Early Recurrent Ischemic Stroke Complicating Intravenous Thrombolysis for Stroke (original) (raw)
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Stroke, 2010
Background and Purpose-Mechanisms of early neurologic deterioration after treatment with intravenous, recombinant, tissue-type plasminogen activator (IV rt-PA) include symptomatic intracerebral hemorrhage (SICH) and early recurrent ischemic stroke. We observed a number of cases of acute deterioration due to recurrent ischemic events. Methods-We undertook a single-center, retrospective analysis of consecutive acute stroke patients treated with IV rt-PA between January 2006 and December 2008 to define the incidence of early neurologic deterioration (Ն4-point drop on the National Institutes of Health Stroke Scale within 72 hours) and its mechanism. Deterioration was attributed to SICH when associated with a PH1 or PH2 hemorrhage on postdeterioration computed tomography scans, to recurrent ischemic stroke when there was clinical and radiologic evidence of a new territorial infarction or new vessel occlusion, and otherwise to evolution of the incident stroke. Results-Of 228 consecutive IV rt-PA-treated patients, 34 (15%) developed early neurologic deterioration, 18 (8%) secondary to incident strokes 10 (4.4%) due to SICH, and 6 (2.6%) due to early recurrent ischemic events, which were significantly associated with atrial fibrillation (present in 5 of 6 patients; 4 paroxysmal, 1 permanent). In 4 patients, sudden clinical deterioration developed during or shortly after IV rt-PA infusion, and in 2, deterioration developed 3 days later. All died 2 days to 2 weeks later. The single case without atrial fibrillation had a recurrent, contralateral, middle cerebral artery stroke during IV rt-PA infusion and multiple high-signal emboli detected by transcranial Doppler. Early recurrent ischemic stroke accounted for 5 of 12 (42%) cases of early neurologic deterioration in patients with atrial fibrillation. Conclusion-In this single-center series, the incidence of early recurrent ischemic stroke after IV rt-PA was 2.6% and was associated with previous atrial fibrillation.
Interdisciplinary Neurosurgery, 2021
Stroke is a significant source of morbidity and mortality within the United States. The current standard of care for treatment of acute ischemic stroke is intravenous recombinant tissue-type plasminogen activator (IV r-tPA). However, IV r-tPA is contraindicated within 3 months of a previous stroke due to concern for symptomatic intracerebral hemorrhage (sICH). We describe the case of a 77-year-old female who developed aphasia and rightsided quadrantanopsia and was found to have a calcified embolus in the M3 branch of her left middle cerebral artery. She was given IV r-tPA with subsequent symptom resolution and no MRI evidence of acute or subacute infarct. 4 days after index stroke, she had recurrence of her symptoms, receiving a second dose of IV r-tPA. She improved clinically. Non-contrast CT 24 hours afterwards showed minimal foci of intraparenchymal hemorrhage without midline shift or mass effect. She remained neurologically stable and improved significantly with inpatient rehabilitation.
Journal of Neurosciences in Rural Practice, 2017
Background: Symptomatic intracranial hemorrhage (sICH) is the most unwanted adverse event in patients with acute ischemic stroke who received intravenous recombinant tissue plasminogen activator (i.v. rt-PA). Many tool scores are available to predict the probability of sICH. Among those scores, the Sugar, Early infarct sign, hyperDense middle cerebral artery, Age, Neurologic deficit (SEDAN) gives the highest area under the curve-receiver operating characteristic value. Objective: We aimed to examine any factors other than the SEDAN score to predict the probability of sICH. Methods: Patients with acute ischemic stroke treated with i.v. rt-PA within 4.5 h time window from January 2010 to July 2012 were evaluated. Compiling demographic data, risk factors, and comorbidity (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation (AF), ischemic heart disease, valvular heart disease, previous stroke, gout, smoking cigarette, drinking alcoholic beverage, family history of stroke, and family history of ischemic heart disease), computed tomography scan of patients prior to treatment with rt-PA, and assessing the National Institutes of Health Stroke Scale (NIHSS) score for the purpose of calculating SEDAN score were analyzed. Results: Of 314 patients treated with i.v. rt-PA, there were 46 ICH cases (14.6%) with 14 sICH (4.4%) and 32 asymptomatic intracranial hemorrhage cases (10.2%). The rate of sICH occurrence was increased in accordance with the increase in the SEDAN score and AF. Age over 75 years, early infarction, hyperdense cerebral artery, baseline blood sugar more than 12 mmol/l, NIHSS as 10 or more, and AF were the risk factors to develop sICH after treated with rt-PA at 1.535, 2.501, 1.093, 1.276, 1.253, and 2.492 times, respectively. Conclusions: Rather than the SEDAN score, AF should be a predictor of sICH in patients with acute ischemic stroke after i.v. rt-PA treatment in Thai population.
Stroke, 2007
Background and Purpose-The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA. Methods-A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition. Results-Sixty-nine patients (meanϮSD age, 60Ϯ13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124Ϯ32 minutes (median, 120 minutes) and IAT, at 288Ϯ57 minutes (median, 285 minutes). IATs consisted of reteplase (nϭ56), alteplase (nϭ7), and urokinase (nϭ6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%). Conclusions-IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved. (Stroke. 2007;38:80-84.)
Case Reports in Vascular Medicine, 2013
Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tomographic scans. The patient did not recover from the second cerebrovascular event and died 25 days after admission. Conclusion. To the best of our knowledge, this is the second case reporting the adverse neurological outcome of a patient with diagnosis of atrial fibrillation undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Our report represents a contribution to the scarce available evidence suggesting that repeated systemic thrombolysis for recurrent ischemic stroke should be avoided.
Very Early Neurologic Improvement After Intravenous Thrombolysis
Archives of Neurology, 2010
To evaluate whether very early neurologic improvement (VENI) after intravenous (IV) recombinant tissue plasminogen activator (rt-PA) perfusion in patients with acute ischemic stroke (AIS) predicts favorable outcome at 3 months. Design: Retrospective analysis of prospective data.
2020
Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tom...
Intravenous thrombolysis in acute ischemic stroke – our experience
Romanian Neurosurgery, 2017
Stroke is a major health problem worldwide and nationally: the second leading cause of death and dementia, the most common cause of epilepsy in the elderly, and a common cause of depression. Stroke is associated with an increased rate of morbidity, but it is also the leading cause of long-term morbidity and disability in industrialized countries. Thrombolysis by administering intravenous recombinant tissue plasminogen activator (IV-rtPA) is the only treatment method "in the therapeutic window" recognized in international protocols. The benefit-risk ratio should be evaluated on a case-by-case basis, with the neurologist's decision being individual and often difficult. The aim of our study was to analyze the outcome of this procedure in our hospital since 2015. We performed a retrospective clinical study of 77 patients with acute ischemic stroke subjected to IV-rtPA. Most patients with ischemic stroke undergoing intravenous thrombolysis did not receive chronic antithrombotictherapy. In most cases (76%) there was a decrease in the NIHSS score at 24 hours after thrombolysis and especially after 7 days (between 3 and 19 points), reflecting a reduction in poststroke disability in thrombolyzed patients. In the series of patients undergoing i.v. thrombolysis 5 deaths (10%) were recorded, the lowestrate of data/death ratereported in the literature (14-18%).