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Bücke P, Jung S, Kaesmacher J, Goeldlin MB, Horvath T, Prange U, Beyeler M, Fischer U, Arnold M, Seiffge DJ, Meinel TR. Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: A target trial analysis after the liberalization of institutional guidelines. Eur Stroke J 2024:23969873241252751. [PMID: 38738861 DOI: 10.1177/23969873241252751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy. PATIENTS AND METHODS We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT. RESULTS Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes. DISCUSSION AND CONCLUSION After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.
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Affiliation(s)
- Philipp Bücke
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martina B Goeldlin
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas Horvath
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Ulrike Prange
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Morin Beyeler
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David J Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas R Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024. [PMID: 38687179 DOI: 10.1111/pace.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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Tsai TY, Liu YC, Huang WT, Tu YK, Qiu SQ, Noor S, Huang YC, Chou EH, Lai ECC, Huang HK. Risk of Bleeding Following Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA Intern Med 2024; 184:37-45. [PMID: 37983035 PMCID: PMC10660269 DOI: 10.1001/jamainternmed.2023.6160] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 11/21/2023]
Abstract
Importance Current guidelines advise against intravenous alteplase therapy for treatment of acute ischemic stroke in patients previously treated with non-vitamin K antagonist oral anticoagulants (NOACs). Objective To evaluate the risk of bleeding and mortality after alteplase treatment for acute ischemic stroke among patients treated with NOACs compared to those not treated with NOACs. Design, Setting, and Participants This nationwide, population-based cohort study was conducted in Taiwan using data from Taiwan's National Health Insurance Research Database from January 2011 through November 2020 and included 7483 patients treated with alteplase for acute ischemic stroke. A meta-analysis incorporating the results of the study with those of previous studies was performed, and the review protocol was prospectively registered with PROSPERO. Exposures NOAC treatment within 2 days prior to stroke, compared to either no anticoagulant treatment or warfarin treatment. Main Outcomes and Measures The primary outcome was intracranial hemorrhage after intravenous alteplase during the index hospitalization (the hospitalization subsequent to alteplase administration). Secondary outcomes were major bleeding events and mortality during the index hospitalization. Propensity score matching was used to control potential confounders. Logistic regression was used to estimate the odds ratio (OR) of outcome events. Meta-analysis was performed using a random-effects model. Results Of the 7483 included patients (mean [SD] age, 67.4 [12.7] years; 2908 [38.9%] female individuals and 4575 [61.1%] male individuals), 91 (1.2%), 182 (2.4%), and 7210 (96.4%) received NOACs, warfarin, and no anticoagulants prior to their stroke, respectively. Compared to patients who were not treated with anticoagulants, those treated with NOACs did not have significantly higher risks of intracranial hemorrhage (risk difference [RD], 2.47% [95% CI, -4.23% to 9.17%]; OR, 1.37 [95% CI, 0.62-3.03]), major bleeding (RD, 4.95% [95% CI, -2.56% to 12.45%]; OR, 1.69 [95% CI, 0.83-3.45]), or in-hospital mortality (RD, -4.95% [95% CI, -10.11% to 0.22%]; OR, 0.45 [95% CI, 0.15-1.29]) in the propensity score-matched analyses. Furthermore, the risks of bleeding and mortality were not significantly different between patients treated with NOACs and those treated with warfarin. Similar results were obtained in the meta-analysis. Conclusions and Relevance In this cohort study with meta-analysis, compared to no treatment with anticoagulants, treatment with NOACs prior to stroke was not associated with a higher risk of intracranial hemorrhage, major bleeding, or mortality in patients receiving intravenous alteplase for acute ischemic stroke.
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Affiliation(s)
- Tou-Yuan Tsai
- Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Chang Liu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wan-Ting Huang
- Epidemiology and Biostatistics Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital and School of Dentistry, National Taiwan University, Taipei, Taiwan
| | - Shang-Quan Qiu
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Sameer Noor
- Texas Tech University Health Sciences Center, School of Medicine, Lubbock
| | - Yong-Chen Huang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Eric H. Chou
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center–Fort Worth, Fort Worth, Texas
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huei-Kai Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
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Lin L, Blair C, Fu J, Cordato D, Cappelen-Smith C, Cheung A, Manning NW, Wenderoth J, Chen C, Bivard A, Butcher K, Kleinig TJ, Choi P, Levi CR, Parsons M. Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke. J Neurointerv Surg 2023; 15:e433-e437. [PMID: 36944493 DOI: 10.1136/jnis-2022-019560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Where stroke occurs with pre-existing atrial fibrillation (AF)studies validating the safety and efficacy of bridging thrombolysis, and the use of endovascular thrombectomy (EVT) in the setting of prior anticoagulation, are limited to single-center reports. METHODS In a retrospective analysis, AF patients undergoing EVT for anterior circulation large vessel occlusion stroke enrolled in a prospectively-maintained, international multicenter database (International Stroke Perfusion Imaging Registry (INSPIRE)) between 2016 and 2019 were studied. Patients were categorized by anticoagulation status: anticoagulated (warfarin/non-vitamin K oral anticoagulants) versus not anticoagulated. Patients not anticoagulated were further divided into intravenous thrombolysis versus no thrombolysis. Outcomes compared between groups included 90-day modified Rankin Scale, 90-day mortality, rates of symptomatic intracerebral hemorrhage (sICH), and good reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3). RESULTS Of 563 AF patients, 118 (21%) were on anticoagulation. AF patients on anticoagulation showed improved 90-day functional outcomes (adjusted odds ratio (aOR) 1.68, 95% confidence interval (95% CI) 1.00 to 2.82). Mortality (26.3% vs 23.8%), sICH (4.5% vs 3.9%), and rates of good reperfusion (91.3% vs 88.0%) were similar between those anticoagulated and those not anticoagulated. Thrombolysis before EVT in AF patients was independently associated with improved 90-day functional outcomes (aOR 1.81, 95% CI 1.18 to 2.79) and reduced mortality (aOR 0.51, 95% CI 0.31 to 0.84), with similar sICH rates (3.4% vs 4.5%). CONCLUSIONS Anticoagulated patients with AF who underwent EVT had improved 90-day functional outcomes and similar sICH rates. Thrombolysis before EVT in AF patients was associated with improved 90-day functional outcomes and reduced mortality.
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Affiliation(s)
- Longting Lin
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Christopher Blair
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - James Fu
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dennis Cordato
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Andrew Cheung
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Nathan W Manning
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Jason Wenderoth
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Chushuang Chen
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Andrew Bivard
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Kenneth Butcher
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Philip Choi
- Department of Neurology, Eastern Health Box Hill, Melbourne, Victoria, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Mark Parsons
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
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Ghannam M, AlMajali M, Galecio‐Castillo M, Al Qudah A, Khasiyev F, Dibas M, Ghazaleh D, Vivanco‐Suarez J, Morán‐Mariños C, Farooqui M, Rodriguez‐Calienes A, Koul P, Roeder H, Shim H, Samaniego E, Leira EC, Adams HP, Ortega‐Gutierrez S. Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e031669. [PMID: 38108256 PMCID: PMC10863770 DOI: 10.1161/jaha.123.031669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. METHODS AND RESULTS A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. CONCLUSIONS Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.
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Affiliation(s)
- Malik Ghannam
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Mohammad AlMajali
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | | | - Abdullah Al Qudah
- Department of NeurologyUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Farid Khasiyev
- Department of NeurologySaint Louis UniversitySaint LouisMO
| | - Mahmoud Dibas
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Dana Ghazaleh
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | | | - Cristian Morán‐Mariños
- Unidad de investigación en Bibliometria, Vicerrectorado de InvestigaciónUniversidad San Ignacio de LoyolaLimaPerú
| | - Mudassir Farooqui
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Aaron Rodriguez‐Calienes
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Neuroscience, Clinical Effectiveness and Public Health Research GroupUniversidad Científica del SurLimaPeru
| | - Prateeka Koul
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Hannah Roeder
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - HyungSub Shim
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Edgar Samaniego
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Department of NeurosurgeryUniversity of Iowa College of MedicineIowa CityIA
- Department of RadiologyUniversity of Iowa College of MedicineIowa CityIA
| | - Enrique C. Leira
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Department of NeurosurgeryUniversity of Iowa College of MedicineIowa CityIA
- Department of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIA
| | - Harold P. Adams
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Santiago Ortega‐Gutierrez
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Department of NeurosurgeryUniversity of Iowa College of MedicineIowa CityIA
- Department of RadiologyUniversity of Iowa College of MedicineIowa CityIA
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Behnoush AH, Khalaji A, Bahiraie P, Gupta R. Meta-analysis of outcomes following intravenous thrombolysis in patients with ischemic stroke on direct oral anticoagulants. BMC Neurol 2023; 23:440. [PMID: 38102548 PMCID: PMC10722877 DOI: 10.1186/s12883-023-03498-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND There has been debate on the use of intravenous thrombolysis (IVT) in patients with ischemic stroke and the recent use of direct oral anticoagulants (DOACs). Studies have compared these patients with non-DOAC groups in terms of outcomes. Herein, we aimed to systematically investigate the association between DOAC use and IVT's efficacy and safety outcomes. RESULTS A comprehensive systematic search was performed in PubMed, Embase, Scopus, and the Web of Science for the identification of relevant studies. After screening and data extraction, a random-effect meta-analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) for comparison of outcomes between patients on DOAC and controls. Six studies were included in the final review. They investigated a total of 254,742 patients, among which 3,499 had recent use of DOACs. The most commonly used DOACs were rivaroxaban and apixaban. The patients on DOAC had significantly higher rates of atrial fibrillation, hypertension, diabetes, and smoking. Good functional outcome defined by modified Rankin Scale (mRS) 0-2 was significantly lower in patients who received DOACs (OR 0.71, 95% CI 0.62 to 0.81, P < 0.01). However, in the subgroup analysis of 90-day mRS 0-2, there was no significant difference between groups (OR 0.71, 95% 0.46 to 1.11, P = 0.14). All-cause mortality was not different between the groups (OR 1.02, 95% CI 0.68 to 1.52, P = 0.93). Similarly, there was no significant difference in either of the in-hospital and 90-day mortality subgroups. Regarding symptomatic intracranial hemorrhage (sICH), the previous DOAC use was not associated with an increased risk of bleeding (OR 0.98, 95% CI 0.69 to 1.39, P = 0.92). A similar finding was observed for the meta-analysis of any ICH (OR 1.15, 95% CI 0.94 to 1.40, P = 0.18). CONCLUSIONS Based on our findings, IVT could be considered as a treatment option in ischemic stroke patients with recent use of DOACs since it was not associated with an increased risk of sICH, as suggested by earlier studies. Further larger studies are needed to confirm these findings and establish the safety of IVT in patients on DOAC.
