Pansy Harris-Lane

Intra-arterial reteplase and intravenous abciximab in patients with acute ischemic stroke: An open-label, dose-ranging, phase I study

OBJECTIVE:New approaches are focusing on using a combination of medication that lyse fibrin and prevent aggregation of platelets to achieve higher rates of recanalization and improved clinical outcomes. METHODS:A prospective, nonrandomized, open-label trial evaluated the safety of an escalating dose of reteplase in conjunction with intravenous abciximab (platelet glycoprotein IIb/IIIa inhibitor) in patients with acute ischemic stroke (3–6 h after symptom onset). The primary endpoint was symptomatic intracerebral hemorrhage at 24 to 72 hours, and secondary endpoints were partial or complete recanalization (≥ one grade improvement), early neurological improvement (decrease in National Institutes of Health Stroke Scale ≥ 4 at 24 h), and favorable outcome at 1 month (defined by modified Rankin scale ≤ 2). RESULTS:A total of 20 patients (mean age, 65 yr; 13 men) were recruited. Five patients were recruited in each of the escalating tiers of intra-arterial reteplase (0.5, 1, 1.5, and 2 units). Intravenous abciximab (0.25 mg/kg bolus followed by 0.125 &mgr;g/kg/min) was successfully administered in 18 out of 20 patients. The safety stopping rule was not activated in any of the tiers. One symptomatic intracerebral hemorrhage was observed in one of the 20 patients (in the 1-unit tier). Partial or complete recanalization was observed in 13 of the 20 patients. Thirteen patients demonstrated early neurological improvement, and favorable outcome at 1 month was observed in six patients. CONCLUSION:In this study, a combination of intra-arterial reteplase and intravenous abciximab was safely administered to patients with ischemic stroke presenting between 3 and 6 hours after symptom onset.

Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines.

Objective:To determine the feasibility and safety of treatment of acute hypertension in patients with intracerebral hemorrhage within 24 hrs of symptom onset. Elevated blood pressure, observed in up to 56% of patients with intracerebral hemorrhage, may predispose to hematoma expansion; on the other hand, reduction of blood pressure may reduce hematoma expansion and subsequent death and disability. Design:Single-center prospective registry supplemented by retrospective chart review. Settings:University-affiliated medical center with dedicated stroke service. Patients:All patients admitted to the stroke service with spontaneous intracerebral hemorrhage and acute hypertension within 24 hrs of symptom onset. Intervention:Patients were treated with intravenous nicardipine within 24 hrs of symptom onset to reduce and maintain mean arterial pressure of <130 mm Hg. The mean arterial pressure goal was consistent with the American Heart Association guidelines. Measurements and Main Results:The primary outcome was the tolerability of the treatment as assessed by achieving and maintaining the mean arterial pressure goals for 24 hrs after initiation of intravenous nicardipine infusion. Other end points ascertained were: neurologic deterioration defined by a decline in Glasgow Coma Scale from pretreatment assessment by ≥2 points or increase in National Institutes of Health Stroke Scale score by ≥2 points and hemorrhage growth defined as an increase in the volume of intraparenchymal hemorrhage of >33% as measured by image analysis on the 24-hr computed tomographic scan compared with the baseline computed tomographic scan. Rates of favorable outcome and death were ascertained at 1 month. Of the total 46 patients admitted with intracerebral hemorrhage in our service, 29 patients were treated. Mean age of the treated patients was 58 ± 13 yrs; ten were women. Initial National Institutes of Health Stroke Scale ranged from 1 to 38. The primary outcome of tolerability was achieved in 25 of the 29 patients (86%). Neurologic deterioration was observed in 4 of 29 patients. Hematoma enlargement was observed in five patients. Favorable outcome (defined as modified Rankin scale of ≤2) and death at 1-month was observed in 11 (38%) and 9 (31%) of the 29 patients, respectively. Conclusions:We observed a high rate of tolerability among patients with intracerebral hemorrhage who were treated with intravenous nicardipine using mean arterial pressure goals defined by American Heart Association guidelines within 24 hrs of symptom onset.

