Timo Kahles1, Marie-Luise Mono1, Mirjam Rachel Heldner1, Ralf Werner Baumgartner1, Hakan Sarikaya1, Andreas Luft1, Stephan Bohlhalter1, Christopher Traenka1, Stefan T Engelter1, Natalia Kurka1, Martin Köhrmann1, Sami Curtze1, Patrik Michel1, Turgut Tatlisumak1, Krassen Nedeltchev2. 1. From the Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland (T.K., K.N.); Inselspital, University Hospital and University of Bern, Bern, Switzerland (M.-L.M., M.R.H., H.S.); Hirslanden Hospital Zurich, Zurich, Switzerland (R.W.B.); University Hospital Zurich, Zurich, Switzerland (A.L.); Cantonal Hospital Lucerne, Lucerne, Switzerland (S.B.); University Hospital Basel, Basel, Switzerland (C.T., S.T.E.); Universitätsklinikum Erlangen, Erlangen, Germany (N.K., M.K.); Helsinki University Central Hospital, Helsinki, Finland (S.C., T.T.); Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and University Hospital Lausanne CHUV, Lausanne, Switzerland (P.M.). 2. From the Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland (T.K., K.N.); Inselspital, University Hospital and University of Bern, Bern, Switzerland (M.-L.M., M.R.H., H.S.); Hirslanden Hospital Zurich, Zurich, Switzerland (R.W.B.); University Hospital Zurich, Zurich, Switzerland (A.L.); Cantonal Hospital Lucerne, Lucerne, Switzerland (S.B.); University Hospital Basel, Basel, Switzerland (C.T., S.T.E.); Universitätsklinikum Erlangen, Erlangen, Germany (N.K., M.K.); Helsinki University Central Hospital, Helsinki, Finland (S.C., T.T.); Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and University Hospital Lausanne CHUV, Lausanne, Switzerland (P.M.). krassen.nedeltchev@ksa.ch.
Abstract
BACKGROUND AND PURPOSE: Intravenous thrombolysis (IVT) within 4.5 hours from symptom onset improves functional outcome in patients with acute ischemic stroke. Its use in patients with previous stroke within the preceding 3 months is contraindicated because of the assumed higher risk of intracranial hemorrhage. In addition, tissue-type plasminogen activator may itself promote neurotoxicity and blood-brain barrier disruption. However, safety and effectiveness of repeated IVT is essentially unknown in patients with early (<3 months) recurrent stroke (ERS), because they were excluded from thrombolysis trials. This article reports the largest case series of repeated IVT in ERS. METHODS: We reviewed databases of prospectively collected patient data of 8 European stroke centers for the presence of patients with ERS, who received IVT for both the index stroke and ERS. Demographics, clinical and radiological data, bleeding complications, and functional outcome were analyzed. RESULTS: We identified 19 subjects with repeated IVT in ERS. Mean age was 68±12 years, and 37% of them were female. Median interthrombolysis interval was 30 days (interquartile range, 13-50). Functional independence (modified Rankin scale score ≤2) was achieved in 79% of patients after the first and in 47.4% after repeated IV tissue-type plasminogen activator, respectively. There was no symptomatic intracranial hemorrhage. Median final infarct volume after the first IVT was 1.5 cm(3) (interquartile range, 0.5-3.1). CONCLUSIONS: Patients with small infarct volumes and robust clinical improvement might be considered for repeated IVT within 3 months. Studies following strict protocols and larger registries incorporating these patients might serve to identify selection criteria for the safe use of repeated IVT in ERS.
BACKGROUND AND PURPOSE: Intravenous thrombolysis (IVT) within 4.5 hours from symptom onset improves functional outcome in patients with acute ischemic stroke. Its use in patients with previous stroke within the preceding 3 months is contraindicated because of the assumed higher risk of intracranial hemorrhage. In addition, tissue-type plasminogen activator may itself promote neurotoxicity and blood-brain barrier disruption. However, safety and effectiveness of repeated IVT is essentially unknown in patients with early (<3 months) recurrent stroke (ERS), because they were excluded from thrombolysis trials. This article reports the largest case series of repeated IVT in ERS. METHODS: We reviewed databases of prospectively collected patient data of 8 European stroke centers for the presence of patients with ERS, who received IVT for both the index stroke and ERS. Demographics, clinical and radiological data, bleeding complications, and functional outcome were analyzed. RESULTS: We identified 19 subjects with repeated IVT in ERS. Mean age was 68±12 years, and 37% of them were female. Median interthrombolysis interval was 30 days (interquartile range, 13-50). Functional independence (modified Rankin scale score ≤2) was achieved in 79% of patients after the first and in 47.4% after repeated IV tissue-type plasminogen activator, respectively. There was no symptomatic intracranial hemorrhage. Median final infarct volume after the first IVT was 1.5 cm(3) (interquartile range, 0.5-3.1). CONCLUSIONS:Patients with small infarct volumes and robust clinical improvement might be considered for repeated IVT within 3 months. Studies following strict protocols and larger registries incorporating these patients might serve to identify selection criteria for the safe use of repeated IVT in ERS.
Authors: Andrej Klepanec; Jan Harsany; Jozef Haring; Miroslav Mako; Matus Hoferica; Matej Rusina; Juraj Cisar; Georgi Krastev Journal: Interv Neuroradiol Date: 2020-03-17 Impact factor: 1.610