Early neurological improvement after intravenous tissue plasminogen activator infusion in patients with ischemic stroke aged 80 years or older

Ong, Cheung-Ter; Sung, Sheng-Feng; Wu, Chi-Shun; Hsu, Yung-Chu; Su, Yu-Hsiang; Li, Chen-Hsien; Hung, Ling-Chien

doi:10.1016/j.jcma.2014.02.002

Cited by 14 publications

(14 citation statements)

References 18 publications

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“…26 Also, in a study by Zeevi et al, 19 older patients treated with IV-rtPA presented with a 12-month modified Barthel Index score comparable to that of younger patients. Moreover, several studies revealed a similar rate of early neurological improvement in younger and older patients, 7,9 and higher rates of early neurological improvement 21 and improved functional outcome among elderly patients who underwent thrombolysis versus elderly patients who did not undergo thrombolysis. 8,25 In the present study, hemorrhagic transformation or mortality rates at day 90 were similar in older and younger patients.…”

Section: Article In Pressmentioning

confidence: 92%

“…Most studies seem to show worse outcome and increased mortality in patients aged over 80 years old with acute ischemic stroke treated with IV-rtPA when compared with younger counterparts. [7][8][9][10][11][12][13][14][15][16][17] Nevertheless, patients from this age group still seem to benefit from this treatment and do not seem to have an increased risk of symptomatic intracranial hemorrhage after IV-rtPA, as demonstrated in several observational studies [7][8][9][11][12][13][14]16,[18][19][20][21][22][23][24][25] and also in a randomized controlled trial. 26 Thus, there is increasing evidence supporting the finding that old age, by itself, should not be a reason to exclude patients from treatment with IV-rtPA.…”

Section: Introductionmentioning

confidence: 97%

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Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

Pego

Nunes

Ferreira

et al. 2016

Journal of Stroke and Cerebrovascular Diseases

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Background: Despite stroke's high prevalence in the elderly, intravenous thrombolysis is licensed in Europe only for patients younger than 80 years old. We aimed to compare the functional outcomes and complication rates in patients older versus younger than 80 years old treated with intravenous thrombolysis. Methods: A retrospective observational study of patients who received intravenous thrombolysis in a stroke unit between January 1, 2009, and June 30, 2012, was conducted. Variables were compared between 2 subgroups (≤80 and >80 years). Results: Overall, 512 patients underwent intravenous thrombolysis, of which 13.1% were over 80 years. The mean age was 65.4 years in the younger subgroup and 82.9 years in the older subgroup. Prior independence rates did not differ between the subgroups. Prevalence of atrial fibrillation and cardioembolic stroke was higher in the older subgroup (P = .004 and .026). Only 3% of the elderly with atrial fibrillation were taking oral anticoagulants. Symptoms-to-needle time was lower in the older subgroup (P = .048). Stroke severity was higher in patients over 80 years (P = .026). There was significant improvement in the National Institutes of Health Stroke Scale score 7 days after intravenous thrombolysis (P < .001) in both subgroups. The proportion of patients with 3 months' favorable outcome and independence, hemorrhagic transformation, and mortality rates were similar in both subgroups. Conclusions: Elderly patients' benefits and outcomes from intravenous thrombolysis treatment were identical to the younger subgroup without excess hemorrhagic transformation or mortality. These results favor the use of intravenous thrombolysis in patients over 80 years. Key Words: Stroke-elderlythrombolysis-over 80 years.

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Section: Article In Pressmentioning

confidence: 92%

Section: Introductionmentioning

confidence: 97%

Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

Pego

Nunes

Ferreira

et al. 2016

Journal of Stroke and Cerebrovascular Diseases

View full text Add to dashboard Cite

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“…21 The patient's neurological condition was evaluated as described in our previous study. 3 Early neurological improvement (ENI) was defined as a decrease of more than 6 points (compared with baseline) or an improvement in the NIHSS of 0 or 1 within 24 hrs after tPA infusion. Neurological improvement (NI) was defined as a >6-point improvement (compared with baseline) or an improvement in the NIHSS of 0 or 1 at discharge.…”

Section: Methodsmentioning

confidence: 99%

“…1 From then on, most studies on thrombolytic therapy for ischemic stroke patients followed the guidelines for thrombolytic therapy for acute stroke, using intravenous tPA (0.9 mg/kg, maximum 90 mg), with a bolus of 10% of the total dose given within 1─2 mins, followed by an infusion lasting 60 mins. [2][3][4] Owing to a higher symptomatic hemorrhagic transformation rate (sHT) in patients who received standard-dose tPA therapy, [5][6][7] a lower dose of tPA for ischemic stroke patients was suggested. 8,9 Subsequently, the Japan Alteplase Clinical Trial (J-ACT) study reported that IV low-dose tPA (0.6 mg/kg) could offer both clinical efficacy and safety as a standard dose, 8 and the Japanese drug safety authority has approved the use of tPA 0.6 mg/kg for patients with ischemic stroke.…”

Section: Introductionmentioning

confidence: 99%

<p>The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy</p>

Wong

Sung

et al. 2020

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Background: Intravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1-2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT). Aim: This study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Methods: In this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0-5), moderate (6-14), severe (15-24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups. Results: In patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose. Conclusion: In severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.

