Showing papers on "Thrombolysis published in 2002"

Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.

Abstract: Background The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism remains controversial. Methods We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dysfunction but without arterial hypotension or shock. The patients were randomly assigned in double-blind fashion to receive heparin plus 100 mg of alteplase or heparin plus placebo over a period of two hours. The primary end point was in-hospital death or clinical deterioration requiring an escalation of treatment, which was defined as catecholamine infusion, secondary thrombolysis, endotracheal intubation, cardiopulmonary resuscitation, or emergency surgical embolectomy or thrombus fragmentation by catheter. Results Of 256 patients enrolled, 118 were randomly assigned to receive heparin plus alteplase and 138 to receive heparin plus placebo. The incidence of the primary end point was significantly higher in the heparin-plus-placebo group than in the heparin-plus-alteplase group (P=0.006), and the probability of 30-day event-free survival (according to Kaplan-Meier analysis) was higher in the heparin-plus-alteplase group (P=0.005). This difference was due to the higher incidence of treatment escalation in the heparin-plus-placebo group (24.6 percent vs. 10.2 percent, P=0.004), since mortality was low in both groups (3.4 percent in the heparin-plus-alteplase group and 2.2 percent in the heparin-plus-placebo group, P=0.71). Treatment with heparin plus placebo was associated with almost three times the risk of death or treatment escalation that was associated with heparin plus alteplase (P=0.006). No fatal bleeding or cerebral bleeding occurred in patients receiving heparin plus alteplase. Conclusions When given in conjunction with heparin, alteplase can improve the clinical course of stable patients who have acute submassive pulmonary embolism and can prevent clinical deterioration requiring the escalation of treatment during the hospital stay.

Diffusion- and perfusion-weighted MRI response to thrombolysis in stroke.

Abstract: Diffusion- and perfusion-weighted magnetic resonance imaging provides important pathophysiological information in acute brain ischemia. We performed a prospective study in 19 sub-6-hour stroke patients using serial diffusion- and perfusion-weighted imaging before intravenous thrombolysis, with repeat studies, both subacutely and at outcome. For comparison of ischemic lesion evolution and clinical outcome, we used a historical control group of 21 sub-6-hour ischemic stroke patients studied serially with diffusion- and perfusion-weighted imaging. The two groups were well matched for the baseline National Institutes of Health Stroke Scale and magnetic resonance parameters. Perfusion-weighted imaging-diffusion-weighted imaging mismatch was present in 16 of 19 patients treated with tissue plasminogen activator, and 16 of 21 controls. Perfusion-weighted imaging-diffusion-weighted imaging mismatch patients treated with tissue plaminogen activator had higher recanalization rates and enhanced reperfusion at day 3 (81% vs 47% in controls), and a greater proportion of severely hypoperfused acute mismatch tissue not progressing to infarction (82% vs -25% in controls). Despite similar baseline diffusion-weighted imaging lesions, infarct expansion was less in the recombinant tissue plaminogen activator group (14cm(3) vs 56cm(3) in controls). The positive effect of thrombolysis on lesion growth in mismatch patients translated into a greater improvement in baseline to outcome National Institutes of Health Stroke Scale in the group treated with recombinant tissue plaminogen activator, and a significantly larger proportion of patients treated with recombinant tissue plaminogen activator having a clinically meaningful improvement in National Institutes of Health Stroke Scale of > or = 7 points. The natural evolution of acute perfusion-weighted imaging-diffusion-weighted imaging mismatch tissue may be altered by thrombolysis, with improved stroke outcome. This has implications for the use of diffusion- and perfusion-weighted imaging in selecting and monitoring patients for thrombolytic therapy.

