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At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stro...
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Early administration of direct oral anticoagulants in patients with acute large vessel occlusion (LVO) and nonvalvular atrial fibrillation (NVAF) is a concern, as endovascular therapy (EVT) became highly utilized. We conducted a historical and prospective multicenter registry at 38 centers in Japan from July 2016 to February 2018. Patients aged ≥ 2...
Citations
... Furthermore, the benefits of intravenous thrombolysis have not been investigated in certain subgroups of minor stroke patients, such as those with tandem proximal intracranial occlusion and cervical internal artery lesion, basilar artery occlusion, and middle cerebral artery-M2 segment occlusion. [25] Considering the limited efficacy of intravenous thrombolysis in achieving recanalization and the potential advantages of DAPT in cases of stroke with LVO, it is worth to exploring the comparative impact of DAPT versus intravenous alteplase in this specific population. ...
... The benefit of intravenous thrombolysis (IVT) in tandem occlusion is debatable [87] because of the large clot burden and the potential need for periprocedural antiplatelet therapy in cases of acute carotid artery stenting, with only 20% of patients have a good clinical outcome after IVT [4]; also, intra-arterial treatment in TOs seems to be related to low efficacy due to length of thrombus [88]. A recent study found that among patients with tandem lesions, favorable outcomes observed in rt-PA-treated patients had no statistically significant difference to those observed in untreated patient [89]; however, it's important to note that IVT is an added value in EVT-treated patients with tandem occlusion and improves early outcome, as highlighted by several studies. TITAN and ETIS investigators found that IVT+EVT group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0-1), and successful reperfusion (express in terms of mTICI), compared to EVT group [90], with no statistical significative difference in the risk of significant hemorrhagic complications between groups [91]. ...
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
... A previous study of 313 AIS patients with an onset below 3 h and NIHSS score ≤ 5 compared IV thrombolysis and oral aspirin and found no significant difference in the mRS scales between the two groups. [19] A more recent study by Wang et al. in early 2020 demonstrated that rTPA increases clinical output (mRS 0-1) in mild strokes (NIHSS ≤ 5) with occlusion of large blood vessels without tandem lesions, but not in mild strokes without occlusion of large blood vessels, or in occlusion of large blood vessels with tandem lesions [20]. Interestingly, patient/family refusal also accounts for a significant proportion for withholding thrombolysis in potentially eligible patients at 18.92%, much higher compared to the 4.2-8% rate reported in previous studies [21][22][23]. ...
Background
Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.
Methods
This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.
Results
One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).
Conclusions
Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.
... Additional screening led to the exclusion of 2 meta-analyses 12,13 related to intravenous thrombolysis, and 14 studies 3,5,14-25 did not meet the inclusion criteria or the grouping design and the subgroup analysis, 1 study was removed due to significant baseline differences with other studies. 43 Ultimately, a total of 14 studies 4,9,10,[26][27][28][29][30][31][32][33][34][35][36] were included in this meta-analysis, and all of them were published in English. The literature screening process was shown in Figure 1. ...
... Ten studies 9,10,26,27,29,30,[32][33][34]36 reported mortality after intravenous thrombolysis, and the I 2 was 0%, indicating that there was no heterogeneity among ...
... Ten studies 4,10,[26][27][28][31][32][33][34]36 reported the incidence of intracranial hemorrhage after intravenous thrombolysis, and the I 2 was 0%, indicating that there was no heterogeneity among the studies; therefore, the fixed effects model was used. There was a significant difference between the two groups (OR=3.89, ...