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“…Other authors defined improvement as the NIHSS score improvement by 40% from baseline and compared patients at 1 h after thrombolysis (very early neurological improvement -VENI) and at 24 h (early neurological improvement -ENI) [18]. Early neurological improvement was also defined as eight or more points in NIHSS 24 h after thrombolysis while neurological improvement was defined as an improvement of at least eight points at discharge (compared with baseline) [19].…”

Section: Introductionmentioning

confidence: 99%

The early outcome of thrombolytic treatment in ischaemic stroke patients: a retrospective analysis

Kotlęga¹,

Meller²,

Gołąb-Janowska³

et al. 2019

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Introduction: The results of early outcome in thrombolysed stroke patients are connected with the long-term effect measured as disability and death rate. There are different definitions of the early improvement in such patients. Aim of the research: To establish potential prognostic factors adversely influencing the early outcome of stroke patients treated with alteplase. Material and methods: The analysis of 245 consecutive ischaemic stroke patients treated intravenously with recombinant tissue plasminogen activator (rt-PA) was conducted. The outcome was analysed 24 h after rt-PA treatment depending on the NIHSS score. Group I consisted of 105 patients with the improvement in NIHSS ≥ 2 points 24 h after intravenous rt-PA administration, and group II comprised of the rest of the patients (n = 140). Results: The independent factors adversely affecting the early outcome were: hypertension, old ischaemic lesions in initial brain computed tomography (CT), longer therapeutic window, higher baseline NIHSS (respectively: OR = 0.34, p < 0.05; OR = 0.55, p < 0.01; OR = 0.99, p < 0.01; OR = 0.91, p < 0.01). Conclusions: There are factors affecting the grade of early neurological improvement assessed 24 h after rt-PA therapy that may help to improve the efficacy of the acute phase treatment and secondary prevention of stroke patients. More attention should be paid to patients with hypertension, those with greater initial neurological deficit, longer onset-to-treatment time, and old ischaemic changes in initial brain CT. Streszczenie Wprowadzenie: Wyniki wczesnego leczenia trombolitycznego pacjentów z udarem niedokrwiennym mózgu wiążą się z długotrwałym efektem w zakresie niepełnosprawności i śmiertelności. Spotykane są różne definicje wczesnej poprawy w tej grupie pacjentów. Cel pracy: Ustalenie potencjalnych czynników prognostycznych niekorzystnie wpływających na wczesny wynik leczenia alteplazą pacjentów z udarem mózgu. Materiał i metody: Analizie poddano 245 kolejnych pacjentów z rozpoznaniem udaru niedokrwiennego mózgu leczonych dożylnie rekombinowanym tkankowym aktywatorem plazminogenu (rt-PA). Wynik oceniono 24 godziny po zastosowaniu leczenia w zależności od wyniku wg skali NIHSS. Grupę I stanowiło 105 pacjentów ze stopniem poprawy ≥ 2 pkt wg skali NIHSS w czasie 24 godzin po leczeniu, a grupę II-pozostali pacjenci (n = 140). Wyniki: Niezależnymi czynnikami ryzyka niekorzystnie wpływającymi na wczesny wynik leczenia są: nadciśnienie tętnicze, stare zmiany niedokrwienne mózgu, dłuższe okno terapeutyczne, wyższy wyjściowo wynik wg skali NIHSS (odpowiednio: OR = 0,34, p < 0,05; OR = 0,55, p < 0,01; OR = 0,99, p < 0,01; OR = 0,91, p < 0,01). Wnioski: Znane są czynniki, które wpływają na stopień wczesnej poprawy neurologicznej ocenianej w czasie 24 godzin po leczeniu trombolitycznym. Mogą one pomóc w poprawie skuteczności terapii ostrej fazy i profilaktyki wtórnej u pacjentów z udarem niedokrwiennym mózgu. Należy poświęcać więcej uwagi pacjentom z nadciśnieniem tętniczym, wyjściowo większym deficytem neurologicznym, z dłu...

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Early neurological improvement after intravenous tissue plasminogen activator infusion in patients with ischemic stroke aged 80 years or older

Abstract: In older patients, thrombolytic treatment increased the rate of neurological improvement compared with patients not receiving the treatment. The study showed that thrombolytic treatment may be beneficial for patients ≥80 years, but should be performed with extreme care.

Cited by 14 publications

References 18 publications

Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

<p>The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy</p>

The early outcome of thrombolytic treatment in ischaemic stroke patients: a retrospective analysis

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