“…In one observational study of 1,212 patients treated with alteplase, only 7 (0.6%) had a history of ICH (hematoma volume: 1–21 cm, 3 elapsed time between previous ICH and ischemic stroke: 1.5–12 years), none of whom developed sICH or died after IVT. 197 There are also case reports. 189,196,198 A key question is the time elapsed since the intracranial haemorrhage, but unfortunately this information is not provided in most reports.Recommendation For patients with acute ischaemic stroke of < 4.5 h duration, and a history of intracranial haemorrhage, there is insufficient evidence to make an evidence-based recommendation.…”
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.
“…In one observational study of 1,212 patients treated with alteplase, only 7 (0.6%) had a history of ICH (hematoma volume: 1–21 cm, 3 elapsed time between previous ICH and ischemic stroke: 1.5–12 years), none of whom developed sICH or died after IVT. 197 There are also case reports. 189,196,198 A key question is the time elapsed since the intracranial haemorrhage, but unfortunately this information is not provided in most reports.Recommendation For patients with acute ischaemic stroke of < 4.5 h duration, and a history of intracranial haemorrhage, there is insufficient evidence to make an evidence-based recommendation.…”
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.
“…All of the seven included studies reported similar rates of sHT following IVT among patients with and without prior ICrH. 10 – 13 , 22 – 24 Four studies reported risk of in-hospital, 11 , 25 , 26 within 30-day, 22 or within 90-day 10 , 13 death. Zand et al 11 reported no in-hospital mortalities in the seven patients with prior ICrH.…”
Section: Resultsmentioning
confidence: 94%
“… 10 – 13 , 22 – 24 Four studies reported risk of in-hospital, 11 , 25 , 26 within 30-day, 22 or within 90-day 10 , 13 death. Zand et al 11 reported no in-hospital mortalities in the seven patients with prior ICrH. Also, Meretoja et al 23 reported no death within 30 days in the three patients with prior ICrH.…”
Section: Resultsmentioning
confidence: 99%
“…Seven articles 10 – 13 , 22 – 24 were eligible for meta-analysis. All of the included studies in the meta-analyses were observational.…”
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.
“…Although multiple studies have investigated the safety of IV thrombolysis in patients with a past history of ICH, data addressing the proper time interval between the ICH and AIS is lacking. Moreover, current evidence does not show whether it is safe in chronic ICH cases with underlying vascular abnormalities or with recurrent cases [10].…”
Intravenous thrombolysis remains the gold standard in the management of acute ischemic stroke if the patient presents within the window period. Endovascular thrombectomy is another line of therapy in selected cases. Nonetheless, one of the most devastating complications of IV thrombolysis is intracranial hemorrhage (ICH); in such cases, the previous history of ICH is considered a potential contraindication to thrombolysis. Evidence regarding the safety of thrombolysis administration in patients with a previous history of ICH is scarce. We encountered a patient with acute ischemic stroke with a past history of hypertensive ICH. A 59-year-old female, presented with complete right-sided body weakness, global aphasia and gaze preference. A computed tomography (CT) brain perfusion scan revealed a mismatch suggestive of left middle cerebral artery (MCA) ischemic stroke. The patient received intravenous thrombolysis and showed significant clinical improvement with no subsequent complications or ICH. In reporting this case, we aim to provide evidence supporting the safety of thrombolytic therapy in selected cases with a previous history of ICH when no alternative line of management is available.
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