Intravenous thrombolysis for suspected ischemic stroke with seizure at onset

Abstract

for the TRISP CollaboratorsObjective: Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke. Methods: In this multicenter, IVT-registry-based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3-month mortality, and 3-month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses. Results: Among 10,074 IVT-treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non-SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio [OR] unadjusted = 1.53 [95% confidence interval (CI) = 0.74-3.14], OR adjusted = 0.52 [95% CI = 0.13-2.16], OR matched = 0.68 [95% CI = 0.15-3.03], OR weighted = 0.95 [95% CI = 0.39-2.32]), mortality (OR unadjusted = 1.49 [95% CI = 1.00-2.24], OR adjusted = 0.98 [95% CI = 0.5-1.92], OR matched = 1.13 [95% View this article online at wileyonlinelibrary.com.

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

“…Data from several observational studies suggests that the risk of sICH is low in patients with stroke mimics 214,215 and also in patients with suspected acute ischaemic stroke with seizure at stroke onset. 216 In an observational study of 5,581 patients treated with alteplase, 100 patients had stroke mimics (1.8%). The rate of sICH in patients with stroke mimics was 1.0% (95% CI: 0.0–5.0) compared with 7.9% (95% CI: 7.2–8.7) in patients with ischaemic strokes.…”

Ischemic stroke mimics: A comprehensive review

“…Although seizues can occur due to ischemic stroke, especially in cortical lesions, early seizures can occur in 3.8% of all cases and only 1.5% had seizure at the onset of stroke symptoms [6,83].…”

CT perfusion: stroke, seizure or both?

“…14 In addition, the number needed to treat for thrombolysis is 10 if administered within 3 hours/with a favourable CT/CT perfusion imaging, and seizure at onset of acute ischaemic stroke is not an independent predictor of poor prognosis. 15 Advanced imaging methods such as CT perfusion or MRI with DWI and apparent diffusion coefficients have not been used in the context of seizures and suspected acute stroke in randomised controlled trials, and their use has the potential to complicate decision-making as our case demonstrates. The major point for discussion in the management of our patient revolves around whether the CT perfusion should have prevented us from thrombolysing the patient, who had in fact suffered bilateral ischaemic thalamic infarcts.…”