Background: Intravenous thrombolysis is the preferred clinical treatment for ultra-early (<4.5 h) ischemic stroke. However, whether intravenous thrombolysis should be used in patients with mild stroke remains controversial. This study reports a systematic review and meta-analysis of the efficacy and safety of intravenous thrombolysis in acute mild stroke. Methods: The PubMed, Cochrane Library, MEDLINE, Embase and CBM disc databases were searched for studies on intravenous thrombolysis versus nonthrombolysis in acute mild stroke. All studies published in English prior to March 2022 were retrieved. The studies were screened and selected based on the inclusion and exclusion criteria. Then, the data were extracted and recorded by trained researchers. RevMan 5.4 statistical software was used to analyze the data on the efficacy (mRS score, stroke recurrence rate and mortality at 90 days) and safety (intracranial hemorrhage, symptomatic intracranial hemorrhage) of the patients with acute mild stroke in the intravenous thrombolysis and nonthrombolysis groups. Results: A total of 14 high-quality studies containing 86,063 patients with acute mild stroke (8,824 in the intravenous thrombolysis group; 77,239 in the nonthrombolysis group) were included in this meta-analysis. The meta-analysis results were as follows: (1) Efficacy: There were significant differences in mRS scores of 0~1 and 0~2 between the intravenous thrombolysis and nonthrombolysis groups (mRS 0-1, OR= 1.53, 95% CI: 1.31~1.79, Z=5.40, P <0.00001; mRS 0-2, OR= 1.33, 95% CI: 1.07~1.65, Z=2.59, P =0.01). (2) Safety: There was no significant difference in the recurrence rate of stroke or mortality between the two groups ( recurrence rate, OR= 0.62, 95% CI: 0.35~1.08, Z=1.68, P =0.09; mortality, OR=0.89, 95% CI: 0.45~1.77, Z=0.33, P =0.74). There were more patients with intracranial hemorrhage in intravenous thrombolysis group than in nonthrombolysis group (asymptomatic intracranial hemorrhage, OR= 2.39, 95% CI:1.19~4.80, Z=2.45, P =0.01; symptomatic intracranial hemorrhage, OR= 7.65, 95% CI:3.07~19.05, Z=4.37, P <0.0001). Conclusion: Intravenous thrombolysis significantly improved the functional outcomes but did not reduce mortality at 90 days in patients with acute mild stroke and had a higher risk of intracranial hemorrhage.
... TEMPO 1, a case series of 50 patients with mild symptoms and intracranial vessel occlusion, which showed that administration of tenecteplase-tissue-type plasminogen activator in minor stroke with intracranial occlusion is feasible and safe (24). Wang et al. found that intravenous thrombolysis benefits though with mild stroke symptoms (NIHSS ≤ 5) and large artery atherosclerosis, though not those who had a tandem proximal intracranial occlusion and cervical internal artery lesion (complete occlusion or severe stenosis ≥ 90%) (30). They found that LAA-type patients (as defined by TOAST criteria) had significantly favorable outcomes after treatment with thrombolysis compared to untreated patients, however no such benefits were observed in other stroke subtypes, such as cardioembolic, small vessel occlusion and undetermined. ...
Management of stroke with minor symptoms may represent a therapeutical dilemma as the hemorrhage risk of acute thrombolytic therapy may eventually outweigh the stroke severity. However, around 30% of patients presenting with minor stroke symptoms are ultimately left with disability. The objective of this review is to evaluate the current literature and evidence regarding the management of minor stroke, with a particular emphasis on the role of IV thrombolysis. Definition of minor stroke, pre-hospital recognition of minor stroke and stroke of unknown onset are discussed together with neuroimaging aspects and existing evidence for IV thrombolysis in minor strokes. Though current guidelines advise against the use of thrombolysis in those without clearly disabling symptoms due to a paucity of evidence, advanced imaging techniques may be able to identify those likely to benefit. Further research on this topic is ongoing.
Background
The efficacy of thrombolysis (IVT) in minor stroke (National Institutes of Health Stroke Scale score, 0–5) remains inconclusive. The aim of this study is to compare the effectiveness and safety of IVT with best medical therapy (BMT) by means of a systematic review and meta-analysis of randomized controlled trials and observational studies.
Methods
We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to IVT in minor stroke from inception until August 10, 2023. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days. The associations were calculated for the overall and preformulated subgroups by using the odds ratios (ORs). This study was registered with PROSPERO (CRD42023445856).
