Frequency and Predictors of Symptomatic Intracerebral Hemorrhage in Patients with Ischemic Stroke Treated with Recombinant Tissue Plasminogen Activator outside Clinical Trials

Combined therapy of intensive statin plus intravenous rt-PA in acute ischemic stroke: the INSPIRE randomized clinical trial

OBJECTIVE

To investigate the safety and efficacy of intensive statin in the acute phase of ischemic stroke after intravenous thrombolysis therapy.

METHODS

A total of 310 stroke patients treated with rt-PA were randomly scheduled into the intensive statin group (rosuvastatin 20 mg daily × 14 days) and the control group (rosuvastatin 5 mg daily × 14 days). The primary clinical endpoint was excellent functional outcome (mRS ≤ 1) at 3 months, and the primary safety endpoint was symptomatic intracranial hemorrhage (sICH) in 90 days.

RESULTS

The intensive statin users did not achieve a favorable outcome in excellent functional outcome (mRS ≤ 1) at 3 months compared with controls (70.3% vs. 66.5%, p = 0.464). Intensive statin also not significantly improved the overall distribution of scores on the modified Rankin scale, as compared with controls (p = 0.82 by the Cochran-Mantel-Haenszel test). The incidence of primary safety endpoint events (sICH) in 90 days did not significantly differ between the intensive statin group and control group (0.6% vs. 1.3%, p > 0.999).

CONCLUSION

The INSPIRE study indicated that intensive statin therapy may not improve clinical outcomes compared with the low dose of statin therapy in AIS patients undergoing intravenous thrombolysis, and the two groups had similar safety profile.

CLINICAL TRIAL REGISTRATION

URL: http://www.chictr.org . Unique identifier: ChiCTR-IPR-16008642.

Intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign: A meta-analysis

Hyperdense middle cerebral artery sign (HMCAS) on admitting to neuroimaging is reported to have prognostic value for poor outcomes after thrombolysis, while evidence from studies comprising a sufficiently large sample size is limited. To detect prognostic predictors after thrombolysis could help improve therapeutic clinical strategies for acute ischemic stroke. We included prospective and retrospective studies of stroke patients that were treated with intravenous thrombolysis, in which functional outcomes (ie, a modified Rankin scale [mRS]) and systematic intracranial hemorrhage (sICH) were assessed in relation to HMCAS during pretreatment head CT. Random-effects models were used to calculate pooled risk ratios (RR) of poor outcomes and sICH for HMCAS patients as compared to patients without HMCAS. Eleven studies permitted identification of 11 818 patients. The risk of poor outcome at 3 months in the HMCAS-positive group was 1.56-fold the negative group (RR, 1.56; 95% CI 1.50-1.62; P < .001). The sICH risk when comparing both groups was found to be non-significant. Sensitivity analysis regarding studies performing thrombolysis within 3 hours also exhibited significant differences in their functional outcomes (RR, 1.56, 95% CI 1.49-1.62; P < .001) in patients with HMCAS as compared to non-HMCAS patients, although this was true for sICH risk. The presence of HMCAS on pretreatment CT predicts a poor outcome at 3 months after intravenous thrombolysis, while its relationship with the incidence of sICH was found to have no statistic value. Our study implies that more aggressive treatment should be considered for HMCAS patients.

Characteristics of blood tests in patients with acute cerebral infarction who developed symptomatic intracranial hemorrhage after intravenous administration of recombinant tissue plasminogen activator

Objective

Patients suspected as having acute ischemic stroke usually undergo blood tests, including coagulation-related indexes, because thrombocytopenia and coagulopathy are contraindications for recombinant tissue plasminogen activator (rtPA) administration. We aimed to identify blood test indexes associated with symptomatic intracranial hemorrhage (sICH) in patients with acute ischemic stroke who received intravenous rtPA.