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Affiliation(s)
- Amir Hossein Behnoush
- School of Medicine, Tehran University of Medical Sciences, Poursina St., Keshavarz Blvd, Tehran, 1417613151, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- School of Medicine, Tehran University of Medical Sciences, Poursina St., Keshavarz Blvd, Tehran, 1417613151, Iran.
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Pegah Bahiraie
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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9
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Brandler ES, Isenberg DL, Herres J, Zhao H, Kraus CK, Ackerman D, Sigal A, Kuc A, Nomura JT, Wojcik S, Mullen MT, Gentile NT. Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi. J Am Coll Emerg Physicians Open 2023; 4:e13048. [PMID: 37840864 PMCID: PMC10568043 DOI: 10.1002/emp2.13048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. Methods This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT. Results Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). Conclusion Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.
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Affiliation(s)
- Ethan S. Brandler
- Department of Emergency MedicineState University of New York‐Stony BrookStony BrookNew YorkUSA
| | - Derek L. Isenberg
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Joseph Herres
- Department of Emergency MedicineJefferson Einstein – Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Huaqing Zhao
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| | - Daniel Ackerman
- Department of NeurologySt. Luke's University HealthBethlehemPennsylvaniaUSA
| | - Adam Sigal
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | - Alexander Kuc
- Department of Emergency MedicineCooper University HealthCamdenNew JerseyUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Susan Wojcik
- Department of Emergency MedicineState University of New York‐UpstateSyracuseNew YorkUSA
| | - Michael T. Mullen
- Department of NeurologyLewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA
| | - Nina T. Gentile
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
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10
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Hindsholm MF, Damgaard D, Gurol ME, Gaist D, Simonsen CZ. Management and Prognosis of Acute Stroke in Atrial Fibrillation. J Clin Med 2023; 12:5752. [PMID: 37685819 PMCID: PMC10489015 DOI: 10.3390/jcm12175752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and mortality compared to non-AF strokes. The management of patients with AF-related strokes is challenging, and it involves weighing individual risks and benefits in the acute treatment and preventive strategies of these patients. This review summarizes the current knowledge of the acute management of ischemic and hemorrhagic stroke in patients with AF, and the prognosis and potential implications for management both in the acute and long-term setting.
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Affiliation(s)
- Mette F. Hindsholm
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
| | - M. Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, 5000 Odense, Denmark;
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
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11
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Liang H, Wang X, Quan X, Qin B, Zhang J, Liang S, Liang Z. Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis. J Neurol 2023; 270:4192-4200. [PMID: 37314507 DOI: 10.1007/s00415-023-11815-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. METHODS Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. RESULTS Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. CONCLUSION The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.
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Affiliation(s)
- Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xue Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xuemei Quan
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China
| | - Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China.
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12
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Burger A, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Binder NB, Nagler M. Determination of Anti-Xa Inhibitor Plasma Concentrations Using a Universal Edoxaban Calibrator. Diagnostics (Basel) 2023; 13:2128. [PMID: 37371023 DOI: 10.3390/diagnostics13122128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
A universal calibrator for the determination of all anti-Xa inhibitors would support laboratory processes. We aimed to test the clinical performance of an anti-Xa assay utilizing a universal edoxaban calibrator to determine clinically relevant concentrations of all anti-Xa inhibitors. Following a pilot study, we enrolled 553 consecutive patients taking rivaroxaban, edoxaban, or apixaban from nine study centers in a prospective cross-sectional study. The Technochrom® anti-Xa assay was conducted using the Technoview® edoxaban calibrator. Using ultra-high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS), anti-Xa inhibitor drug concentrations were determined. Sensitivities and specificities to detect three clinically relevant drug concentrations (30 µgL-1, 50 µgL-1, 100 µgL-1) were determined. Overall, 300 patients treated with rivaroxaban, 221 with apixaban, and 32 with edoxaban were included. The overall correlation coefficient (rs) was 0.95 (95% CI 0.94, 0.96). An area under the receiver operating characteristic curve of 0.96 for 30 µgL-1, 0.98 for 50 µgL-1, and 0.99 for 100 µgL-1 was found. The sensitivities were 92.3% (95% CI 89.2, 94.6), 92.7% (89.4, 95.1), and 94.8% (91.1, 97.0), respectively (specificities 82.2%, 93.7%, and 94.4%). In conclusion, the clinical performance of a universal, edoxaban-calibrated anti-Xa assay was solid and most drug concentrations were predicted correctly.
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Affiliation(s)
- Annika Burger
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology, Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, 3012 Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine, Clinic of Medical Oncology and Hematology, Municipal City Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine, 9001 St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Nikolaus B Binder
- Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, 1230 Vienna, Austria
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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13
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Ojha PK, Aundhakar A. Acute Stroke Treatment in Patients Receiving Direct Oral Anticoagulants: Is it Time to Review the Guidelines? Ann Indian Acad Neurol 2023; 26:215-216. [PMID: 37538434 PMCID: PMC10394440 DOI: 10.4103/aian.aian_241_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/29/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Pawan K. Ojha
- Director of Neurology, Fortis Hiranandani Hospital, Navi Mumbai, Maharashtra, India
| | - Aditya Aundhakar
- Consultant Neurologist, Fortis Hiranandani Hospital, Navi Mumbai, Maharashtra, India
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14
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Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
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Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Kolahchi Z, Rahimian N, Momtazmanesh S, Hamidianjahromi A, Shahjouei S, Mowla A. Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Life (Basel) 2023; 13:life13010185. [PMID: 36676135 PMCID: PMC9863165 DOI: 10.3390/life13010185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/15/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND The current guideline recommends using an intravenous tissue-type plasminogen activator (IV tPA) prior to mechanical thrombectomy (MT) in eligible acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). Some recent studies found no significant differences in the long-term functional outcomes between bridging therapy (BT, i.e., IV tPA prior to MT) and direct MT (dMT). METHODS We conducted a systematic review and meta-analysis to compare the safety and functional outcomes between BT and dMT in AIS patients with ELVO who were eligible for IV tPA administration. Based on the ELVO location, patients were categorized as the anterior group (occlusion of the anterior circulation), or the combined group (occlusion of the anterior and/or posterior circulation). A subgroup analysis was performed based on the study type, i.e., RCT and non-RCT. RESULTS Thirteen studies (3985 patients) matched the eligibility criteria. Comparing the BT and dMT groups, no significant differences in terms of mortality and good functional outcome were observed at 90 days. Symptomatic intracranial hemorrhagic (sICH) events were more frequent in BT patients in the combined group (OR = 0.73, p = 0.02); this result remained significant only in the non-RCT subgroup (OR = 0.67, p = 0.03). The RCT subgroup had a significantly higher rate of successful revascularization in BT patients (OR = 0.73, p = 0.02). CONCLUSIONS Our meta-analysis uncovered no significant differences in functional outcome and mortality rate at 90 days between dMT and BT in patients with AIS who had ELVO. Although BT performed better in terms of successful recanalization rate, there is a risk of increased sICH rate in this group.
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Affiliation(s)
- Zahra Kolahchi
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Nasrin Rahimian
- Department of Neurology, Creighton University Medical Center, Omaha, NE 68124, USA
| | - Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Anahid Hamidianjahromi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Shima Shahjouei
- Department of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Correspondence: ; Tel.: +323-409-7422; Fax: +323-226-7833
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16
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Koga M, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Kanzawa T, Ohtaki M, Kamiyama K, Yakushiji Y, Igarashi S, Doijiri R, Ito Y, Takagi Y, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Toyoda K. Intravenous Alteplase at 0.6 mg/kg for Unknown Onset Stroke with Prior Antithrombotic Medication: THAWS Randomized Clinical Trial. J Atheroscler Thromb 2023; 30:15-22. [PMID: 35197420 PMCID: PMC9899700 DOI: 10.5551/jat.63337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIM This study aimed to assess the potential effect of prior antithrombotic medication for thrombolysis in an unknown onset stroke. METHODS This was a predefined sub-analysis of the THAWS trial. Stroke patients with a time last known well >4.5 h who had a DWI-fluid-attenuated inversion recovery mismatch were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg (alteplase group) or standard medical treatment (control group). Patients were dichotomized by prior antithrombotic medication. RESULTS Of 126 patients (intention-to-treat population), 40 took antithrombotic medication (24 with antiplatelets alone, 13 with anticoagulants alone, and 3 with both), and the remaining 86 did not before stroke onset. Of these, 17 and 52 patients, respectively, received alteplase, and 23 and 34, respectively, had standard medical treatment. Antithrombotic therapy was initiated within 24 h after randomization less frequently in the alteplase group (12% vs. 86%, p<0.01). Both any intracranial hemorrhage within 22-36 h (26% vs. 14%) and a modified Rankin Scale score of 0-1 at 90 days (good outcome) (47% vs. 48%) were comparable between the two groups. A good outcome was more common in the alteplase group than in the control group in patients with prior antithrombotic medication [relative risk (RR) 2.25, 95% confidence interval (CI) 1.02-4.99], but it tended to be less common in the alteplase group in those without (RR 0.69, 95% CI 0.46-1.03) (p<0.01 for interaction). The frequency of any intracranial hemorrhage did not significantly differ between the two groups in any patients dichotomized by prior antithrombotic medication. CONCLUSION Alteplase appears more beneficial in patients with prior antithrombotic medication.
