Endovascular stroke treatment does not preclude high thrombolysis rates

Abstract

Background and purpose In 1995 intravenous recombinant tissue plasminogen activator (IVRTPA) was the first reperfusion therapy to be approved in patients with acute ischaemic stroke (AIS). The significance and impact of IVRTPA in times of modern endovascular stroke treatment (EST) were analysed in a German academic stroke centre. Methods A retrospective observational cohort analysis of 1034 patients with suspected AIS presenting at the emergency department in 2014 was performed. Patients were evaluated for baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcome, symptomatic intracranial haemorrhage (sICH) and mortality. Data acquisition was part of an investigator‐initiated, prospective and blinded end‐point registry. Results In 718 (69%) patients the diagnosis of symptomatic AIS was confirmed. 419 (58%) patients presented within 4.5 h of symptom onset and of those 260 (62%) received reperfusion therapy (IVRTPA alone, n = 183; combination or bridging therapy, n = 60; EST alone, n = 17). Subtracting cases with absolute contraindications for IVRTPA resulted in an effective thrombolysis rate of 82%. sICH occurred in two patients treated with IVRTPA alone (1.1%). The median door‐to‐needle interval was 30 min. Fifty (17%) non‐EST eligible AIS patients presenting within 4.5 h without absolute contraindications did not receive IVRTPA mainly due to mild or regressive symptoms. Most of these untreated IVRTPA eligible patients (82%) were discharged with a good clinical outcome (modified Rankin Scale ≤ 2). Conclusions Intravenous recombinant tissue plasminogen activator remains the most frequently applied reperfusion therapy in AIS patients presenting within 4.5 h of onset in a tertiary stroke centre. An effective thrombolysis rate of over 80% can be achieved without increased rates of sICH.

Recovery from stroke: current concepts and future perspectives

“…While thrombolysis and thrombectomy are highly effective in reducing stroke-related morbidity and mortality [ 21 , 66 ], only a relatively small minority of patients meet the criteria to obtain them [ 2 , 45 ]. While the thrombolysis rate for single hospitals may reach up to 34% patients [ 17 ], numbers reported in larger regional registries including tens of thousands of patients are considerably smaller. For example, in 2018, approx.. 14.5% of the stroke patients in the German Northrhine area received thrombolysis (Medical Chamber Northrhine/Germany, Quality report 2018).…”

Neuroinflammation and COVID-19 Ischemic Stroke Recovery—Evolving Evidence for the Mediating Roles of the ACE2/Angiotensin-(1–7)/Mas Receptor Axis and NLRP3 Inflammasome

“…Previous studies have characterized the mechanism of post-stroke neuroplasticity and brain repair into four major and overlapping phases, including inflammatory cascade and resolution of injury, diaschisis (i.e., damage-mediated remote effects on distal structurally and functionally connected brain parenchyma), tissue repair, and neuro-glial compensation [ 104 , 105 ]. However, the uncontrolled inflammatory reaction following ischemia can further impact the tissue damage (for several days to months), thereby expanding the lesion and neurological damage [ 106 ].…”

Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence

“…Still, less than 60% of cases with in-time presentation receive IVT. 5 Other commonly encountered factors that may prompt withholding IVT include minimal or very severe neurological deficits at presentation, anticoagulation pre-treatment, history of recent stroke or myocardial infarction, history of recent surgery or bleeding, and sometimes older age combined with pre-stroke morbidity. The list grows considerably when taking also into account the several relative contraindications of IVT.…”