Effect of Intravenous Thrombolysis on MRI Parameters and Functional Outcome in Acute Stroke <6 Hours

Abstract: Background and Purpose— The goals of this study were to examine MRI baseline characteristics of patients with acute ischemic stroke (AIS) and to study the influence of intravenous tissue plasminogen activator (tPA) on MR parameters and functional outcome using a multicenter approach. Methods— In this open-label, nonrandomized study of AIS patients with suspected anterior circulation stroke, subjects received a multiparametric stroke MRI protocol (diffusion- and perfusion-weighted imaging and MR angiography) within 6 hours after symptom onset and on follow-up. Patients were treated either with tPA (thrombolysis group) or conservatively (no thrombolysis group). Functional outcome was assessed on day 90 (modified Rankin Score; mRS). Results— We enrolled 139 AIS patients (no thrombolysis group, n=63; thrombolysis group, n=76). Patients treated with tPA were more severely affected (National Institutes of Health Stroke Scale score, 10 versus 13; P=0.002). Recanalization rates were higher in the thrombolysis gro...

Magnetic Resonance Imaging Detection of Microbleeds Before Thrombolysis An Emerging Application

Abstract: Background— Hemorrhagic transformation (HT) is a major complication of thrombolytic treatment for acute ischemic stroke. Although a history of prior intracerebral hemorrhage diagnosed by head CT is a contraindication to thrombolysis, there are no guidelines or data regarding evidence of prior asymptomatic microbleeds visualized with T2*-weighted magnetic resonance imaging (MRI). Methods— Pretreatment T2*-weighted MRI sequences were retrospectively analyzed in all patients receiving intra-arterial thrombolytic therapy and undergoing a pretreatment MRI at our institution. The frequency and location of prior microbleeds was determined and compared with the frequency and location of secondary HT after therapy. Results— Five of 41 patients undergoing MRI before receiving intra-arterial thrombolytic therapy demonstrated evidence of prior microbleeds on the pretreatment MRI studies. Major symptomatic hemorrhage occurred in 1 of 5 patients with microbleeds compared with 4 of 36 patients without. Only 1 patient in...

The "no-reflow" phenomenon: basic science and clinical correlates.

Abstract: To achieve early and complete reperfusion of the myocardium in acute coronary syndromes is the daily challenge for every physician in clinical cardiology. However, restoration of epicardial blood flow by thrombolysis, primary angioplasty or bypass surgery does not necessarily imply complete reperfusion, even if the target stenosis is adequately removed or bypassed. The amount of microvascular integrity may limit reperfusion to the previously ischaemic tissue despite complete restoration of epicardial vessel diameters. A 74 year old man with acute distress is admitted to the emergency room because of acute onset of severe, substernal, crushing chest pain two hours ago. He has never suffered from similar symptoms before. The ECG shows ST segment elevation in leads I, aVL, V2–V4. After aspirin and heparin, the patient is immediately transferred to the catheterisation laboratory. Coronary angiography confirms a thrombotic occlusion of the proximal left anterior descending artery. The guide wire easily crosses the occlusion. After coronary artery balloon dilatation and stent implantation the epicardial artery appears to have gained sufficient luminal diameter. However, the contrast medium is only slowly conveyed to the distal artery and not adequately washed out. Even the final angiogram after glyceryl trinitrate in different projections shows no satisfactory flow albeit no visible flow limiting obstacles, such as coronary artery dissection or recurrent thrombus formation. The battle, undertaken to restore myocardial blood supply, seems to be lost and won, finally leading to compromised tissue perfusion despite a successful restoration of patency to the epicardial blood vessel. A bolus of abciximab, followed by a continuous infusion, is initiated. ST segment elevations resolve only slightly during the next hours; the patient requires prolonged intensive medical care because of recurrent pulmonary oedema. Finally, the patient is stabilised on cardiovascular medication including an angiotensin converting enzyme (ACE) inhibitor, oxygen, and aspirin. The echocardiography shows …

Clinical characteristics and outcome of patients with early ( 4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction.

