. Their outcomes were determined in terms of subsequent development of symptomatic ICH as defined by the NINDS trial. Results: Brain imaging for 640 patients was reviewed. A total of 27 patients showed evidence of prior ICH at the time of IV thrombolysis, all intra-parenchymal. Only 1 patient (3.7%) developed subsequent symptomatic ICH after the administration of IV rtPA. Of the remaining 613 patients who received IV rtPA, 25 patients (4.1%) developed symptomatic ICH. Conclusion: This retrospective study provides Level C evidence that patients with imaging evidence of prior asymptomatic intra-parenchymal hemorrhage presenting with an acute ischemic stroke do not show an increased risk of developing symptomatic ICH after IV thrombolysis.