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Affiliation(s)
- Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Obihiro, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Japan,Department of Neurology, Kansai Medical University, Hirakata, Japana
| | - Shuichi Igarashi
- Department of Neurology, Niigata City General Hospital, Niigata, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Yasuhiro Ito
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuo Minematsu
- Headquarters of the Medical Corporation ISEIKAI, Osaka, Japan
| | - Haruko Yamamoto
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Brakta C, Stépanian A, Reiner P, Delrue M, Mazighi M, Curis E, Siguret V. Practical Nomogram Predicting Apixaban or Rivaroxaban Concentrations from Low-Molecular-Weight Heparin Anti-Xa Values: Special Interest in Acute Ischemic Stroke Patients. J Stroke 2023; 25:126-131. [PMID: 36592965 PMCID: PMC9911839 DOI: 10.5853/jos.2022.03034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/23/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) using a direct oral factor-Xa anticoagulant (DOAC) during the last 48 hours, a fixed plasma heparin-calibrated anti-Xa activity (0.5 IU/mL) was proposed as a threshold below which patients could be eligible for thrombolysis and/or thrombectomy. Besides, specific DOAC-calibrated anti-Xa thresholds up to 50 ng/mL have been proposed. However, specific DOAC assays are not widely available contrarily to low-molecularweight heparin (LMWH) anti-Xa activity. We developed and validated a nomogram for predicting apixaban and rivaroxaban concentrations based on LMWH anti-Xa assay. METHODS Our prospective study included apixaban (n=325) and rivaroxaban (n=276) patients. On the same sample, we systematically measured specific DOAC concentration and LMWH anti-Xa activity, using STA®-Liquid-Anti-Xa (Stago) and specific DOAC- or LMWH-calibrators, respectively. The nomogram was built using quantifiable values for both assays on the derivation cohorts with a log-linear regression model. Model performances including sensitivity, specificity, and true positive rate for different thresholds were checked on the validation cohorts. RESULTS The models built from the derivation cohorts predicted that values <30 ng/mL and <50 ng/ mL DOAC thresholds corresponded to LMWH-anti-Xa values <0.10 IU/mL and <0.64 IU/mL for apixaban; <0.10 IU/mL and <0.71 IU/mL for rivaroxaban. The model accurately predicted apixaban/ rivaroxaban concentrations in the validation cohort. CONCLUSIONS This easy-to-use nomogram, developed with our reagent, allowed accurately predicting DOAC concentrations based on LMWH-anti-Xa results in emergency situations such as AIS when drug-specific assessments are not rapidly available. Using DOAC <50 ng/mL equivalent threshold, instead of the fixed LMWH <0.5 IU/mL one, would allow proposing thrombolysis to more patients.
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Affiliation(s)
- Charlyne Brakta
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Alain Stépanian
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,EA 3518, Université de Paris Cité, Paris, France
| | - Peggy Reiner
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Maxime Delrue
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Mikaël Mazighi
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Emmanuel Curis
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Virginie Siguret
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,INSERM UMRS-1140, Université de Paris Cité, Paris, France,Correspondence: Virginie Siguret Department of Hematology, Thrombosis Unit, Lariboisière Hospital (AP-HP), INSERM UMRS-1140, University Paris Cité, 2 rue Ambroise Paré 75010, Paris, France Tel: +33-6-63-53-37-55 Fax: +33-1-49-95-64-11 E-mail:
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18
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Behrndtz AB, Damsbo AG, Blauenfeldt RA, Andersen G, Speiser LO, Simonsen CZ. Too risky, too large, too late, or too mild-Reasons for not treating ischemic stroke patients and the related outcomes. Front Neurol 2022; 13:1098779. [PMID: 36619917 PMCID: PMC9815765 DOI: 10.3389/fneur.2022.1098779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Background Despite effective treatments, many patients are still not offered reperfusion therapy for acute ischemic stroke. Methods We present a single-center observational study on acute ischemic stroke patients, who presented as candidates for reperfusion therapy but were deemed ineligible after work-up. Reasons for non-treatment were obtained by studying patient files and subsequently grouped into "too risky" (e.g., anticoagulant use, comorbidities), "too large" (large infarct), "too late" (late presentation of stroke and wake-up strokes), or "too mild" (clinically mild/remitting symptoms). Modified Rankin scale (mRS) score was prospectively collected in all patients by a structured telephone interview. All non-treated patients with a National Institute of Health Stroke Scale (NIHSS) score of 0-5 were compared with a similar cohort that was treated. Results Of 529 patients with acute ischemic stroke arriving as reperfusion therapy candidates, 198 (37.4%) were not treated. The majority (42%) were not treated due to admission outside the treatment window (too late) and 24% had absolute contraindications (too risky). Only 8% was excluded because their infarct was too large [median Alberta Stroke Program Early CT score 3 (2-4)]. In the "too mild" group (14%) the percentage of patients not being independent at 90 days was 30%. The adjusted odds ratio for a better outcome (lower mRS) among treated patients with NIHSS 0-5 compared with non-treated was 1.93 (95% confidence interval 1.15-3.23). Conclusion Presenting outside the treatment window is still the most common reason for not receiving therapy. Our study suggests a benefit of thrombolysis for patients with mild symptoms.
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Affiliation(s)
- Anne Brink Behrndtz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark,*Correspondence: Anne Brink Behrndtz ✉
| | - Andreas Gammelgaard Damsbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rolf Ankerlund Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lasse Ole Speiser
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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19
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Moorthamers S, Mattar N, Frezals L, Preseau T, Gazagnes MD. Thrombolysis in an Acute Ischemic Stroke Patient on Direct Anticoagulant Therapy Outside of the Traditional Time Window: A Case Report. Cureus 2022; 14:e29673. [PMID: 36321003 PMCID: PMC9614184 DOI: 10.7759/cureus.29673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
A stroke is a life-threatening medical condition that could be disabling if left untreated. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) can be effective when initiated in an acute stroke, but their benefit is time-dependent and their use may be restricted by contraindications (CIs) such as anticoagulation therapy. The critical therapeutic time window, which was previously limited to 4.5-6 hours, is now extended to 24 hours in selected patients due to the development of advanced neuroimaging techniques. Herein, we discuss the case of a 50-year-old patient on rivaroxaban who developed acute ischemic stroke (AIS) and was treated successfully with intravenous recombinant tissue plasminogen activator thrombolysis more than six hours after the time he was last seen well (LSW). Our case demonstrates the importance of advanced neuroimaging techniques in identifying AIS candidates for IVT and/or MT with late or unknown time windows as well as the importance of case-by-case assessment when challenged by theoretical contraindications for thrombolysis.
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20
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Okada T, Yoshimoto T, Wada S, Yoshimura S, Chiba T, Egashira S, Kimura S, Shiozawa M, Inoue M, Ihara M, Toyoda K, Takashima H, Koga M. Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants. J Am Heart Assoc 2022; 11:e025809. [PMID: 36129032 PMCID: PMC9673692 DOI: 10.1161/jaha.122.025809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background We elucidated the safety of treatment with alteplase at 0.6 mg/kg within 24 hours for patients on direct oral anticoagulants (DOACs) before ischemic stroke onset. Methods and Results Consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis using alteplase at 0.6 mg/kg from 2011 to 2021 were enrolled from our single‐center prospective stroke registry. We compared outcomes between patients taking DOACs and those not taking oral anticoagulants within 48 hours of stroke onset. The primary safety outcome was the rate of symptomatic intracranial hemorrhage with a ≥4‐point increase on the National Institutes of Health Stroke Scale score from baseline. The efficacy outcome was defined as 3‐month modified Rankin Scale score of 0 to 2 after stroke onset. Of 915 patients with acute ischemic stroke who received intravenous thrombolysis (358 women; median age, 76 years; median National Institutes of Health Stroke Scale score, 10), 40 patients took DOACs (6 took dabigatran, 8 took rivaroxaban, 16 took apixaban, and 10 took edoxaban) within 24 hours of onset and 753 patients did not take any oral anticoagulants. The rate of symptomatic intracranial hemorrhage was comparable between patients on DOACs and those not on oral anticoagulants (2.5% versus 2.4%, P=0.95). The rate of favorable outcomes was comparable between the 2 groups (59.4% versus 58.2%, P=0.46), although the admission National Institutes of Health Stroke Scale score was higher in patients on DOACs. No significant differences showed in any intracranial hemorrhage within 36 hours or mortality at 3 months. Conclusions Intravenous thrombolysis would be safely performed for patients on DOACs following the recommendations of the Japanese guidelines. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02251665.
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Affiliation(s)
- Takashi Okada
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Takeshi Yoshimoto
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management National Cerebral and Cardiovascular Center Suita Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shuhei Egashira
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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Sabahi M, Ahmadi SA, Kazemi A, Mehrpooya M, Khazaei M, Ranjbar A, Mowla A, Giudetti AM. The Effect of Oleoylethanolamide (OEA) Add-On Treatment on Inflammatory, Oxidative Stress, Lipid, and Biochemical Parameters in the Acute Ischemic Stroke Patients: Randomized Double-Blind Placebo-Controlled Study. Oxidative Medicine and Cellular Longevity 2022; 2022:1-11. [PMID: 36120593 PMCID: PMC9477639 DOI: 10.1155/2022/5721167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/01/2022] [Accepted: 06/05/2022] [Indexed: 11/18/2022]
Abstract
Methods Sixty patients with a mean age of 68.60 ± 2.10 comprising 29 females (48.33%), who were admitted to an academic tertiary care facility within the first 12 hours poststroke symptoms onset or last known well (LKW), in case symptom onset time is not clear, were included in this study. AIS was confirmed based on a noncontrast head CT scan and also neurological symptoms. Patients were randomly and blindly assigned to OEA of 300 mg/day (n = 20) or 600 mg/day (n = 20) or placebo (n = 20) in addition to the standard AIS treatment for three days. A blood sample was drawn at 12 hours from symptoms onset or LKW as the baseline followed by the second blood sample at 72 hours post symptoms onset or LKW. Blood samples were assessed for inflammatory and biochemical parameters, oxidative stress (OS) biomarkers, and lipid profile. Results Compared to the baseline, there is a significant reduction in the urea, creatinine, triglyceride, high-density lipoprotein, cholesterol, alanine transaminase, total antioxidant capacity, malondialdehyde (MDA), total thiol groups (TTG), interleukin-6 (IL-6), and C-reactive protein levels on the follow-up blood testing in the OEA (300 mg/day) group. In patients receiving OEA (600 mg/day) treatment, there was only a significant reduction in the MDA level comparing baseline with follow-up blood testing. Also, the between-group analysis revealed a statistically significant difference between patients receiving OEA (300 mg/day) and placebo in terms of IL-6 and TTG level reduction when comparing them between baseline and follow-up blood testing. Conclusion OEA in moderate dosage, 300 mg/day, add-on to the standard stroke treatment improves short-term inflammatory, OS, lipid, and biochemical parameters in patients with AIS. This effect might lead to a better long-term neurological prognosis.
