Thrombolysis Despite Recent Stroke

Abstract

Background and Purpose— Thrombolysis in ischemic stroke is contraindicated in patients who have had a stroke within 3 months. However, it is unclear whether thrombolytic therapy is associated with adverse outcomes in this population. We report the characteristics and outcomes of patients treated with systemic recombinant tissue-type plasminogen activator in the context of known or unknown recent stroke. Methods— We identified patients who received recombinant tissue-type plasminogen activator despite recent stroke (within 3 months of acute thrombolysis). Clinical and radiological findings were collected, including early neurological worsening and hemorrhagic transformation on unenhanced computed tomography at 24 hours. Clinical outcome measured by modified Rankin Scale was determined at 3 months from onset. Results— Six patients presenting with acute stroke within 3 months of previous stroke were identified (median age, 76 years; median National Institutes of Health Stroke Scale, 8.5). Hemorrhagic transformation was seen in the follow-up computed tomography scan in 3 of 6 cases: all were hemorrhagic transformation 1 (petechial hemorrhage), asymptomatic, and mostly located within the area of subacute infarction. There was no early neurological deterioration, and 3 patients had modified Rankin Scale ≤2 after 3 months. Conclusions— In our center, we thrombolysed 6 patients despite recent stroke. Three patients had asymptomatic petechial hemorrhagic transformation within the area of subacute infarct, without apparent neurological worsening. Prospective studies are needed to explore the possible safety of tissue-type plasminogen activator in the context of previous subacute stroke in otherwise eligible patients.

Response to Letter by Gaillard et al Regarding Article, “Thrombolysis Despite Recent Stroke: A Case Series”

“…1 We agree with the points raised in the letter, and it is reassuring that other centers have similar observations. …”

“…1 We agree with the points raised in the letter, and it is reassuring that other centers have similar observations. 2 The case of Gaillard showed well the risks associated with this approach, although the final outcome was excellent.…”

Repeated Intravenous Thrombolysis for Early Recurrent Stroke

“…Our findings are in line with the observations in all the 11 other patients with repeated IVT in ERS published to date. 4,[7][8][9][10][11] In this series, the decision to dare a repeated IVT has been motivated by the favorable clinical (modified Rankin scale score and 24-hour National Institutes of Health Stroke Scale) and radiological outcomes (small infarct volume and high recanalization rates) after the first IVT (Figure and Table 2). Thus, a repeated IVT to reinstate the positive results of the first one was reasonable.…”

“…However, in recent years, several registry-based studies showed that IVT can be safely and effectively administered to patients who would have been excluded if the exclusion criteria were strictly applied, 1,2 including early (<3 months) recurrent stroke (ERS). [3][4][5] There is a subgroup of patients with ERS, who already received IVT for their index stroke and may benefit from a repeated thrombolysis. Repeated IVT for the treatment of myocardial infarction or pulmonary embolism is safe.…”

Letter by Gaillard et al Regarding Article, “Thrombolysis Despite Recent Stroke: A Case Series”

“…We read with great interest the article by Alhazzaa et al, 1 reporting a retrospective analysis of a case series of 6 patients with previous ischemic stroke within the previous 3 months treated with recombinant tissue-type plasminogen activator (rtPA) for acute ischemic stroke beyond current guidelines. They found a 50% (3/6) post-thrombolysis hemorrhagic transformation rate among remote prior infarction, asymptomatic in all cases and without any parenchymal hemorrhage according to European Cooperative Acute Stroke Study trial definition.…”