Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study

Early Neurological Deterioration in Acute Ischemic Minor Stroke Patients with Large Vessel Occlusion Following Intravenous Thrombolysis

OBJECTIVE

Early identification of risk factors associated with early neurological deterioration (END) in patients with acute minor stroke and large vessel occlusion (LVO) receiving intravenous thrombolysis (IVT) could assist in formulating treatment decisions.

METHODS

Consecutive patients with acute minor stroke and LVO were extracted from a single-center prospective database spanning from January 2020 to December 2023. END was defined as an increase of ≥4 points in the National Institutes of Health Stroke Scale score from baseline or ≥2 points in any single National Institutes of Health Stroke Scale item, within 24 hours of IVT. Multivariate logistic regression analysis, adjusted for confounding variables, was employed to identify risk factors associated with END.

RESULTS

A total of 163 patients were included in this study, of which 36 (22.1%) patients encountered END. Patients in the END group had a higher proportion of isolated internal carotid artery (ICA) occlusion (30.6% vs. 6.3%), delayed antiplatelet therapy (88.9% vs. 66.1%), and a larger Tmax > 4 seconds volume (142 vs. 114 mL) (all P < 0.05). Multivariate logistic regression analysis after adjusting for confounding factors showed that isolated (ICA) occlusion (adjusted odds ratio = 2.49, 95% confidence interval = 1.97-4.41; P < 0.001) and delayed antiplatelet therapy (adjusted odds ratio = 1.46, 95% confidence interval = 1.17-1.84; P < 0.001) were significantly associated with END.

CONCLUSIONS

Isolated ICA occlusion and delayed antiplatelet therapy were significantly associated with END in minor stroke patients with LVO following IVT. Bridging thrombectomy and early administration of antiplatelet therapy may be considered reasonable strategies.

Effect of intravenous urokinase vs best medicine treatment on functional outcome for patients with acute minor stroke (TRUST): a randomized controlled trial

BACKGROUND

The benefits of intravenous thrombolysis in patients with acute minor stroke remain controversial. For the aim of providing a better therapeutic strategy, high-quality trials are required to validate the efficacy of thrombolytic medicine other than intravenous recombinant tissue plasminogen and tenecteplase. In the trial, we evaluate the efficacy and safety of urokinase (UK) in acute minor stroke.

METHODS

This multicenter, open-label, blinded-endpoint, randomized controlled clinical trial enrolled patients with minor stroke within 6 h of symptom onset, with a NIHSS score ≤ 5. The trial was conducted at 25 hospitals in China between October 2020 and February 2023. Eligible patients were randomized to the UK group (1,000,000 U) or the best medicine treatment group. The responsible investigator recommended and implemented the best medicine treatment based on guidelines. The primary endpoint was an excellent functional outcome, defined as a modified Rankin scale (mRS) score of 0-1 at 90 days. The primary safety outcome was symptomatic intracranial hemorrhage (sICH) within 36 h.

RESULTS

A total of 999 patients were enrolled in the trial, the median age was 64 years, 371 (36.9%) were women; the median (IQR) NIHSS score was 3 (2-4). At 90 days, the primary endpoint was observed in 427 patients (84.9%) in the UK group and 425 patients (85.7%) in the control group (adjusted risk ratio [RR] 1.00, 95% CI 0.96-1.05, p = 0.87). A total of 3 patients in the UK-treated (0.6%) group experienced sICH compared to 1 patient (0.2%) in the control group (RR 1.83, 95% CI 0.16-20.27, p = 0.62).

CONCLUSIONS

For patients with acute minor stroke treated within 6 h of symptom onset, UK intravenous thrombolysis treatment was not found to be beneficial in terms of excellent functional outcome at 90 days, whereas it was safe.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04420351.

Intravenous thrombolysis in patients with acute dizziness or imbalance and suspected ischemic stroke-systematic review

BACKGROUND

Correct identification of those patients presenting with an acute vestibular syndrome (AVS) or an acute imbalance syndrome (AIS) that have underlying posterior-circulation stroke (PCS) and thus may benefit from revascularization (intravenous thrombolysis (IVT), endovascular therapy (EVT)) is important. Treatment guidelines for AVS/AIS patients are lacking. We reviewed the evidence on acute treatment strategies in AVS/AIS focusing on predictors for IVT/EVT and outcome.

METHODS

We performed a systematic search (MEDLINE, Embase) to identify studies reporting on acute treatment in PCS presenting as AVS/AIS (PROSPERO-registration = CRD42024537272). Key parameters were extracted. Risk of bias was assessed (Downs-and-Black quality assessment checklist).

RESULTS

We identified 3883 citations and included seven study cohorts (n = 1000 patients including 950 ischemic strokes). Overall, 251/1000 patients (25.1%) received IVT; EVT was performed in 46/368 (12.5%). Acute vertigo/dizziness was reported in 295/1000 (29.5%) patients. AVS criteria were met in 186/407 (45.7%) patients evaluated, and AIS criteria in 82/346 (23.7%). IVT was reported in 71/195 (36.4%) AVS/AIS patients and EVT in 13/77 (16.9%) cases, whereas the door-to-needle time (DNT) was significantly longer for PCS compared to anterior-circulation stroke (90 ± 29min vs. 74 ± 30min, p = 0.003) in one study. DNT was similar in those patients presenting with AVS/AIS compared to all PCS presentations in another study (70 ± 39min (AVS/AIS) vs. 63 ± 35min (all)). An mRS ≤ 2 after 90 days was noted in 68.4-69.6% of PCS. No outcome data were identified for AVS/AIS patients.