Abstract: Aims We examined the clinical characteristics and outcome of patients with early ( 4h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction. Methods and Results We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2h), intermediate presentation (2–4h), and late presentation (≥4h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5·8% in the angioplasty group vs 12·5% in the thrombolysis group, in patients with intermediate presentation, 8·6% vs 14·2%, respectively, and in patients presenting late 7·7% vs 19·4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event. Conclusions Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.

Clinical and Vascular Outcome in Internal Carotid Artery Versus Middle Cerebral Artery Occlusions After Intravenous Tissue Plasminogen Activator

Abstract: Background and Purpose— Early reperfusion is a predictor of good outcome in acute ischemic stroke. We investigated whether middle cerebral artery (MCA) occlusions have a better clinical outcome and proportion of recanalization compared with internal carotid artery (ICA) occlusion after standard treatment with intravenous (IV) tissue plasminogen activator (tPA). Patients— In a retrospective analysis of our prospective stroke database between January 7, 1998, and January 30, 2002, we identified 36 consecutive patients who were treated with IV tPA within 3 hours after symptom onset of a stroke in the distribution of a documented ICA or MCA occlusion. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before tPA, at 24 hours, 3 days, and 3 months after stroke. Three-month outcome was recorded by modified Rankin scale. Magnetic resonance angiography or computed tomographic angiography was obtained before tPA. The presence of recanalization was assessed by transcranial Doppler and/or magn...

Thrombolysis-related hemorrhagic infarction: a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion.

Abstract: Background and Purpose— The role of early and delayed recanalization after thrombolysis in the development of hemorrhagic transformation (HT) subtypes remains uncertain. We sought to explore the association between the timing of recanalization and HT risk in patients with proximal middle cerebral artery (MCA) occlusion treated with intravenous recombinant tissue plasminogen activator (rtPA) <3 hours of stroke onset and to investigate the relationship between HT subtypes, infarct volume, and outcome. Methods— Thirty-two patients with acute stroke caused by proximal MCA occlusion treated with rtPA <3 hours of symptom onset were prospectively studied. Serial transcranial Doppler examinations were performed on admission and at 6, 12, 24, and 48 hours. Presence and type of HT were assessed on CT at 36 to 48 hours. Modified Rankin scale was used to assess outcome at 3 months. Results— Early and delayed recanalization was identified in 17 patients (53.1%) and 8 patients (25%), respectively. HT was detected in 14...

Intra-Arterial Thrombolysis in 100 Patients With Acute Stroke Due to Middle Cerebral Artery Occlusion

Abstract: Background and Purpose — The purpose of this study was to evaluate the safety and efficacy of local intra-arterial thrombolysis (LIT) using urokinase in patients with acute stroke due to middle cerebral artery (MCA) occlusion. Methods — We analyzed clinical and radiological findings and functional outcome 3 months after LIT with urokinase of 100 consecutive patients. To measure outcome, the modified Rankin scale (mRs) score was used. Results — Angiography showed occlusion of the M 1 segment of the MCA in 57 patients, of the M 2 segment in 21, and of the M 3 or M 4 segment in 22. The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 14, and, on average, 236 minutes elapsed from symptom onset to LIT. Forty-seven patients (47%) had an excellent outcome (mRs score 0 to 1), 21 (21%) a good outcome (mRs score 2), and 22 (22%) a poor outcome (mRs score 3 to 5). Ten patients (10%) died. Excellent or good outcome (mRs score ≤2) was seen in 59% of patients with M 1 or M 2 and 95% of those with M 3 or M 4 MCA occlusions. Recanalization as seen on angiography was complete (thrombolysis in myocardial infarction [TIMI] grade 3) in 20% of patients and partial (TIMI grade 2) in 56% of patients. Age P P P =0.0004) were independently associated with excellent or good outcome and diabetes with poor outcome ( P =0.002). Symptomatic cerebral hemorrhage occurred in 7 patients (7%). Conclusions — LIT with urokinase that is administered by a single organized stroke team is safe and can be as efficacious as thrombolysis has been in large multicenter clinical trials.

Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion.

Abstract: Background and Purpose — The objective of this study was to determine the clinical features, angiographic findings, and response to treatment with thrombolytic therapy in patients with ischemic stroke caused by acute occlusion of the distal internal carotid artery. Methods — This is a retrospective case series from a prospectively collected stroke database for patients with acute internal carotid occlusion presenting within 6 hours of stroke onset to evaluate safety, feasibility, and response to thrombolytic therapy. The University Hospital–based brain attack database was reviewed over a 5-year period. Demographics, clinical features, stroke mechanisms, severity, imaging findings, type of thrombolysis, treatment responses, mortality, and long-term outcome using modified Rankin Scale and Barthel Index were determined. The short-term outcome was assessed using the National Institutes of Health Stroke Scale (NIHSS). Acute thrombolytic therapy was administered using recombinant tissue plasminogen activator or urokinase given intra-arterially or in combination with intravenous (IV) routes. Results — Two hundred seven patients treated with thrombolysis between 1995 and 2000 were reviewed, and of these, 101 were studied with cerebral angiography. Eighteen patients were identified with acute ischemic stroke and ipsilateral occlusion of the distal internal carotid artery. Time to treatment was the most powerful predictor of response to thrombolytic therapy ( P <0.001). The response to therapy also correlated well with the severity of the initial clinical deficit as judged by the NIHSS ( P <0.001). There was no difference in recanalization rate, symptomatic hemorrhage, and NIHSS for IV/intra-arterial (IA) versus IA alone ( P =NS). Complete angiographic recanalization was accomplished in 80% of those who received combined IV/IA thrombolysis and in 62% of those who received IA therapy ( P =NS). Those with distal occlusions extending to the middle and anterior cerebral arteries were the least likely to respond to thrombolysis. Symptomatic intracerebral hemorrhage occurred in 20% of the patients receiving IV/IA therapy, and in 15% of the IA only ( P =NS). At 24 hours, the NIHSS dropped by 3 points in the IA group and 4 points in the IV/IA group ( P =NS). Mild disability with independence was found in 77% of the survivors at 3-month follow-up. The mortality rate was 50% in this group despite thrombolysis. Conclusions — Thrombolytic therapy using a combination of IV and IA routes and using the IA-only route may be effective in improving outcome for the patients suffering from occlusion of the distal internal carotid artery. Shorter intervals between onset and treatment seem to be correlated with higher rate of recanalization and improved outcome.

Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume.

Abstract: Background and Purpose— Hemorrhagic transformation (HT) is a potentially dangerous complication of thrombolytic therapy. Recent studies suggest that diffusion-weighted MRI (DWI) can help to predict the risk of intracerebral hemorrhage (ICH) after thrombolysis. We sought to examine which pretreatment DWI parameters and clinical data are predictive of ICH after intravenous thrombolysis. Methods— We retrospectively reviewed our prospective stroke database for patients with ischemic stroke treated with intravenous recombinant tissue plasminogen activator (rtPA) within 3 hours from symptom onset who had DWI before treatment and MRI with T2* sequence or CT 24 to 48 hours later to assess for ICH over the past 4 years. We measured the volumes and voxel-by-voxel apparent diffusion coefficient (ADC) values of the initial DWI lesions and retrieved demographic data, risk factors, National Institutes of Health Stroke Scale (NIHSS) scores on admission, and blood tests results. We examined several variables using univar...