Prehospital neurologic deterioration in patients with intracerebral hemorrhage

Objective:Early neurologic deterioration has been studied in patients with intracerebral hemorrhage during hospitalization, but rates and factors associated with prehospital neurologic deterioration (PND) are unknown. We sought to determine the prevalence of PND among patients with intracerebral hemorrhage during Emergency Medical Services transportation to the hospital. Design:Historical cohort study. Settings:U.S. acute care hospital from 2000 to 2004. Patients:Hospitalized patients with a diagnosis of spontaneous intracerebral hemorrhage were identified by codes of the International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Methods:The initial Glasgow Coma Scale score ascertained at the scene by the Emergency Medical Services was compared with the subsequent evaluation in the emergency department to identify neurologic deterioration (defined as a decrease in Glasgow Coma Scale of ≥2 points). Interventions:None. Measurements and Main Results:Of the 98 patients with acute intracerebral hemorrhage, 22 patients (22%) showed PND during Emergency Medical Services transport, with a mean decrease in the Glasgow Coma Scale score during transport of 6 points. The patients who demonstrated neurologic deterioration tended to have higher diastolic blood pressure at the scene (p = .045), greater rates of intraventricular extension (p < .0001), and radiologic signs of herniation (p < .0001) on initial computed tomographic scan. There was a statistically significant decrease in diastolic blood pressure between the evaluations of the Emergency Medical Services and the emergency department among both patients with and without PND. Conclusions:PND occurs in nearly one fifth of patients with intracerebral hemorrhage. Higher diastolic blood pressure at the scene, intraventricular extension, and radiologically evident herniation seem to be associated with PND. Prospective studies are needed to evaluate the efficacy of Emergency Medical Services interventions to reduce this early clinical deterioration.

Mechanical Disruption of Thrombus Following Intravenous Tissue Plasminogen Activator for Ischemic Stroke

Background and Purpose: We prospectively evaluated the safety of aggressive mechanical disruption of thrombus following full‐dose intravenous (IV) recombinant tissue plasminogen activator (rt‐PA) to treat ischemic stroke in 24 patients with an initial National Institutes of Health stroke scale (NIHSS) score of ≥10. Methods: Clinical evaluations were performed at presentation and 24 hours, 7 to 10 days, and 1 to 3 months (using modified Rankin scale) after treatment. These end points were compared to matched historical controls treated with IV rt‐PA alone. Results: Of the 24 patients, mechanical disruption was undertaken in 17 patients with persistent angiographic occlusion using microcatheter exploration (n= 3), angioplasty (n= 5), snare maneuvers (n= 7), and combination of both (n= 2). Partial or complete recanalization was observed in 10 of the 17 patients. Neurological improvement at 24 hours (≥4 point reduction in NIHSS score) was observed in 11 of 17 patients. Comparisons with matched controls suggest potential equivalence for symptomatic ICH (0% vs 12%), asymptomatic ICH (18% vs 15%), and early neurological improvement (65% vs 53%). Conclusion: The study shows that aggressive mechanical thrombus disruption in large artery occlusion in the setting of acute ischemic stroke is safe with acceptable rates of ICH and promotes angiographic recanalization.

Postprocedure Intravenous Eptifibatide Following Intra-Arterial Reteplase in Patients with Acute Ischemic Stroke

Early use of intravenous platelet glycoprotein IIB/IIIA antagonists after intra‐arterial (IA) thrombolysis may reduce the risk of reocclusion and microvascular compromise.

Changes in Serum Calcium Levels Associated with Catheter-Based Cerebral Angiography

Digital subtraction angiography is performed with agents such as iodinated contrast and intravenous heparin, which can alter electrolyte levels. If severe enough, these alterations may produce symptoms in patients in the post‐procedural period. We performed this study to evaluate serum calcium level changes after cerebral angiography.