CONCLUSIONS

Insufficient data exist to drive any firm recommendation about treating otherwise eligible patients with AVS/AIS with IVT/EVT and judgments must be made on a case-by-case basis. Further research on this specific patient group is needed.

Acute treatment and secondary prevention for patients with minor stroke or transient ischemic attack: A Bayesian network meta-analysis

INTRODUCTION

The efficacy of different antiplatelet treatment in minor strokes (MSs) or transient ischemic attacks (TIAs) and that of antiplatelet and intravenous thrombolysis (IVT) in MSs remain controversial.

METHODS

We searched PubMed, Embase, Web of Science and the Cochrane Library to identify all eligible articles until April 12, 2024. Efficacy outcomes were all-cause mortality, excellent outcome, functional independence and recurrent stroke. Safety outcomes were any types of bleeding and intracerebral hemorrhage (ICH). The associations were calculated for the overall data by using odds ratios (ORs).

RESULTS

Twenty three high-quality studies with 10 RCTs and 13 non-RCTs were included, involving 47,135 patients with MSs or TIAs. In MSs or TIAs, dual antiplatelet therapies (DAPTs) significantly improved the modified Rankin Scale (mRS) scores for patients with recurrent stroke, major vascular events and ischemic stroke although it was associated with an increased risk of ICH and bleeding when compared to aspirin. In MSs, compared to IVT, DAPT had a significant advantage in improving the mRMS scores and SAPT and DAPT significantly reduced the risk of any bleeding or sICH. IVT significantly reduced all-cause mortality, although it also increased the risk of sICH and ICH compared to no IVT.

CONCLUSIONS

In MSs or TIAs, compared to aspirin, DAPTs can effectively prevent the recurrence of post-stroke neurological dysfunction and ischemic events, but it may increase the risk of ICH together with moderate or severe bleeding. Dipyridamole + aspirin resulted in the lowest risk of bleeding. In MSs, compared to IVT, DAPT may be associated with better improvements in neurological function, and it may not increase the risk of bleeding.

Intravenous alteplase in minor nondisabling ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Minor ischemic stroke, defined as National Institute of Health Stroke Scale score of 0-5 on admission, represents half of all acute ischemic strokes. The role of intravenous alteplase (IVA) among patients with minor stroke is inconclusive; therefore, we evaluated clinical outcomes of these patients treated with or without IVA.

MATERIALS AND METHODS

We searched Medline, Embase, Scopus, and the Cochrane library until August 1, 2023. Inclusion was restricted to the English literature of studies that reported on minor nondisabling stroke patients treated with or without IVA. Odds ratios (ORs) with their corresponding 95% CIs were utilized using a random-effects model. Efficacy outcomes included rates of excellent (modified Rankin scale [mRS] of 0-1) and good (mRS of 0-2) functional outcome at 90 days. The main safety outcome was symptomatic intracerebral hemorrhage (sICH).

RESULTS

Five eligible studies, two RCTs and three observational studies, comprising 2764 patients (31.8% female) met inclusion criteria. IVA was administered to 1559 (56.4%) patients. Pooled analysis of the two RCTs revealed no difference between the two groups in terms of 90-days excellent functional outcomes (OR 0.76 [95% CI, 0.51-1.13]; I2 = 0%) and sICH rates (OR 3.76 [95% CI, 0.61-23.20]). No significant differences were observed between the groups in terms of good functional outcomes, 90-day mortality, and 90-day stroke recurrence.

CONCLUSION

This meta-analysis of minor nondisabling stroke suggests that IVA did not prove more beneficial compared to no-IVA.

Intravenous Alteplase Versus Best Medical Therapy for Patients With Minor Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

The efficacy of thrombolysis (IVT) in minor stroke (National Institutes of Health Stroke Scale score, 0-5) remains inconclusive. The aim of this study is to compare the effectiveness and safety of IVT with best medical therapy (BMT) by means of a systematic review and meta-analysis of randomized controlled trials and observational studies.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to IVT in minor stroke from inception until August 10, 2023. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days. The associations were calculated for the overall and preformulated subgroups by using the odds ratios (ORs). This study was registered with PROSPERO (CRD42023445856).

RESULTS

A total of 20 high-quality studies, comprised of 13 397 patients with acute minor ischemic stroke, were included. There were no significant differences observed in the modified Rankin Scale scores of 0 to 1 (OR, 1.10 [95% CI, 0.89-1.37]) and 0 to 2 (OR, 1.16 [95% CI, 0.95-1.43]), mortality rates (OR, 0.67 [95% CI, 0.39-1.15]), recurrent stroke (OR, 0.89 [95% CI, 0.57-1.38]), and recurrent ischemic stroke (OR, 1.09 [95% CI, 0.68-1.73]) between the IVT and BMT group. There were differences between the IVT group and the BMT group in terms of early neurological deterioration (OR, 1.81 [95% CI, 1.17-2.80]), symptomatic intracranial hemorrhage (OR, 7.48 [95% CI, 3.55-15.76]), and hemorrhagic transformation (OR, 4.73 [95% CI, 2.40-9.34]). Comparison of modified Rankin Scale score of 0 to 1 remained unchanged in subgroup patients with nondisabling deficits or compared with those using antiplatelets.

CONCLUSIONS

These findings indicate that IVT does not yield significant improvement in the functional prognosis of patients with acute minor ischemic stroke. Additionally, it is associated with an increased risk of symptomatic intracranial hemorrhage when compared with the BMT. Moreover, IVT may not have superiority over BMT in patients with nondisabling deficits or those using antiplatelets.