Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis

Whiteley, William; Emberson, Jonathan; Lees, Kennedy R.; Blackwell, Lisa; Albers, Gregory W.; Bluhmki, Erich; Brott, Thomas G.; Cohen, Geoff; Davis, Stephen M.; Donnan, Geoffrey A; Grotta, James C.; Howard, George; Kaste, Markku; Koga, Masatoshi; Kummer, Rüdiger von; Lansberg, Maarten G.; Lindley, Richard I; Lyden, Patrick D.; Olivot, Jean Marc; Parsons, Mark; Toni, Danilo; Toyoda, Kazunori; Wahlgren, Nils; Wardlaw, Joanna M.; Zoppo, Gregory J. del; Sandercock, Peter; Hacke, Werner; Baigent, Colin

doi:10.1016/s1474-4422(16)30076-x

Cited by 193 publications

(149 citation statements)

References 37 publications

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“…A possible relation between onset to assessment time and SICH rate that is independent of treatment was apparent in the control group of the pooled RCT, published by STTC. 4 The absolute incidence of SITS-MOST hemorrhage was 0.4% <3h, 0.6% >3-4.5h and 0.7% >4.5h, though the small numbers do not permit reliable estimation, and stratification by age groups was not performed.…”

Section: Discussionmentioning

confidence: 96%

Outcome after stroke thrombolysis in patients >80 years treated within 3 hours vs >3–4.5 hours

Ahmed¹,

Lees²,

Ringleb³

et al. 2017

Neurology

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Supplemental dataNo funding sources had part in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. SICH/SITS 2.7% vs. 1.6%, aOR 1.62(1.12-2.34, p=0.01). 5Conclusions: In this observational study, unselected patients >80-years treated with IVT after 3h versus earlier had a slightly higher rate of SICH but similar unadjusted functional outcome but poorer adjusted outcome. The absolute difference between the treatment groups is small and elderly patients should not be denied IVT in the later time window solely for age without other contraindications. Main text:

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Section: Discussionmentioning

confidence: 96%

Outcome after stroke thrombolysis in patients >80 years treated within 3 hours vs >3–4.5 hours

Ahmed¹,

Lees²,

Ringleb³

et al. 2017

Neurology

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“…and M.A.M.). ICH was classified according to the Heidelberg bleeding classification [15], symptomatic ICH by using the European Cooperative Acute Stroke Study II [16], and fatal ICH in accordance to the Safe Implementation of Thrombolysis In Stroke-Monitoring Study criteria [17].…”

Section: Methodsmentioning

confidence: 99%

Renal Impairment Is Associated with Intracerebral Hemorrhage after Mechanical Thrombectomy in Vertebrobasilar Stroke

et al. 2019

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Background and Purpose: Renal dysfunction (RD) is overall associated with unfavorable functional outcome and higher risk of mortality after acute ischemic stroke. Associations between RD and outcome in patients with acute vertebrobasilar stroke treated with thrombectomy have not been evaluated so far. Materials and Methods: Consecutive patients with vertebrobasilar stroke treated with mechanical thrombectomy between October 2010 and July 2017 at our center were analyzed. RD was defined as glomerular filtration rate (GFR) < 60 mL/min/1.73 m² at admission. Endpoints were (I) poor clinical outcome (modified Rankin Scale > 2) at 3 months, (II) 3-month mortality, and (III) intracerebral hemorrhage (ICH) after treatment. Results: Overall, 106 patients were included. Median age was 73.0 years (interquartile range 62.0–80.0), and RD was present in 20.8%. Multivariate analysis revealed that RD was associated with a higher risk for any ICH (OR 3.54; 95% CI 1.09–11.49; p = 0.035). Stroke severity at onset predicted poor clinical outcome (OR 1.08; 95% CI 1.03–1.14; p = 0.003). Neither low GFR nor any ICH, but stroke severity (OR 1.08; 95% CI 1.03–1.14; p = 0.002) and poor recanalization results (OR 11.38; 95% CI 2.01–64.41; p = 0.006) were associated with a higher risk for mortality. Conclusions: Patients with RD and acute vertebrobasilar stroke should be thoroughly monitored to prevent ICH after thrombectomy. Our results support performing mechanical thrombectomy in acute stroke patients with large vessel occlusions of the posterior circulation, irrespective of their renal function.

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“…11,14 Several factors increase SICH risk, 15,16 but stroke severity is the strongest predictor (with or without thrombolysis). 17 Excess risk of SICH rises from 1.5% for NIHSS 0-4 to 3.7% for NIHSS>25 (Fig 2 ). There is no evidence to support procoagulant therapy or surgical intervention for SICH.…”

Section: Complicationsmentioning

confidence: 95%

“…5 While the relative benefit of treatment remains constant across age groups and severities, the absolute benefit varies by time to treatment and should be balanced against the risk of symptomatic intracerebral haemorrhage (SICH). Relative risk of SICH appears constant across the first 4.5 hours.…”

Section: Indications and Contraindicationsmentioning

confidence: 99%

Thrombolysis and thrombectomy for acute ischaemic stroke

Tawil

Muir

2017

Clinical Medicine

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The likelihood of disability-free recovery after acute ischemic stroke is significantly improved by reperfusion either by intravenous thrombolytic drug treatment or with endovascular mechanical thrombectomy in selected cases. The use of intravenous thrombolysis is limited by the short treatment window and you need to assess individual balance of benefit and risk of symptomatic intracranial haemorrhage. Benefit is greater for shorter onset-to-reperfusion time intervals, requiring optimisation of pre-hospital and inhospital pathways. Symptomatic haemorrhage is more likely with more severe strokes, but a greater proportion of patients are left free of disability than suffer a treatmentrelated haemorrhage at all levels of severity. Extracranial haemorrhage and orolingual angioedema are less common complications. Endovascular mechanical thrombectomy can be used in selected patients with imaging-proven large artery occlusion. Successful therapy depends on well-organised services that can deliver treatment within a short time window at centres with adequate expertise to perform the procedure.

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Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis

Abstract: UK Medical Research Council, British Heart Foundation, University of Glasgow, University of Edinburgh.

Cited by 193 publications

References 37 publications

Outcome after stroke thrombolysis in patients >80 years treated within 3 hours vs >3–4.5 hours

Outcome after stroke thrombolysis in patients >80 years treated within 3 hours vs >3–4.5 hours

Renal Impairment Is Associated with Intracerebral Hemorrhage after Mechanical Thrombectomy in Vertebrobasilar Stroke

Thrombolysis and thrombectomy for acute ischaemic stroke

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