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22
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Mujanovic A, Kurmann CC, Dobrocky T, Olivé-Gadea M, Maegerlein C, Pierot L, Mendes Pereira V, Costalat V, Psychogios M, Michel P, Beyeler M, Piechowiak EI, Seiffge DJ, Mordasini P, Arnold M, Gralla J, Fischer U, Kaesmacher J, Meinel TR. Bridging intravenous thrombolysis in patients with atrial fibrillation. Front Neurol 2022; 13:945338. [PMID: 35989924 PMCID: PMC9382124 DOI: 10.3389/fneur.2022.945338] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purpose 40% of acute ischemic stroke patients treated by mechanical thrombectomy (MT) have a clinical history of atrial fibrillation (AF). The safety of bridging intravenous thrombolysis (IVT) (MT + IVT) is currently being discussed. We aimed to analyze the interaction between oral anticoagulation (OAC) status or AF with bridging IVT, regarding the occurrence of symptomatic intracranial hemorrhage (sICH) and functional outcome. Materials and Methods Multicentric observational cohort study (BEYOND-SWIFT registry) of consecutive patients undergoing MT between 2010 and 2018 (n = 2,941). Multinomial regression models were adjusted for prespecified baseline and plausible pathophysiological covariates identified on a univariate analysis to assess the association of AF and OAC status with sICH and good outcomes (90-day modified Rankin Scale score 0–2). Results In the total cohort (median age 74, 50.6% women), 1,347 (45.8%) patients had AF. Higher admission National Institutes of Health Stroke Scale (NIHSS) score (aOR 1.04 [95% 1.02–1.06], per point of increase) and prior medication with Vitamin K antagonists (VKA) (aOR 2.19 [95% 1.27–3.66]) were associated with sICH. Neither AF itself (aOR 0.71 [95% 0.41–1.24]) nor bridging IVT (aOR 1.08 [0.67–1.75]) were significantly associated with increased sICH. Receiving bridging IVT (aOR 1.61 [95% 1.24–2.11]) was associated with good 90-day outcome, with no interaction between AF and IVT (p = 0.92). Conclusion Bridging IVT appears to be a reasonable clinical option in selected patients with AF. Given the increased sICH risk in patients with VKA, subgroup analysis of the randomized controlled trials should analyze whether patients with VKA might benefit from withholding bridging IVT. Registration clinicaltrials.gov; Unique identifier: NCT03496064.
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Affiliation(s)
- Adnan Mujanovic
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C. Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Laurent Pierot
- Department of Neuroradiology, University Hospital Reims, Reims, France
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Marios Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Morin Beyeler
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - David J. Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- *Correspondence: Thomas R. Meinel
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Basso C, Goldstein E, Dai X, Rana M, Shu L, Chen C, Sweeney J, Stretz C, Smith EE, Gurol ME, de Havenon A, Burton T, Fussell-Louie D, Furie K, Yaghi S. Acute ischemic stroke on anti-Xa inhibitors: Pharmacokinetics and outcomes. J Stroke Cerebrovasc Dis 2022; 31:106612. [PMID: 35863261 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/16/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Direct oral anticoagulant (DOAC) ingestion within 48 h is an exclusion for thrombolysis in acute ischemic stroke (AIS) patients. We aim to shed light on pharmacokinetic correlates and outcomes in patients with AIS excluded from thrombolysis due to DOAC use. METHODS This is a single center retrospective study of consecutive patients with AIS within 4.5 h from last known normal and excluded from thrombolytic therapy due to confirmed Xa inhibitor DOAC (DOACXa) intake within the prior 48 h. We used linear regression to test the correlation between time from last DOACXa ingestion and anti-Xa level. RESULTS Over a period of 2.5 years, we identified 44 patients who did not receive thrombolysis because of presumed DOAC intake within 48 h. In adjusted linear regression, there was an association between time from last DOAC ingestion and Xa level (beta = -0.69, p < 0.001). Among the 37 patients with known atrial fibrillation not receiving alteplase due to DOAC use, the 90-day mortality was 35.1% (13/37) and 77% (10/13) of deaths were stroke related. CONCLUSIONS Patients with AIS on DOAC therapy face a heightened risk of mortality. Studies are needed to investigate the safety and efficacy of thrombolysis in such patients based on time of last DOAC ingestion and/or anti-Xa/drug level.
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Affiliation(s)
- Colin Basso
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Eric Goldstein
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Xing Dai
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Maheen Rana
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Liqi Shu
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Casandra Chen
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Joseph Sweeney
- Department of Hematology, Brown University, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam de Havenon
- Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA
| | - Tina Burton
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | | | - Karen Furie
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI 02903, USA
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Kolahchi Z, Khanmirzaei M, Mowla A. Acute ischemic stroke and vaccine-induced immune thrombotic thrombocytopenia post COVID-19 vaccination; a systematic review. J Neurol Sci 2022; 439:120327. [PMID: 35752132 PMCID: PMC9212261 DOI: 10.1016/j.jns.2022.120327] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 12/12/2022]
Abstract
Introduction One of the rare but potentially serious side effects of COVID-19 vaccination is arterial and venous thrombosis. Acute ischemic stroke (AIS) cases have been reported post COVID-19 vaccination. Herein, we systematically reviewed the reported cases of AIS after COVID-19 vaccination. Method This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We searched PubMed and Scopus until April 14, 2022 to find studies that reported AIS post COVID-19 vaccination. Results We found 447 articles. From those, 140 duplicates were removed. After screening and excluding irrelevant articles, 29 studies (43 patients) were identified to be included. From all cases, 22 patients (51.1%) were diagnosed with AIS associated with Vaccine-induced immune thrombotic thrombocytopenia (VITT). Among AIS associated with VITT group, all received viral vector vaccines except one. The majority of cases with AIS and VITT were female (17 cases, 77.2%) and aged below 60 years (15 cases, 68%). Fourteen patients (32.5%) had additional thrombosis in other sites. Four of them (0.09%) showed concurrent CVST and ischemic stroke. Hemorrhagic transformation following AIS occurred in 7 patients (16.27%). Among 43 patients with AIS, at least 6 patients (14%) died during hospital admission. Conclusion AIS has been reported as a rare complication within 4 weeks post COVID-19 vaccination, particularly with viral vector vaccines. Health care providers should be familiar with this rare consequence of COVID-19 vaccination in particular in the context of VITT to make a timely diagnosis and appropriate treatment plan.
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Affiliation(s)
| | | | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, CA, USA.
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25
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Pellegrino MP, Guerra FBD, Perissinotti IN. Decision-making strategies for reperfusion therapies: navigating through stroke trials gaps. Arq Neuropsiquiatr 2022; 80:60-71. [PMID: 35976313 PMCID: PMC9491414 DOI: 10.1590/0004-282x-anp-2022-s123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Despite there being a robust amount of literature and numerous randomized clinical trials regarding acute ischemic stroke treatment, the trials have not included some frequent controversial situations for which decision-making strategies are an urgent and unmet need in clinical practice. This article tries to summarize the current evidence about some selected situations (mechanical thrombectomy in low ASPECTS, low NIHSS with proximal occlusion, acute basilar occlusion, distal and medium vessel occlusion, among others), make suggestions on how to approach them in clinical practice and show what to expect in acute stroke research in the near future.
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Affiliation(s)
- Mateus Paquesse Pellegrino
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo, SP, Brazil
| | | | - Iago Navas Perissinotti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto Central, Departamento de Neurologia, São Paulo, SP, Brazil
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Kermer P, Schellinger PD, Ringleb PA, Köhrmann M. SOP: thrombolysis in ischemic stroke under oral anticoagulation therapy. Neurol Res Pract 2022; 4:7. [PMID: 35177127 PMCID: PMC8851794 DOI: 10.1186/s42466-022-00174-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/11/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Based on demographical trends and the expected worldwide increase in the number of individuals with atrial fibrillation, the rate of patients who are on oral anticoagulation therapy for secondary prevention of stroke rises continuously. Despite correct drug intake and good adherence to the respective medication, recurrent ischemic stroke still occurs in ~ 3% of patients. The question how to deal with such patients with regard to intravenous thrombolysis with rt-PA within the 4.5 h time window is of great relevance for daily clinical routine. However, international guidelines can be considered heterogenous or do even lack recommendations on this topic especially in light of available reversal agents. Therefore, we provide this SOP. Comments Beyond the identification of acute stroke patients on oral anticoagulation therapy, the type of medication, time since last intake, renal function and laboratory exams as well as the availability of reversal agents have to be considered before rt-PA application and potential endovascular therapy. Treatment on a Stroke Unit or Neuro-ICU is certainly recommended in any of those patients. Conclusions This standardized operating procedure was designed to guide stroke physicians through questions on eligibility for rt-PA treatment in patients with acute ischemic stroke who are on approved oral anticoagulation therapy thereby increasing the number of patients benefitting from thrombolysis and minimizing door-to-needle times.
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Affiliation(s)
- Pawel Kermer
- Department of Neurology, Friesland Kliniken gGmbH, Campus Nordwest-Krankenhaus Sanderbusch, Am Gut Sanderbusch 1, 26452, Sande, Germany. .,Department of Neurology, University Medicine Göttingen, 37075, Göttingen, Germany.
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatrics, University Hospital, Johannes Wesling Klinikum/RU Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Abstract
PURPOSE OF REVIEW The aim of this study was to summarize available evidence regarding the safety and efficacy of intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with specific comorbidities and potential contraindications to systemic reperfusion therapy. Recent advances in IVT implementation in wake-up stroke and in extended time window using advanced neuroimaging will also be highlighted. RECENT FINDINGS Despite theoretical concerns of a higher bleeding risk with IVT, there are no data showing increased risk of symptomatic intracerebral haemorrhage (sICH) in patients with stroke mimics, including seizures, increasing age and dual antiplatelet pretreatment. In addition, recent randomized evidence allows us to expand the time window of IVT for AIS using advanced neuroimaging both in wake-up stroke patients and in patients presenting within 4.5-9 h from symptom onset fulfilling certain neuroimaging criteria (based on DWI/FLAIR mismatch or perfusion mismatch). SUMMARY IVT is a highly effective systemic reperfusion therapy that counts 25 years of everyday clinical experience but still presents several challenges in its application. Appropriate patient selection and adherence to rt-PA protocol is paramount in terms of safety. The effort to simplify the indications, expand the therapeutic time window and eliminate specific initial contraindications is continuously evolving.