Factors Influencing Early Admission in a French Stroke Unit

Abstract: Background and Purpose — Intravenous tissue plasminogen activator improves outcome after ischemic stroke when given within 3 hours of symptoms onset in carefully selected patients. However, only a small proportion of acute stroke patients are currently eligible for thrombolysis, mainly because of excessive delay to hospital presentation. We sought to determine the factors associated with early admission in a French stroke unit. Methods — We prospectively studied the admission delay of acute stroke patients in a French stroke unit during a 12-month period ending July 1999. Univariate and multivariate regression analyses were performed to evaluate the factors influencing early stroke unit admission and transport by the Emergency Medical Services (EMS) or Fire Department (FD) ambulances. Results — One hundred sixty-six patients were primarily admitted to the stroke unit, with a median admission time of 4 hours 5 minutes. Twenty-nine percent presented within 3 hours of symptoms onset and 75% within 6 hours. Univariate analysis showed that early stroke unit arrival was significantly associated with the following factors: female sex, stroke severity assessed by the National Institutes of Health Stroke Scale score, lowered consciousness, sudden onset of stroke, not living alone, recognition of symptoms by bystanders, and transport by EMS or FD ambulances. Age, ethnicity, level of education, employment status, nocturnal onset, distance from place of stroke to the stroke unit, stroke lesion location, presence of brain hemorrhage, and awareness about the symptoms and risk factors of stroke had no measurable effect on early admission. A multivariate regression model demonstrated that the most significant factors associated with early stroke unit arrival were transport by EMS or FD ambulances and sudden onset of stroke. Female sex and not living alone were also significantly associated with early admission in the multivariate model. Multivariate analysis of the mode of transport showed that transport by EMS or FD ambulances was significantly more frequent among female patients, when stroke symptoms were recognized by bystanders, and when the general practitioner was not the first medical contact. Conclusions — The present study shows that hospital arrival within the first hours of stroke is feasible in a French stroke unit. As many as 75% of the patients are admitted within the first 6 hours of stroke. This is the first study demonstrating that stroke unit admission in France is fastest in patients brought to the hospital by EMS or FD ambulances. However, only 35% of stroke patients activate the emergency telephone system and are currently transported by EMS or FD ambulances. French stroke patients should be encouraged to seek immediate medical attention by using the emergency telephone system, and stroke management should be reprioritized in the French EMS as a time-dependent medical emergency, with the same level of organization and expertise currently applied to myocardial infarction.

Predictors of Hemorrhagic Transformation in Patients Receiving Intra-Arterial Thrombolysis

Abstract: Background and Purpose— Hemorrhagic transformation (HT) is a major complication of intra-arterial (IA) thrombolytic therapy. Identifying significant predictors of hemorrhage after thrombolysis would be useful in guiding patient selection for IA treatment. Methods— Data were collected retrospectively on consecutive patients with acute focal cerebral ischemia within the anterior or posterior circulation who were treated with combined intravenous (IV)-IA or pure IA thrombolysis over an 8-year period at the UCLA Medical Center. Results— Eighty-nine patients were treated. Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 16, and mean age was 69 years. Twenty-six patients received IA tissue plasminogen activator (tPA) only, 22 received IV-IA tPA, and 41 received IA urokinase only. Asymptomatic HT occurred in 29 patients (33%), minor symptomatic HT (1- to 3-point worsening in NIHSS score) occurred in 10 patients (11%), and major symptomatic HT (≥4-point worsening in NIHSS score) occurr...

Aggressive Mechanical Clot Disruption and Low-dose Intra-arterial Third-generation Thrombolytic Agent for Ischemic Stroke: A Prospective Study