Methods

This retrospective observational study included patients diagnosed with acute ischemic stroke who were treated with intravenous rtPA at the emergency department of a tertiary hospital in Seoul between February 2008 and January 2018. Blood test indexes were compared between the sICH and non-sICH groups. Logistic regression and receiver-operating characteristic curve analyses were performed.

Results

In this study, 375 patients were finally included. Of 375 patients, 42 (11.2%) showed new intracranial hemorrhage on follow-up brain computed tomography, of whom 14 (3.73%) had sICH. Platelet count, aspartate aminotransferase and lactate dehydrogenase levels were significantly different between the sICH and non-sICH groups, and platelet count showed statistical significance in the regression analysis. Significantly lower platelet counts were observed in the sICH group than in the non-sICH group (174,500 vs. 228,000/mm³, P=0.020). The best cutoff platelet count was 195,000/mm³, and patients with platelet counts of <195,000/mm³ had a 5.4- times higher risk of developing sICH than those with platelet counts of ≥195,000/mm³.

Conclusion

Platelet count was the only independent parameter associated with sICH among the blood test indexes. Mild thrombocytopenia may increase the risk of sICH after intravenous administration of rtPA.

Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke

Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients Receiving Antiplatelet Therapy: A Systematic Review and Meta-analysis of 19 Studies

BACKGROUND

The safety and long-term outcome of systemic thrombolysis in patients receiving antiplatelet medications remain subjects of great clinical significance. The objective of this meta-analysis was to determine how prestroke antiplatelet therapy affects the risks and benefits of intravenous thrombolysis in patients with acute ischemic stroke.

METHODS AND RESULTS

A dual-reviewer search was conducted in PubMed and EMBASE databases through November 2015, from which 19 studies involving a total of 108 588 patients with acute ischemic stroke were identified based on preset inclusion criteria. Information on study designs, patient characteristics, exposures, outcomes, and adjusting confounders was extracted, and estimates were combined by using random-effects models. The pooled crude estimates suggested that taking long-term antiplatelet medications was associated with higher odds of symptomatic intracranial hemorrhage (odds ratio [OR] 1.70, 95% CI 1.47-1.97) and death (OR 1.46, 95% CI 1.22-1.75) and lower odds of favorable functional outcomes (OR 0.86, 95% CI 0.80-0.93). However, the combined confounder-adjusted results only confirmed a relatively weak positive association between prior antiplatelet therapy and symptomatic intracranial hemorrhage (OR 1.21, 95% CI 1.02-1.44) and demonstrated no significant relationship between antiplatelet therapy and the other 2 outcomes (favorable outcome OR 1.09, 95% CI 0.96-1.24; death OR 1.02, 95% CI 0.98-1.07). Subgroup analyses revealed that the associations between prestroke antiplatelet therapy and outcomes were dependent on time and antiplatelet agents.

CONCLUSIONS

Patients with acute ischemic stroke receiving long-term antiplatelet medications were associated with greater risks of developing symptomatic intracranial hemorrhage after systemic thrombolysis. However, the overall independent association between prestroke antiplatelet therapy and unfavorable outcomes or mortality was insignificant.

Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke

In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%–15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion.

Prediction of intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke using multiple artificial neural networks

OBJECTIVES

Artificial neural networks (ANNs) have been increasingly used in diagnosis and the prediction of outcome, mortality, and risk factors in ischemic stroke. Each model may have different accuracy, sensitivity, and specificity in processing the same clinical information. Thus, using only one model of ANNs may mislead the prediction. The present study aimed to predict symptomatic intracerebral hemorrhage (SICH) following thrombolysis in acute ischemic stroke based on clinical, laboratory, and imaging data using multiple ANN models.

METHODS

Models for radial basis function (RBF), multilayer perceptron (MLP), probabilistic neural network (PNN), and support vector machine (SVM) were generated to analyze 194 datasets with 29 predictive variables. The relative importance of each predictor variable was calculated using sensitivity analysis.