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Affiliation(s)
- Klearchos Psychogios
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Dolatshahi M, Sabahi M, Shahjouei S, Koza E, Abedi V, Zand R. Intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage: a meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864221074144. [PMID: 35126671 PMCID: PMC8808019 DOI: 10.1177/17562864221074144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/01/2022] [Indexed: 01/01/2023] Open
Abstract
Background: The history of intracranial hemorrhage (ICrH) is considered a contraindication for intravenous thrombolysis (IVT) among patients with acute ischemic stroke (AIS). Objective: This study aimed at comparing the safety of IVT among patients with and without a history of ICrH. Methods: We performed a systematic review of the literature. Data regarding all AIS patients with prior ICrH who received IVT were retrieved. Meta-analysis was performed to compare the rate of symptomatic hemorrhagic transformation (sHT), death within 90 days, and favorable and unfavorable 90-day functional outcomes based on modified Rankin Scale (mRS) among stroke patients with and without prior ICrH. Results: Out of 13,032 reviewed records, 7 studies were included in the systematic review and meta-analysis. Quantitative synthesis of data regarding the rate of sHT (5068 patients) revealed no significant difference between the two groups [odds ratio, OR: 1.55 (0.77, 3.12); p = 0.22]. However, a significantly higher risk of death within 90 days [OR: 3.91 (2.16, 7.08); p < 0.00001] and a significantly higher 90-day poor functional outcomes (mRS, 4–6) [OR: 1.57 (1.07, 2.30); p = 0.02] were observed among patients with prior ICrH. Likewise, the percentage of 90-day good functional outcomes (mRS, 0–1) was lower in the prior ICrH group [OR: 0.54 (0.35, 0.84); p = 0.06]. Subgroup analyses in patients with a history of ICrH (based on both patients’ medical history and imaging confirmation) revealed no significant between-group differences in rates of sHT. Also, sensitivity analysis consisting of only studies using standard-dose IVT showed no difference in sHT rates and 90-day outcomes between the two groups. There was no evidence of heterogeneity (I2 >50%) among included studies. Conclusion: The results of this study indicated that prior history of ICrH does not increase the risk of sHT post-IVT, but it is associated with a higher risk of death and poor functional outcomes in 90 days.
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Affiliation(s)
- Mahsa Dolatshahi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Mohammadmahdi Sabahi
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USANeurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Vida Abedi
- Neuroscience Institute, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, 100 North Academy Avenue, Danville, PA 17822, USA. Neuroscience Institute, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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Sibon I, Mazighi M, Smadja D. Decision-Making Process for the Management of Acute Stroke in Patients on Oral Anticoagulant: From Guidelines to Clinical Routine. Front Neurol 2022; 12:794001. [PMID: 35069423 PMCID: PMC8766998 DOI: 10.3389/fneur.2021.794001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The occurrence of both ischaemic (IS) and haemorrhagic stroke in patients on anticoagulation is a major issue due to the frequency of their prescriptions in westernised countries and the expected impact of anticoagulant activity on recanalization during an IS or on the outcomes associated with intracerebral haemorrhage (ICH). Several guidelines are available but sometimes differ in their conclusions or regarding specific issues, and their application in routine emergency settings may be limited by particular individual issues or heterogeneous local specificities. Methods: Based on the current guidelines and additional published data, the algorithms proposed in this paper aim to help the decision-making process regarding stroke management in the setting of concurrent anticoagulants by addressing specific clinical situations based on clinical variables commonly encountered in real-world practise. Results: For patients on non-vitamin K oral anticoagulants, reversion can be achieved with specific antidotes, but only idarucizumab, the specific dabigatran antidote, is indicated in both IS and ICH. Due to the low risk of a prothrombotic effect, idarucizumab can be immediately used in IS patients eligible for thrombolysis before the dabigatran concentration is known. To optimise ICH management, the time since symptom onset, with thresholds proposed at 6 and 9 hours based on the expected timing of haematoma expansion, could also to be taken into account. Conclusions: Anticoagulant reversal in patients presenting with a stroke remains a major issue, and algorithms based on a step-by-step approach may be useful for clinical practise. Real-life studies strongly support the benefits of idarucizumab availability in stroke units and emergency departments.
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Affiliation(s)
- Igor Sibon
- Stroke Unit, Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | - Didier Smadja
- Stroke Unit, INSERM U895, Department of Neurology, Centre Hospitalier Sud-Francilien, Paris-Saclay University, Corbeil-Essonnes, France
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30
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Mowla A, Shakibajahromi B, Arora A, Seifi A, Sawyer RN, Shirani P. Thrombolysis for stroke in elderly in the late window period. Acta Neurol Scand 2021; 144:663-668. [PMID: 34314036 DOI: 10.1111/ane.13512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Safety of intravenous thrombolysis (IVT) within 3-4.5 hours of stroke onset in patients ≥80 years is still disputable. We evaluated the association of symptom onset-to-treatment time (SOTT) with the symptomatic intracranial hemorrhage (sICH), poor outcome, and mortality in patients≥80 years. MATERIALS AND METHODS In a retrospective study, patients treated with IVT following stroke were registered. Outcomes were poor outcome (mRS>2), sICH/ECASS-2, and in-hospital mortality. We compared the patients≥80 years who received IVT within 3 hours with those receiving IVT within 3-4.5 hours. We further compared the patients who were <80 years with those ≥80 years and SOTT of 3-4.5 hours. RESULTS Of 834 patients, 265 aged over 80. In those above 80 and in multivariable analysis, the associations of SOTT with poor outcome (aOR: 1.401, CI: 0.503-3.903, p=0.519), sICH (aOR=2.50, CI=0.76-8.26, p= 0.132) and mortality (aOR=1.12, CI=0.39-3.25, p= 0.833) were not significant. 106 patients received IVT within 3-4.5 hours. In multivariable analysis, the associations of age (≥80 versus <80) with poor outcome (aOR=1.87, CI=0.65-5.37, p=0.246), sICH (aOR=0.65, CI=0.14-3.11, p=0.590), and mortality (aOR=0.87, 95% CI=0.16-4.57, p=0.867) were not significant in patients with SOTT of 3-4.5 hours. CONCLUSION IVT within 3-4.5 hours in patients ≥80 years is not associated with increased sICH, poor outcome, and mortality compared to the early time window, and also compared to the younger patients in 3-4.5 hours window period. The decision of IVT administration in this age group should not be made solely on the basis of stroke onset timing.
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Affiliation(s)
- Ashkan Mowla
- Division of Endovascular Neurosurgery Department of Neurological Surgery Keck School of Medicine University of Southern California (USC Los Angeles CA USA
| | | | - Ashish Arora
- Department of Neurology Cone Health Greensbro NC USA
| | - Ali Seifi
- Department of Neurosurgery University of Texas Health Science Center at San Antonio San Antonio TX USA
| | - Robert N. Sawyer
- Department of Neurology University at Buffalo State University of New York Buffalo NY USA
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery University of Cincinnati Medical Center Cincinnati OH USA
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Siller T, Chandratheva A, Bücke P, Werring DJ, Seiffge D. Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option? Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients.
Recent Findings
Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients.
Summary
IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.
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32
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Stretz C, Wu TY, Wilson D, Seiffge DJ, Smith EE, Gurol ME, Yaghi S. Ischaemic stroke in anticoagulated patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2021; 92:1164-1172. [PMID: 34446528 DOI: 10.1136/jnnp-2020-323963] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023]
Abstract
Anticoagulation substantially reduces the risk of stroke in patients with atrial fibrillation (AF). However, recent studies have shown that up to 22%-36% of patients on anticoagulation will suffer an ischaemic stroke (IS). In this narrative review, we provide an overview of risk factors, mechanisms, management of acute IS and strategies for secondary prevention for patients with AF with stroke despite oral anticoagulation. For this paper, we reviewed available literature from important studies (randomised clinical trials, meta-analyses, reviews and case series) on patients with IS despite anticoagulation. We focused on recent studies that examined safety and efficacy of acute stroke treatments and evaluation and management strategies for secondary prevention. The literature review suggests that patients with AF with IS despite anticoagulation are a heterogeneous group with several possible mechanisms, which may include reduced or non-adherence to anticoagulation, competing non-cardioembolic stroke aetiologies or cardioembolic mechanisms separate from AF. The identification of one or more possible mechanisms of stroke despite anticoagulation may allow for a more targeted and individualised approach for secondary prevention. There are limited data to guide management in such patients, and strategies to prevent recurrent strokes include strict risk factor control and therapies targeting the most likely stroke mechanism. In cases where AF is suspected to be the culprit, clinical trials are needed to test the safety and efficacy of left atrial appendage occlusion plus anticoagulation versus continued anticoagulation alone.
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Affiliation(s)
- Christoph Stretz
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Duncan Wilson
- Stroke Research Centre, UCL Institute of Neurology, London, UK
| | - David J Seiffge
- Department of Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island, USA
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Sibon I, Liegey JS. Management of stroke in patients on antithrombotic therapy: Practical issues in the era of direct oral anticoagulants. Rev Neurol (Paris) 2021; 178:185-195. [PMID: 34688480 DOI: 10.1016/j.neurol.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Antithrombotic drugs (ADs) are the mainstay of secondary prevention of thrombotic vascular diseases. Management of patients under long-term treatment with ADs admitted for acute cerebrovascular disease, either ischemic stroke (IS) or intracerebral hemorrhage (ICH), has become a frequent situation that might influence decision-making processes from diagnosis to therapeutic strategies. The aim of this review is to summarize current data from the literature to help clinicians in their decisions for stroke care in patients taking ADs. While a large body of data have made it possible to codify the management of patients presenting IS or ICH under antiplatelet drugs and vitamin K antagonists, the increasing use of direct oral anticoagulants (DOAs) and future development of new antiplatelet drugs raise new problems. Development of rapid assessment tools measuring specific biological activity and reversion agents dedicated to each class of DOAs should make it possible to optimize individual therapeutic strategies. This review highlights the main steps of IS and ICH management from early identification of ADs, and use of dedicated biological assays, to the stepwise strategy to apply revascularization or reversal therapies and finally the resumption of ADs with a focus on individual clinical and radiological characteristics for more personalized care.