Abstract: Objective We prospectively evaluated the safety and effectiveness of aggressive mechanical disruption of clot in conjunction with intra-arterial administration of a low-dose third-generation thrombolytic agent (reteplase) to treat ischemic stroke in patients who were considered poor candidates for intravenous alteplase therapy or who failed to improve after intravenous thrombolysis. Mechanical clot disruption was used if low-dose pharmacological thrombolysis was ineffective. This strategy was adopted to increase the recanalization rate without increasing the risk of intracerebral hemorrhage. Methods Patients were considered poor candidates for intravenous therapy because of severity of neurological deficits, interval from symptom onset to presentation of at least 3 hours, or recent major surgery. We administered a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. After the initial doses were administered, we performed mechanical angioplasty (for proximal occlusion) or snare manipulation (for distal occlusion) at the occlusion site if recanalization had not occurred. The remaining doses of thrombolytics were subsequently administered if required for further recanalization. Angiographic responses were graded using modified Thrombolysis in Myocardial Infarction (TIMI) criteria. Clinical evaluations were performed before and 24 hours, 7 to 10 days, and 1 to 3 months after treatment. Results Nineteen consecutive patients were treated (mean age, 64.3 +/- 16.2 yr; 10 were men). Initial National Institutes of Health Stroke Scale scores ranged from 11 to 42. Time from onset to treatment ranged from 1 to 9 hours. Occlusion sites were in the following arteries: cervical internal carotid (n = 7), intracranial internal carotid (n = 1), middle cerebral (n = 9), and basilar (n = 2). Of the 19 patients, thrombolysis alone was used in 5 patients, angioplasty was performed in 11 patients, and snare maneuvers were used in 5 patients. Complete restoration of blood flow (modified TIMI Grade 4) was observed in 12 patients, near-complete restoration of flow (modified TIMI Grade 3) in 4 patients, minimal response (modified TIMI Grade 1) in 1 patient, and no response in 2 patients (modified TIMI Grade 0). Neurological improvement at 24 hours (decline of at least 4 points in National Institutes of Health Stroke Scale score) was observed in seven patients. Five other patients experienced further improvement in National Institutes of Health Stroke Scale score at 7 to 10 days. No vessel rupture, dissection, or symptomatic intracranial hemorrhages were observed. At the time of follow-up evaluation, 7 of 19 patients were functionally independent. Conclusion A high rate of recanalization and clinical improvement can be observed in patients with ischemic stroke using low-dose thrombolytic agents with adjunctive mechanical disruption of clot. Moreover, this strategy may reduce the risk of intracerebral hemorrhage observed with thrombolytics.

ATLANTIS Trial Results for Patients Treated Within 3 Hours of Stroke Onset

Abstract: Background and Purpose — Only a single study has demonstrated beneficial effects of intravenous tissue plasminogen activator (tPA) in stroke patients Methods — We evaluated the clinical outcomes of the 61 patients enrolled in the Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) study who were randomized to receive intravenous tPA or placebo within 3 hours of symptom onset Results — Despite a significant increase in the rate of symptomatic intracranial hemorrhage, tPA-treated patients were more likely to have a very favorable outcome (score of ≤1) on the National Institutes of Health Stroke Scale at 90 days ( P =001) Conclusions — These data support current recommendations to administer intravenous tPA to eligible ischemic stroke patients who can be treated within 3 hours of symptom onset

Relation of time to treatment and mortality in patients with acute myocardial infarction undergoing primary coronary angioplasty

Abstract: The benefit of thrombolysis is dependent on time to treatment, but there is lack of evidence of this relation in patients undergoing primary percutaneous transluminal coronary angioplasty (PTCA). The hypothesis that the relation of time to treatment to mortality is dependent on patient risk was tested in a series of 1,336 patients who underwent successful primary PTCA and were stratified into “low-risk” and “not low-risk” patient groups according to the Thrombolysis In Myocardial Infarction criteria. After stratification, 942 patients (71%) were at not low risk, and 394 (29%) were at low risk. The 6-month mortality rate was 9.3% for not low-risk patients and 1.3% for low-risk patients (p

Randomized Comparison of Enoxaparin, a Low-Molecular-Weight Heparin, With Unfractionated Heparin Adjunctive to Recombinant Tissue Plasminogen Activator Thrombolysis and Aspirin Second Trial of Heparin and Aspirin Reperfusion Therapy (HART II)