Results
A total of 20 high-quality studies, comprised of 13 397 patients with acute minor ischemic stroke, were included. There were no significant differences observed in the modified Rankin Scale scores of 0 to 1 (OR, 1.10 [95% CI, 0.89–1.37]) and 0 to 2 (OR, 1.16 [95% CI, 0.95–1.43]), mortality rates (OR, 0.67 [95% CI, 0.39–1.15]), recurrent stroke (OR, 0.89 [95% CI, 0.57–1.38]), and recurrent ischemic stroke (OR, 1.09 [95% CI, 0.68–1.73]) between the IVT and BMT group. There were differences between the IVT group and the BMT group in terms of early neurological deterioration (OR, 1.81 [95% CI, 1.17–2.80]), symptomatic intracranial hemorrhage (OR, 7.48 [95% CI, 3.55–15.76]), and hemorrhagic transformation (OR, 4.73 [95% CI, 2.40–9.34]). Comparison of modified Rankin Scale score of 0 to 1 remained unchanged in subgroup patients with nondisabling deficits or compared with those using antiplatelets.
Conclusions
These findings indicate that IVT does not yield significant improvement in the functional prognosis of patients with acute minor ischemic stroke. Additionally, it is associated with an increased risk of symptomatic intracranial hemorrhage when compared with the BMT. Moreover, IVT may not have superiority over BMT in patients with nondisabling deficits or those using antiplatelets.
Background and Purpose
The role of intravenous thrombolysis in patients with acute mild ischemic stroke remains highly controversial. Therefore, this study aims to analyze the efficacy and safety of intravenous thrombolysis in patients with mild ischemic stroke based on admission National Institutes of Health Stroke Scale (NIHSS) score.
Methods
The present study enrolled 507 patients with acute mild ischemic stroke admitted within 4.5 hours of symptom onset with an admission NIHSS score of 0 to 5. Patients were assigned to two groups based on admission NIHSS scores of 0 to 2 and 3 to 5, and subsequent analyses compared functional outcomes between thrombotic and non-thrombotic patients within these groups. The primary outcome was a modified Rankin score (mRS) of 0 or 1 at 90 days, representing functional independence. The safety outcomes were symptomatic intracranial hemorrhage (sICH), early neurological deterioration (END), and the rate of stroke recurrence within 90 days.
Results
Among the 267 patients with NIHSS scores of 0 to 2, 112 (41.9%) patients received intravenous thrombolysis. Overall, thrombolysis administration did not significantly improve the patient's functional prognoses at 90 days (adjusted OR=1.046, 95%CI=0.587-1.863, p = 0.878). However, there was a marked increase in the risk of sICH (p = 0.030). Of the 240 patients with NIHSS scores of 3 to 5, 155 (64.6%) patients received intravenous thrombolysis, resulting in a significant improvement in 90-day functional prognosis (adjusted OR=3.284, 95%CI=1.876- 5.749, p ＜ 0.001) compared to those that did not receive thrombolysis intervention. Importantly, there was no significant increase in sICH incidence (adjusted OR=2.770, 95%CI=0.313-24.51, p = 0.360). There were no statistically significant differences in END or the rate of stroke recurrence within 90 days between thrombotic and non-thrombotic groups
Conclusions
Intravenous thrombolysis is safe and effective in patients with baseline NIHSS scores of 3 to 5. In contrast, it did not improve 90-day functional outcomes in patients with NIHSS scores of 0 to 2 and instead increased the risk of sICH.
Importance:
Intravenous thrombolysis is increasingly used in patients with minor stroke, but its benefit in patients with minor nondisabling stroke is unknown.
Objective:
To investigate whether dual antiplatelet therapy (DAPT) is noninferior to intravenous thrombolysis among patients with minor nondisabling acute ischemic stroke.