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Affiliation(s)
- I Sibon
- Hôpital Pellegrin, CHU de Bordeaux, Unité Neurovasculaire, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France.
| | - J S Liegey
- Hôpital Pellegrin, CHU de Bordeaux, Unité Neurovasculaire, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
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34
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Mowla A, Razavi SM, Lail NS, Mohammadi P, Shirani P, Kavak KS, Sawyer RN, Kamal H. Hyperdense middle cerebral artery sign and response to combination of mechanical Thrombectomy plus intravenous thrombolysis in acute stroke patients. J Neurol Sci 2021; 429:117618. [PMID: 34418800 DOI: 10.1016/j.jns.2021.117618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/20/2021] [Accepted: 08/15/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Combining intra-arterial mechanical thrombectomy (IAMT) and intravenous thrombolysis (IVT) has shown to have an excellent recanalization rate and better clinical outcome in acute ischemic stroke (AIS) patients. Hyperdense middle cerebral artery sign (HMCAS) on pretreatment non-contrast head CT scan of AIS patients is one of the early ischemic radiological findings in middle cerebral artery territory AIS. We aimed to evaluate whether the presence of HMCAS predicts the outcome of AIS patients receiving combination therapy with IAMT and IVT. METHODS We retrospectively reviewed medical records and cerebrovascular images of the patients treated with IAMT and IVT for AIS in our center. Patients with occlusion in the terminal internal carotid artery or middle cerebral artery on pretreatment CT angiogram of the head were included. Clinical outcome was compared between subjects with HMCAS and those without. Modified Rankin Score (mRS) and symptomatic intracranial hemorrhage (sICH) were used as measures of efficacy and safety, respectively. RESULTS Of 93 patients, 46 (49%) had HMCAS on their initial head CT scan. Both groups had comparable baseline characteristics and stroke severity. After adjusting for age, NIHSS score, time from symptom onset to starting IVT, and history of diabetes mellitus in multivariate logistic regression analysis, there was no difference in terms of a poor outcome (mRS >2) (OR = 0.5 [CI 0.2-1.4], p = 0.188) or rate of sICH (OR = 3.3 [CI 0.6-19.0], p = 0.190) between the two groups. CONCLUSIONS HMCAS is not a predictor of poor outcome in AIS patients receiving combination therapy with IAMT and IVT and does not affect treatment safety.
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Affiliation(s)
- Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
| | - Seyed-Mostafa Razavi
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America; Heart and Rhythm Clinic, San Jose, CA, United States of America
| | - Navdeep S Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Pegah Mohammadi
- Department of Medicine, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Katelyn S Kavak
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
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Thalerová S, Pešková M, Kittová P, Gulati S, Víteček J, Kubala L, Mikulík R. Effect of Apixaban Pretreatment on Alteplase-Induced Thrombolysis: An In Vitro Study. Front Pharmacol 2021; 12:740930. [PMID: 34603054 PMCID: PMC8479181 DOI: 10.3389/fphar.2021.740930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/27/2021] [Indexed: 12/22/2022] Open
Abstract
Benefit of thrombolytic therapy in patients with acute stroke, who are on anticoagulant treatment, is not well addressed. The aim of this study was to investigate whether apixaban can modify the thrombolytic efficacy of alteplase in vitro. Static and flow models and two variants of red blood cell (RBC) dominant clots, with and without apixaban, were used. Clots were prepared from the blood of healthy human donors and subsequently exposed to alteplase treatment. Apixaban and alteplase were used in clinically relevant concentrations. Clot lysis in the static model was determined both by clot weight and spectrophotometric determination of RBC release. Clot lysis in the flow model was determined by measuring recanalization time, clot length and spectrophotometric determination of RBC release. In the static model, clots without apixaban; compared to those with apixaban had alteplase-induced mass loss 54 ± 8% vs. 53 ± 8%, p = 1.00; RBC release 0.14 ± 0.04 vs. 0.12 ± 0.04, p = 0.14, respectively. Very similar results were obtained if plasma was used instead of physiological buffered saline as the incubation medium. In the flow model, clot lysis without apixaban; compared to those with apixaban was as follows: recanalization time 107 ± 46 min vs. 127 ± 31 min, p = 1.00; recanalization frequency 90 ± 22% vs. 90 ± 22%, p = 1.00; clot volume reduction 32 ± 15% vs. 34 ± 10%, p = 1.00; RBC release 0.029 ± 0.007 vs. 0.022 ± 0.007, p = 0.16, respectively. Apixaban had no positive effect on alteplase-induced thrombolysis in both the in vitro static and flow models. Our data support current clinical practice, such that thrombolysis is contraindicated in stroke treatment for patients who have been treated with anticoagulants.
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Affiliation(s)
- Sandra Thalerová
- Neurology Department, International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Institute of Biophysics of the Czech Academy of Sciences, Brno, Czechia.,Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czechia
| | - Michaela Pešková
- Institute of Biophysics of the Czech Academy of Sciences, Brno, Czechia
| | - Patrícia Kittová
- Institute of Biophysics of the Czech Academy of Sciences, Brno, Czechia
| | - Sumeet Gulati
- Neurology Department, International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia.,Institute of Biophysics of the Czech Academy of Sciences, Brno, Czechia
| | - Jan Víteček
- Institute of Biophysics of the Czech Academy of Sciences, Brno, Czechia.,Center of Biomolecular and Cell Engineering, International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Lukáš Kubala
- Institute of Biophysics of the Czech Academy of Sciences, Brno, Czechia.,Center of Biomolecular and Cell Engineering, International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Robert Mikulík
- Neurology Department, International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
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Yaghi S, Mistry E, de Havenon A, Leon Guerrero CR, Nouh A, Liberman AL, Giles J, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, Fakhri H, Brown Espaillat K, Asad SD, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Scher E, Trivedi T, Wu T, Khan M, Keyrouz S, Furie K, Henninger N. Effect of Alteplase Use on Outcomes in Patients With Atrial Fibrillation: Analysis of the Initiation of Anticoagulation After Cardioembolic Stroke Study. J Am Heart Assoc 2021; 10:e020945. [PMID: 34323120 PMCID: PMC8475683 DOI: 10.1161/jaha.121.020945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology Brown University Providence RI
| | - Eva Mistry
- Department of Neurology Vanderbilt University Nashville TN
| | - Adam de Havenon
- Department of Neurology University of Utah Salt Lake City UT
| | | | - Amre Nouh
- Department of Neurology Hartford Hospital Hartford CT
| | - Ava L Liberman
- Department of Neurology Montefiore Medical Center New York NY
| | - James Giles
- Department of Neurology Washington University Saint Louis MO
| | - Angela Liu
- Department of Neurology Washington University Saint Louis MO
| | - Muhammad Nagy
- Department of Neurology Hackensack Medical Center Hackensack NJ
| | | | - Idrees Azher
- Department of Neurology Brown University Providence RI
| | | | - Hiba Fakhri
- Department of Neurology Vanderbilt University Nashville TN
| | | | | | | | - Heather Martin
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Jose Tan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | | | - Charles Esenwa
- Department of Neurology Montefiore Medical Center New York NY
| | - Natalie Cheng
- Department of Neurology Montefiore Medical Center New York NY
| | | | | | - Mithilesh Siddu
- Department of Neurology George Washington University Washington DC
| | - Erica Scher
- Department of Neurology New York University New York NY
| | | | - Teddy Wu
- Department of Neurology Christchurch Hospital Christchurch New Zealand
| | - Muhib Khan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Salah Keyrouz
- Department of Neurology Washington University Saint Louis MO
| | - Karen Furie
- Department of Neurology Brown University Providence RI
| | - Nils Henninger
- Department of Neurology University of Massachusetts Worcester MA.,Department of Psychiatry University of Massachusetts Worcester MA
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Ahmed MK, Kamal H, Weiss JL, Crumlish A, Shirani P, Sawyer RN, Mowla A. Transesophageal echocardiogram in the evaluation of acute ischemic stroke of young adults. Brain Circ 2021; 7:85-91. [PMID: 34189351 PMCID: PMC8191534 DOI: 10.4103/bc.bc_68_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/06/2021] [Accepted: 02/22/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION: Acute ischemic stroke (AIS) in the young age (≤50 years) is a major cause of disability. The underlying mechanism of AIS in this age group is usually different from elderly. Transthoracic echocardiography (TTE) is used to detect the potential cardiac sources of embolism in AIS patients. Transthoracic echocardiogram (TEE) is superior to detect specific underlying cardio-aortic source of embolism when compared to TTE. We aim to evaluate the diagnostic yield and therapeutic impact of TEE in AIS of young adults. METHODS: We retrospectively reviewed the consecutive patients with AIS in our comprehensive center in a 5-year period from our prospectively collected registry. We selected patients with age ≤50 years who had acute infarcts on brain magnetic resonance imaging or head computed tomography and underwent TEE as part of their diagnostic workup. Demographic details including, age, gender, body mass index, cardiovascular risk factors profile, and TEE findings were collected. RESULTS: Among a total 7,930 patients, 876 (11.04%) were found to be ≤50 years old. Among those, TEE was done in 113 patients (12.8%) in addition to TTE. Those who underwent TEE had a mean age of 40.4 ± 7.9 years, 60 were male (53%), 7 (6.2%) had a history of coronary artery disease, 38 (33%) had a history of diabetes, and 45 (40%) had a history of smoking. TEE showed new abnormal findings in a total of 15 patients (13.2%) that were not reported in their TTEs. Out of these, left atrial appendage thrombus was found in 5, infective endocarditis in 4, atrial septal aneurysms associated with patent foramen ovale (PFO) in 3, and spontaneous mobile echo density in three patients. Overall, new findings from TEE resulted in change in the secondary stroke prevention strategy in 14 patients of those who underwent TEE (12.3%). TEE also confirmed the presence of PFO, which was present on TTE with bubble study in 20 (17.6%) patients. CONCLUSION: TEE may provide additional information in the evaluation of the AIS in young adults, which could lead to change of the secondary stroke prevention strategy.
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Affiliation(s)
- Muhammad K Ahmed
- Department of Neurology, Georgia School of Medicine, HCA Education Consortium, Rome, GA, USA.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Haris Kamal
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Jessica L Weiss
- Department of Medicine, Division of Cardiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Annemarie Crumlish
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Robert N Sawyer
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Ashkan Mowla
- Department of Neurological Surgery, Division of Endovascular Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Seiffge DJ, Meinel T, Purrucker JC, Kaesmacher J, Fischer U, Wilson D, Wu TY. Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants. J Neurol Neurosurg Psychiatry 2021; 92:534-541. [PMID: 33542084 PMCID: PMC8053326 DOI: 10.1136/jnnp-2020-325456] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake-as a surrogate for anticoagulant activity-is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.