RESULTS

Comparison among the models based on the areas under the receiver operating characteristic curves (AUC) showed no significantly statistical difference in predictive performance among RBF, MLP, and PNN. PNN showed significantly better performance than SVM. With a minimum importance score of 50 together with an AUC value ≥0·50, three models identified stroke subtype as an important predictive variable for SICH. Other potential predictors were stroke location, prothrombin time, low-density-lipoprotein cholesterol, diastolic blood pressure, International Normalized Ratio, and brain computed tomography findings.

DISCUSSION

Although ANN models showed similar performance, the classification results were not totally alike, suggesting an advantage of using multiple classification models over a single model. The predictive results are supported by previous statistical studies on different datasets, suggesting generalizability of the utility of ANN analyses.

Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)

Cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD) is high, and the presence of CKD worsens outcomes of cardiovascular disease (CVD). CKD is associated with specific risk factors. Emerging evidence indicates that the pathology and manifestation of CVD differ in the presence of CKD. During a clinical update conference convened by the Kidney Disease: Improving Global Outcomes (KDIGO), an international group of experts defined the current state of knowledge and the implications for patient care in important topic areas, including coronary artery disease and myocardial infarction, congestive heart failure, cerebrovascular disease, atrial fibrillation, peripheral arterial disease, and sudden cardiac death. Although optimal strategies for prevention, diagnosis, and management of these complications likely should be modified in the presence of CKD, the evidence base for decision making is limited. Trials targeting CVD in patients with CKD have a large potential to improve outcomes.

Statin pretreatment may increase the risk of symptomatic intracranial haemorrhage in thrombolysis for ischemic stroke: results from a case-control study and a meta-analysis

The influence of statins on the results of intravenous thrombolysis for ischemic stroke is controversial. We studied the risks and benefits of statin pretreatment (SP) in patients treated with intravenous alteplase (t-PA) at our institution, and included our data to a meta-analysis of previous related studies. We reviewed prospectively collected data from consecutive patients with acute ischemic stroke treated with IV rt-PA at our institution over the past 9 years. We compared symptomatic intracranial haemorrhage (SICH), favourable short-term outcome (decrease of ≥4 points on the NIHSS score after 24 h from baseline assessment), favourable long-term outcome (mRS score ≤2 at 3 months) and mortality rates between statin-pretreated (SPP) and nonstatin-pretreated patients (NSPP). We performed a systematic search through MEDLINE/PubMed and Embase datasets to identify similar English language studies. A total of 182 patients were included (mean age 68.3 ± 11.4 years, 54.3% men). There were no significant differences between SPP and NSPP regarding SICH (3.3 vs. 1.7%, p = 0.47), favourable short-term outcome (44.8 vs 56%, p = 0.31) and favourable long-term outcome rates (40 vs 44.1%, p = 0.84). In a meta-analysis of 1,055 patients, SP was neither related to long-term functional outcome nor mortality, but it was a risk factor for SICH (OR 1.99, 95% CI 1.03-3.84, p = 0.04). Statin pretreatment may increase the risk of SICH in patients receiving IV t-PA for ischemic stroke, though it does not influence the 3 months outcome. Prospective studies are needed to confirm this safety concern.

[Pharmacologically-induced neurocatastrophes]

Drug-induced adverse reactions represent a significant health problem in developed countries. These events cause 5% of hospital admissions and are one of the main causes of mortality. Neurological manifestations are among the most frequent. This article reviews catastrophic cerebrovascular situations and confusional syndromes, as well as epilepsy, structural encephalopathy, neuromuscular disorders, catastrophic movement disorders and infections, all of which can be drug-induced.

Influence of antiplatelet pre-treatment on the risk of intracranial haemorrhage in acute ischaemic stroke after intravenous thrombolysis

BACKGROUND

Pre-treatment with antiplatelet agents (AP) is present amongst 30% of acute stroke patients. Previous studies have shown conflicting results on the effect of these drugs regarding haemorrhagic transformation after thrombolytic therapy. The hypothesis that pre-treatment with AP may increase the risk of cerebral haemorrhage (ICH) after intravenous tissue plasminogen activator (tPA) was assessed.