Design, setting, and participants:
This multicenter, open-label, blinded end point, noninferiority randomized clinical trial included 760 patients with acute minor nondisabling stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤5, with ≤1 point on the NIHSS in several key single-item scores; scale range, 0-42). The trial was conducted at 38 hospitals in China from October 2018 through April 2022. The final follow-up was on July 18, 2022.
Interventions:
Eligible patients were randomized within 4.5 hours of symptom onset to the DAPT group (n = 393), who received 300 mg of clopidogrel on the first day followed by 75 mg daily for 12 (±2) days, 100 mg of aspirin on the first day followed by 100 mg daily for 12 (±2) days, and guideline-based antiplatelet treatment until 90 days, or the alteplase group (n = 367), who received intravenous alteplase (0.9 mg/kg; maximum dose, 90 mg) followed by guideline-based antiplatelet treatment beginning 24 hours after receipt of alteplase.
Main outcomes and measures:
The primary end point was excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 (range, 0-6), at 90 days. The noninferiority of DAPT to alteplase was defined on the basis of a lower boundary of the 1-sided 97.5% CI of the risk difference greater than or equal to -4.5% (noninferiority margin) based on a full analysis set, which included all randomized participants with at least 1 efficacy evaluation, regardless of treatment group. The 90-day end points were assessed in a blinded manner. A safety end point was symptomatic intracerebral hemorrhage up to 90 days.
Results:
Among 760 eligible randomized patients (median [IQR] age, 64 [57-71] years; 223 [31.0%] women; median [IQR] NIHSS score, 2 [1-3]), 719 (94.6%) completed the trial. At 90 days, 93.8% of patients (346/369) in the DAPT group and 91.4% (320/350) in the alteplase group had an excellent functional outcome (risk difference, 2.3% [95% CI, -1.5% to 6.2%]; crude relative risk, 1.38 [95% CI, 0.81-2.32]). The unadjusted lower limit of the 1-sided 97.5% CI was -1.5%, which is larger than the -4.5% noninferiority margin (P for noninferiority <.001). Symptomatic intracerebral hemorrhage at 90 days occurred in 1 of 371 participants (0.3%) in the DAPT group and 3 of 351 (0.9%) in the alteplase group.
Conclusions and relevance:
Among patients with minor nondisabling acute ischemic stroke presenting within 4.5 hours of symptom onset, DAPT was noninferior to intravenous alteplase with regard to excellent functional outcome at 90 days.
Trial registration:
ClinicalTrials.gov Identifier: NCT03661411.
Background
Cerebral revascularization is a neurosurgical procedure used to restore the cerebral collateral circulation channel. This study examines the countries, institutions, authors, journals, keywords, and references related to the disease in the field of cerebral revascularization from 1999 to 2022 from a bibliometrics perspective, evaluates the changes of knowledge structure clustering and identifies the new hot spots and new research directions in this field.
Methods
The Web of Science Core Collection (WOSCC) database and the PICOS retrieval method were used to conduct a comprehensive search for articles and reviews pertaining to cerebral revascularization. The final filtered data were bibliometrically and visually drawn using Microsoft office 365, CiteSpace (v.6.1.R2), and VOSviewer (v.1.6.18).
Results
From 1999 to 2022, a total of 854 articles pertaining to cerebral revascularization, which originated from 46 nations, 482 institutions, and 686 researchers, were extracted from the WOSCC database, and the number of publications in this field of study was rising. The United States held the highest proportion in the ranking analysis of countries, institutions, authors, and journals. By analyzing co-citations, the scientific organization of this field and the development status of frontier fields were realized. Cerebral revascularization, moyamoya disease, extracranial intracranial bypass, and occlusion are the current research focal points in the field of cerebral revascularization. Hyperperfusion and vascular disorder may also become a new study focus in this discipline in the near future.
Conclusion
Using the method of bibliometrics, this study analyzed and reviewed the articles in the field of cerebral revascularization, which enabled scholars to better comprehend the dynamic process in this field and provided a foundation for future in-depth research.