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Affiliation(s)
- David J Seiffge
- Stroke Research Center, Queen Square Institute of Neurology, London, UK .,Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | | | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric RadiologyUniversity Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Duncan Wilson
- Stroke Research Center, Queen Square Institute of Neurology, London, UK.,Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Teddy Y Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
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Mowla A, Sharifian-Dorche M, Mehla S, Lail NS, Sharifian-Dorche A, Vaughn CB, Sawyer RN, Shirani P. Safety and efficacy of antiplatelet use before intravenous thrombolysis for acute Ischemic stroke. J Neurol Sci 2021; 425:117451. [PMID: 33882341 DOI: 10.1016/j.jns.2021.117451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/18/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022]
Abstract
AIM To study the effects of pretreatment with Antiplatelet (AP) before IV thrombolysis (IVT) on the rate of symptomatic intracranial hemorrhage (sICH) and functional outcome in patients with Acute Ischemic stroke (AIS). METHOD In this retrospective study, the medical records and cerebrovascular images of all the patients who received IVT for AIS in our center in a 9.6-year period were reviewed. Patients who took at least one dose of any APs in the last 24 h prior to IVT were identified. They were categorized according to the type of AP, single versus dual AP therapy (DAPT), and dose of AP. Rate of sICH and functional outcome at discharge were compared between the AP users and non-users. RESULTS A total of 834 patients received IVT for AIS in our center during a 9.6- year period. Multivariate models were adjusted for age, NIHSS on admission, history of atrial fibrillation, history of hypertension, INR on admission, history of stroke and diabetes mellitus. In multivariate regression analyses and after adjusting for the variables mentioned above, the use of any AP was not associated with an increased rate of sICH (OR = 1.28 [0.70-2.34], p = 0.425). Furthermore, the use of DAPT did not significantly increase the rate of sICH in multivariate regression analyses. (OR = 0.663 [0.15-2.84], p = 0.580). The patients on any AP had a lower chance of having good functional outcome in univariate analysis (OR = 0.735 [0.552-0.979], p = 0.035). However, when adjusted for age, baseline NIHSS, history of diabetes, hypertension and prior stroke, AP use was not associated with a decreased chance of having a good functional outcome at discharge. (OR = 0.967 [0.690-1.357], p = 0.848). In addition, no significant difference was noted in the rate of good functional outcome between patients on DAPT and no AP users in multivariate regression analyses. (OR = 1.174 [0.612-2.253], p = 0.629). CONCLUSION Our study did not show any significant association between the risk of sICH and good functional outcome after IVT for AIS patients on AP therapy (dual or single) in comparison with AP naïve patients.
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Affiliation(s)
- Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
| | - Maryam Sharifian-Dorche
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Sandhya Mehla
- Ayer Neurosciences Institute, Hartford HealthCare Medical Group, University of Connecticut School of Medicine, Norwich, CT, United States of America
| | - Navdeep S Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | | | - Caila B Vaughn
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
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Mowla A, Memon A, Razavi SM, Lail NS, Vaughn CB, Mohammadi P, Sawyer RN, Shirani P. Safety of Intravenous Thrombolysis for Acute Ischemic Stroke in Patients Taking Warfarin with Subtherapeutic INR. J Stroke Cerebrovasc Dis 2021; 30:105678. [PMID: 33640783 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105678] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Current guidelines allow the administration of intravenous recombinant tissue plasminogen activator (IV r-tPA) to warfarin-treated patients with acute ischemic stroke (AIS) who have an international normalized ratio (INR) of ≤1.7. However, concerns remain about the safety of using IV r-tPA in this situation due to a conceivable risk of symptomatic intracranial hemorrhage (sICH), lack of dedicated randomized controlled trials and the conflicts in the available data. We aimed to determine the risk of sICH in warfarin-treated patients with subtherapeutic INR who received IV r-tPA for AIS in our large volume comprehensive center. METHODS Patients who had received IV r-tPA for AIS in a 9.6-year period were retrospectively investigated (n = 834). Patients taking warfarin prior to presentation were identified (n = 55). One patient was excluded due to elevated INR beyond the acceptable range for IV r-tPA treatment. Because of the significant difference in the sample size (54 vs 779), warfarin group was matched with 54 non-warfarin patients adjusted for independent risk factors for sICH (age, admission NIHSS, history of diabetes). Good outcome was defined as mRS of 0-2 on discharge and sICH was defined as an ICH causing increase in NIHSS ≥4 or death. Warfarin-treated group was further dichotomized based on INR (1-1.3 vs 1.3-1.7) and safety and outcome measures were compared between resultant groups. RESULTS No significant difference was found between warfarin-treated and the non-warfarin groups in terms of chance of good outcome on discharge (27.8% in warfarin group vs 26.4% in non-warfarin group; p-value >0.05), or the rate of occurrence of sICH (3.7% in warfarin group vs 11.1% in non-warfarin group; p-value >0.05). Furthermore, rate of sICH (5.1% in patients with INR <1.3 versus 0.0% in patients with INR 1.3-1.7; p-value >0.05) or chance of good outcome on discharge (28.2% of patients with INR <1.3 versus 26.7% in patients with INR 1.3-1.7; p-value >0.05) were not found to be different after the warfarin-treated group was dichotomized. CONCLUSION Administration of IV r-tPA for AIS in warfarin-treated patients with subtherapeutic INR <1.7 does not increase the risk of sICH.
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Tsivgoulis G, Kargiotis O, De Marchis G, Kohrmann M, Sandset EC, Karapanayiotides T, de Sousa DA, Sarraj A, Safouris A, Psychogios K, Vadikolias K, Leys D, Schellinger PD, Alexandrov AV. Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence. Ther Adv Neurol Disord 2021; 14:1756286421997368. [PMID: 33737956 PMCID: PMC7934037 DOI: 10.1177/1756286421997368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens 15344, Greece
| | | | - Gianmarco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Martin Kohrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | - Theodore Karapanayiotides
- Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Amrou Sarraj
- Department of Neurology, The University of Texas at Houston, Houston, TX, USA
| | - Apostolos Safouris
- Second Department of Neurology, National & Kapodistiran University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Didier Leys
- Department of Neurology (Stroke Unit), Lille Neuroscience and Cognition, Degenerative and Vascular Cognitive Disorders, University of Lille, INSERM (U-1172), Lille, France
| | - Peter D Schellinger
- Department of Neurology, Johannes Wesling Medical Center Minden, UK RUB Minden, Germany
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 179] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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Zambrano Espinoza MD, Lail NS, Vaughn CB, Shirani P, Sawyer RN, Mowla A. Does Body Mass Index Impact the Outcome of Stroke Patients Who Received Intravenous Thrombolysis? Cerebrovasc Dis 2021; 50:141-146. [PMID: 33423033 DOI: 10.1159/000511489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We sought to investigate the effect of obesity and BMI on functional outcome and rate of symptomatic intracranial hemorrhage (sICH) in a large sample of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT). METHODS In a single-center retrospective, but prospectively collected data, study of patients with AIS treated with IVT in a 10-year period, patients were placed into groups based on their BMI defined as underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), or obese (<30 kg/m2). The rate of sICH and discharge modified Rankin Scale (mRS) were compared between the groups using logistic regression analysis. RESULTS In a total of 834 patients who received IVT for AIS during a 10-year period, 224 (27.0%) were obese. Obese patients did not have a higher rate of sICH after IVT for AIS on the unadjusted or adjusted analysis (adjusted OR 0.95, 95% CI 0.48-1.88). We did not find an association between obesity and poor functional outcome at discharge (adjusted OR 0.76, 95% CI 0.53-1.09). CONCLUSIONS After adjusting for confounding factors such as age, baseline National Institute of Health Stroke Scale (NIHSS), and comorbidities, obesity was not associated with an unfavorable functional outcome at discharge nor with a higher risk of sICH in patients with AIS treated with IVT.
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Affiliation(s)
| | - Navdeep Singh Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Caila B Vaughn
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, California, USA,
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Kamal H, Mehta BK, Ahmed MK, Kavak KS, Zha A, Lail NS, Shirani P, Al-Mufti F, Sawyer RN, Mowla A. Laboratory factors associated with symptomatic hemorrhagic conversion of acute stroke after systemic thrombolysis. J Neurol Sci 2020; 420:117265. [PMID: 33333324 DOI: 10.1016/j.jns.2020.117265] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/13/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Laboratory factors associated with hemorrhagic conversion (HC) after Intravenous thrombolysis with rtPA (IVT) for Acute Ischemic Stroke (AIS) remain nebulous despite advances in our knowledge of AIS. This study aimed to investigate the laboratory factors predisposing to HC in AIS patients receiving IVT. METHODS We retrospectively reviewed the medical records of patients who received IV tPA for AIS at our comprehensive stroke center over a 9.6-year period. Besides age, gender, NIHSS, history of diabetes mellitus (DM), history of atrial fibrillation (Afib), we gathered their laboratory data including International Normalized Ratio (INR), lipid panel, serum albumin, serum creatinine, hemoglobin A1c (HbA1c), and admission blood glucose. Post-thrombolysis brain imagings were reviewed to evaluate for symptomatic ICH (sICH). The mean values of above mentioned laboratory data were compared between the group with sICH and patients with no sICH. Univariate and multivariate logistic regression were performed to evaluate the association of the laboratory findings with presence of sICH. sICH was defined as ICH causing an increase in NIHSS ≥4. RESULTS Of the 794 subjects in this study 51 (6.4%) had sICH. In the univariate analysis, patients who developed sICH had significantly higher NIHSS on admission (14.2 ± 5.4 vs 11.2 ± 6.5, p < .001), LDL-cholesterol (113.3 mg/dl ±36.9 vs. 101.8 mg/dl ± 38.2, p = .032), HbA1c (6.9% ± 2.3 vs. 6.1 ± 1.3, p = .003) and lower levels of Albumin (3.5 g/dl ±0.4 vs. 3.9 g/dl ± 0.5, p < .001). Furthermore, a higher prevalence of history of DM (45% vs. 21.6%, p = .020) and Afib (25.4% vs. 10.4%, p = .028) was found in subjects who developed sICH. There were no significant group differences regarding age, sex, total cholesterol, blood glucose on admission, serum creatinine or INR levels (p > .05). After adjusting for multiple covariates, lower Albumin level and and higher HbA1c were significantly associated with an increased risk for sICH development (p < .05). Chances of sICH increased by 33% for every 1 g/dl below a normal albumin level of 4.0 g/dl (p < .05). CONCLUSION Lower endogenous albumin level and higher HbA1c have shown to predispose to a higher risk of sICH after IVT for AIS and might be good predictors of sICH post IVT.