METHODS

Retrospective study of consecutive prospectively registered patients with acute ischaemic stroke treated with iv tPA (n = 235) in the last 5 years. Baseline characteristics and prior AP therapy were registered on admission. Computed tomography (CT) scan was performed on admission and 24-36 h after tPA. ICH was classified according to the ECASS II criteria into haemorrhagic infarction and parenchymal haematoma (PH). Symptomatic intracerebral haemorrhage (SICH) was defined as a worsening of > or = 4 points in the NIHSS score during the first 36 h in any haemorrhage subtype.

RESULTS

Seventy-two (30.6%) patients were pre-treated with AP (55 aspirin, 14 clopidogrel, 2 aspirin + clopidogrel, 1 triflusal). PH was observed in 33 (14.1%) patients (PH1 13, PH2 12, PHr 8) of whom 16 were symptomatic. Male gender (78.8% vs. 21.2%, P = 0.036), prior AP therapy (54.5% vs. 26.9%, P = 0.001), stroke severity (median NIHSS, 17 vs. 12, P = 0.005) and early CT signs of infarction (12.5% vs. 2.1%, P = 0.004) were associated with PH. The adjusted odds ratios of PH for patients pre-treated with AP therapy was 3.5 (1.5-7.8, P = 0.002) and for SICH 1.9 (0.6-5.9, P = 0.2).

CONCLUSIONS

Pre-treatment with AP is associated with an increased risk of PH after intravenous thrombolysis in patients with acute ischaemic stroke.

Outcomes of Intravenous Recombinant Tissue Plasminogen Activator Therapy According to Gender

Background and Purpose— The natural history of stroke is worse in women than in men. Controversial data have been published on the efficacy of thrombolysis with recombinant tissue plasminogen activator (rtPA) according to gender. We evaluated gender differences in the efficacy and safety outcomes of intravenous rtPA using a clinical registry and systematic review.

Methods— Since January 2002, we collected baseline characteristics and efficacy and safety outcomes for patients who received intravenous rtPA in our center. We performed a systematic PubMed literature search for previous observational studies that examined gender effects on outcomes after intravenous rtPA treatment.

Results— No gender difference in good outcome at 3 months (adjusted OR for women, 1.41; 95% CI, 0.76 to 2.60) and in 90-day mortality (adjusted OR, 1.38; 95% CI, 0.59 to 3.19) was found in our registry. We identified 16 studies that evaluated the gender effect among intravenous rtPA-treated patients. None of these studies supported a gender difference in favorable outcome, and one suggested an increased risk of mortality in men. In unadjusted partial meta-analysis in 4074 women and 5840 men including our registry data, we found a trend toward a lower risk of symptomatic intracranial hemorrhage in women (crude OR, 0.87; 95% CI, 0.68 to 1.10).

Conclusions— These results suggest no gender difference in outcome among patients treated with intravenous rtPA.

A risk score to predict intracranial hemorrhage after recombinant tissue plasminogen activator for acute ischemic stroke

BACKGROUND

Ability to predict risk of postthrombolysis intracerebral hemorrhage (ICH) is currently limited.

METHODS

Using data from the Multicenter Recombinant Tissue Plasminogen Activator Stroke Survey Group, we developed a score to predict this risk. One point was assigned for the presence of each of 4 variables: age older than 60 years, baseline National Institutes of Health Stroke Scale score greater than 10, glucose greater than 8.325 mmol/L, and platelet count less than 150,000/mm(3).

RESULTS

Rate of any ICH increased with higher scores: 0 points, 2.6%; 1 point, 9.7%; 2 points, 15.1%; and greater than or equal to 3 points, 37.9%. The model had reasonable discriminatory capability (C-statistic 0.69). A similar pattern was seen with symptomatic and asymptomatic ICH separately, and with radiographically defined parenchymal hemorrhage.

CONCLUSION

A simple risk score may be useful for predicting postthrombolysis ICH.