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Affiliation(s)
- Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Bijal K Mehta
- Department of Neurology, Harbor-UCLA Medical Center, Los Angeles, CA, United States of America
| | - Muhammad K Ahmed
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Katelyn S Kavak
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Alicia Zha
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, TX, United States of America
| | - Navdeep S Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
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Neves G, Lee J, Bueso T, Montalvan V, Iskandir M, Shurmur S, Kim J. Intravenous thrombolysis for the management of acute ischemic stroke in patients therapeutically anticoagulated with heparin: A review. Clin Neurol Neurosurg 2021; 200:106382. [PMID: 33276218 DOI: 10.1016/j.clineuro.2020.106382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with alteplase is effective in acute ischemic stroke (AIS). However, its use rate remains low due to the many exclusion criteria. Recent guidelines recommend excluding patients suffering AIS with an elevated aPTT secondary to heparin exposure from receiving IVT. The purpose of this review is to explore the safety and efficacy of IVT in patients therapeutically anticoagulated with heparin. We also propose a treatment algorithm for IVT in patients with AIS that are therapeutically anticoagulated with heparin. METHODS We performed a systematic review of PubMed and Embase through March 2020 to identify the literature regarding AIS in patients exposed to heparin, followed by IVT treatment, emphasizing safety, efficacy, and clinical outcome using PRISMA guidelines. RESULTS We included thirteen articles in the final analysis, including three retrospective studies, two observational studies, one randomized trial, five case reports, and two case series. CONCLUSION There is limited information about the off-label use of IVT in patients with elevated aPTT. Patients with AIS are excluded from IVT if they have recent exposure to heparin. Our review indicates that this population of patients may benefit from IVT as the cases of active bleeding after IVT are few, and functional outcomes are favorable in the long term suggesting that IVT in therapeutically anticoagulated patients may be safe and efficacious.
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46
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Ajam T, Cumpian TL, Tilkens BL, Jahangir IA, Frost J, Ceretto C, Jahangir A. Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly. Expert Rev Clin Pharmacol 2020; 13:1309-1327. [PMID: 33107345 DOI: 10.1080/17512433.2020.1842191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF). Since NOACs are predominantly used in the elderly with AF at high risk for stroke and bleeding and with comorbidities requiring polypharmacy, it is important to assess their safety and efficacy in this population. AREAS COVERED We review changes in pharmacokinetics and pharmacodynamics observed with senescence and the effect on NOACs and drug and food interactions. We also provide an update on challenges related to NOAC use in situations that increases the risk for bleeding or require temporary discontinuation and address practical issues in the elderly AF patients managed on NOACs. Clinical studies and trials with cardiovascular outcomes reported from January 1990 to August 2020 were identified through the Medline database using PubMed, Cochrane Library, and EMBASE database. EXPERT OPINION NOACs are highly effective in preventing stroke in AF patients with non-inferior or superior efficacy to warfarin, with reduced risk of major bleeding. However, in the older-elderly, evidence comes mainly from observational studies or extrapolation from studies in populations with minimal functional limitations or comorbidities. The high upfront cost and out-of-pocket expense for copayment or deductibles also limit the use of this effective therapy in a substantial number of patients. The cost reduction may further improve long-term use for NOACs in stroke prevention in elderly patients with AF.
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Affiliation(s)
- Tarek Ajam
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA
| | - Tabitha L Cumpian
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
| | - Blair L Tilkens
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA
| | | | - Jared Frost
- Pharmacy Services, Advocate Aurora Health , Milwaukee, WI, USA
| | - Cheryl Ceretto
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
| | - Arshad Jahangir
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
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Abstract
INTRODUCTION Amongst the 25.7 million survivors and 6.5 million deaths from stroke between 1990 and 2013, ischemic strokes accounted for approximately 70% and 50% of the cases, respectively. With patients still suffering from complications and stroke recurrence, more questions have been raised as to how we can better improve patient management. AREAS COVERED The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Newcastle-Ottawa Scale (NOS) were adopted to ensure a comprehensive inclusion of quality literature from various sources. PubMed and Embase were searched for evidence on thrombolysis, mechanical thrombectomy, artificial intelligence (AI), antiplatelet therapy, anticoagulation and hypertension management. EXPERT OPINION The directions of future research in these areas are dependent on the current level of validation. Endovascular therapy and applications of AI are relatively new compared to the other areas discussed in this review. As such, future studies need to focus on validating their efficacy. As for thrombolysis, antiplatelet and anticoagulation therapy, their efficacy has been well-established and future research efforts should be directed toward adjusting its use according to patient-specific factors, starting with factors with the most clinical relevance and prevalence.
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Affiliation(s)
- Ka Hou Christien Li
- Medicine, Newcastle University , Newcastle, UK.,Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | | | | | - Ruth Davies
- Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University , Tianjin, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
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Meinel TR, Branca M, De Marchis GM, Nedeltchev K, Kahles T, Bonati L, Arnold M, Heldner MR, Jung S, Carrera E, Dirren E, Michel P, Strambo D, Cereda CW, Bianco G, Kägi G, Vehoff J, Katan M, Bolognese M, Backhaus R, Salmen S, Albert S, Medlin F, Berger C, Schelosky L, Renaud S, Niederhauser J, Bonvin C, Schaerer M, Mono ML, Rodic B, Tarnutzer AA, Mordasini P, Gralla J, Kaesmacher J, Engelter S, Fischer U, Seiffge DJ. Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation. Ann Neurol 2020; 89:42-53. [PMID: 32996627 PMCID: PMC7756294 DOI: 10.1002/ana.25917] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes. METHODS This was a cohort study of consecutive patients (2014-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0-2) at 3 months. RESULTS Of 8,179 patients (mean [SD] age, 79.8 [9.6] years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, [interquartile range 2-11]) compared with VKA (6, [2-14]) and controls (7, [3-15], p < 0.001; quantile regression: β -2.1, 95% confidence interval [CI] -2.6 to -1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 [63%]; adjusted odds ratio [aOR] 0.67; 95% CI 0.50-0.90) and particularly in patients on DOACs (69 of 464 [15%]; aOR 0.06; 95% CI 0.05-0.08) compared with controls (1,544 of 2,504 [74%]). sICH after IVT occurred in 3.6% (2.6-4.7%) of controls, 9 of 195 (4.6%; 1.9-9.2%; aOR 0.93; 95% CI 0.46-1.90) patients on VKA and 2 of 65 (3.1%; 0.4-10.8%, aOR 0.56; 95% CI 0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3-month outcome (aOR 1.24; 1.01-1.51). INTERPRETATION Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42-53.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mattia Branca
- Clinicial Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabeth Dirren
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital Zurich, Basel, Switzerland
| | | | | | | | | | | | | | - Ludwig Schelosky
- Neurology, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Susanne Renaud
- Neurology, Cantonal Hospital Neuchatel, Neuchâtel, Switzerland
| | | | | | | | | | - Biljana Rodic
- Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatic Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Kamal H, Ahmed MK, Zha A, Lail NS, Shirani P, Sawyer RN, Mowla A. Strokes occurring in the hospital: Symptom recognition and eligibility for treatment in the intensive care units versus hospital wards. Brain Circ 2020; 6:196-199. [PMID: 33210045 PMCID: PMC7646397 DOI: 10.4103/bc.bc_24_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/14/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND: Studies have shown that 4%–17% of acute ischemic strokes (AISs) occur in patients hospitalized for another reason; scanty data are available about the care delivery and outcome of this patient population. MATERIALS AND METHODS: All consecutive inhospital AISs over a 10-year period at our comprehensive stroke center were included in the study. We compared the meantime from last known neurologically intact to symptom detection and also eligibility for acute treatment of patients based on their physical location in the hospital with respect to the level of care when they were found to have the stroke symptoms. RESULTS: Fifty-three patients suffered inhospital AIS during this period (28 in intensive care units/emergency department [ICUs/ED] vs. 25 in regular floors). Only in four patients (7.5%), initial brain imaging was done within 25 min from symptom recognition (as recommended by the American Heart Association/American Society of Anesthesiologists guidelines). Forty-two (79%) underwent brain imaging within 6 h of symptom recognition; of them, 11 (26%) received intravenous thrombolysis (IVT) within the first 4.5 h of symptom onset and 7 (17%) underwent endovascular treatment (EVT). The mean (±standard deviation) time in minutes from last known neurologically intact to symptom detection for floor patients was significantly longer compared to the ICU/ED patients (194 [±149] vs. 74 [±45], P = 0.0003). Patients admitted to the ICU/ED had more chance of being recognized earlier and being eligible for IVT or/and EVT compared to the patients admitted to the regular floors (44% vs. 25%, P = 0.14); however, the difference did not reach statistical significance. CONCLUSIONS: ICU/ED patients had a significantly shorter time to stroke symptom detection from last known neurologically intact when compared to the regular floor patients. Furthermore, they had a trend toward a higher likelihood of being eligible for acute treatment compared to the regular floors, although the result did not reach statistical significance.
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Affiliation(s)
- Haris Kamal
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, Texas, USA
| | - Muhammad K Ahmed
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, Texas, USA
| | - Alicia Zha
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, Texas, USA
| | - Navdeep S Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Peyman Shirani
- Department of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Ashkan Mowla
- Department of Neurological Surgery, Division of Endovascular Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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50
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Mowla A, Shah H, Lail NS, Vaughn CB, Shirani P, Sawyer RN. Statins Use and Outcome of Acute Ischemic Stroke Patients after Systemic Thrombolysis. Cerebrovasc Dis 2020; 49:503-508. [PMID: 32927457 DOI: 10.1159/000510095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/13/2020] [Indexed: 11/19/2022] Open
Abstract
AIM The aim of this was to study the effects of statins and their intensity on symptomatic intracranial hemorrhage (sICH) and outcome after IV thrombolysis (IVT) for acute ischemic stroke (AIS). METHODS We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with IVT for AIS in our center in a 10-year period. Patients were further characterized as any statin users versus non-users on admission to the emergency department. Statins were categorized in high intensity or low intensity statin based on its propensity to reduce lower low-density cholesterol by ≥45% or <45%, respectively. Safety and discharge modified Rankin Score were compared between statin users versus non-users and also between high-intensity versus low-intensity groups. RESULTS A total of 834 patients received IVT for AIS in our center during a 10-year period. Multivariate models were adjusted for age, NIH Stroke Scale at admission, INR, and history of DM and atrial fibrillation. There was no association between odds of sICH and any statin use (OR = 0.52 [0.26-1.03], p = 0.06). In multivariate model, any statin use was not associated with odds of poor outcome (Table 4: OR = 1.01 [0.79-1.55], p = 0.57). There was no significant association between odds of sICH among patients on high-intensity statin compared to low intensity statin (multivariate model OR = 0.39 [0.11-1.40], p = 0.15). There was 47% reduced odds of poor outcome among patients on high-intensity statin as compared to low-intensity statin (OR = 0.53[0.32-0.88] p = 0.01). However, this significant association was lost in the multivariate model (OR = 0.60 [0.35-1.05], p = 0.07). CONCLUSION Our study does not show any significant association between risk of sICH and poor outcome after IVT for patients on prior statin therapy. We also did not find significant association between the risk of sICH and poor outcome after IVT and the intensity of the stain used.
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Affiliation(s)
- Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, California, USA,
| | - Harshit Shah
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Navdeep Singh Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Caila B Vaughn
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, New York, USA
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