Abstract: Background— Adjunctive unfractionated heparin (UFH) during thrombolytic therapy for acute myocardial infarction (AMI) promotes the speed and magnitude of coronary artery recanalization and reduces reocclusion Low-molecular-weight heparins offer practical and potential pharmacological advantages over UFH in multiple applications but have not been systematically studied as adjuncts to fibrinolysis in AMI Methods and Results— Four hundred patients undergoing reperfusion therapy with an accelerated recombinant tissue plasminogen activator regimen and aspirin for AMI were randomly assigned to receive adjunctive therapy for at least 3 days with either enoxaparin or UFH The study was designed to show noninferiority of enoxaparin versus UFH with regard to infarct-related artery patency Ninety minutes after starting therapy, patency rates (thrombolysis in myocardial infarction [TIMI] flow grade 2 or 3) were 801% and 751% in the enoxaparin and UFH groups, respectively Reocclusion at 5 to 7 days from TIMI gra

Aspirin Plus Coumarin Versus Aspirin Alone in the Prevention of Reocclusion After Fibrinolysis for Acute Myocardial Infarction Results of the Antithrombotics in the Prevention of Reocclusion In Coronary Thrombolysis (APRICOT)-2 Trial

Abstract: Background— Despite the use of aspirin, reocclusion of the infarct-related artery occurs in ≈30% of patients within the first year after successful fibrinolysis, with impaired clinical outcome. This study sought to assess the impact of a prolonged anticoagulation regimen as adjunctive to aspirin in the prevention of reocclusion and recurrent ischemic events after fibrinolysis for ST-elevation myocardial infarction. Methods and Results— At coronary angiography <48 hours after fibrinolytic therapy, 308 patients receiving aspirin and intravenous heparin had a patent infarct-related artery (Thrombolysis In Myocardial Infarction [TIMI] grade 3 flow). They were randomly assigned to standard heparinization and continuation of aspirin alone or to a 3-month combination of aspirin with moderate-intensity coumarin, including continued heparinization until a target international normalized ratio (INR) of 2.0 to 3.0. Angiographic and clinical follow-up were assessed at 3 months. Median INR was 2.6 (25 to 75th percenti...

Thrombolysis vs heparin in the treatment of pulmonary embolism: a clinical outcome-based meta-analysis.

Abstract: Background In patients with acute pulmonary embolism, thrombolysis results in a more rapid resolution of pulmonary emboli than heparin treatment. Whether this advantage results in an improved clinical outcome is unclear. We sought to perform a clinical outcome–based meta-analysis of studies comparing thrombolytic and heparin treatment in patients with pulmonary embolism. Methods Data concerning adverse outcome events (death, recurrent pulmonary embolism, and major bleeding events) were extracted from the identified randomized studies. Results A total of 56 (23.2%) of 241 patients treated with thrombolytic agents in 9 randomized trials experienced an adverse outcome event compared with 57 (25.9%) of 220 patients treated with heparin (relative risk [RR], 0.9; 95% confidence interval [CI], 0.57-1.32). In the thrombolysis group, 11 patients (4.6%) died compared with 17 (7.7%) in the heparin group (RR, 0.59; 95% CI, 0.27-1.25). Thirty-one patients (12.9%) undergoing thrombolysis had a major bleeding episode compared with 19 patients (8.6%) treated with heparin (RR, 1.49; 95% CI, 0.85-2.81). Five fatal bleeding episodes (2.1%) occurred in the thrombolysis group and none in the heparin group. Six studies provided data on recurrent pulmonary embolism. A recurrence occurred in 14 (6.6%) of 214 patients treated with thrombolytic agents and in 22 (10.9%) of 201 patients treated with heparin (RR, 0.60; 95% CI, 0.29-1.15). Recurrence and/or death occurred in 25 (10.4%) of 241 and in 38 (17.3%) of 220 patients treated with thrombolytic agents and heparin, respectively (RR, 0.55; 95% CI, 0.33-0.96; P = .03). Conclusions In patients with pulmonary embolism, thrombolysis had a lower composite end point of death/recurrence than heparin treatment. Excessive bleeding is the trade-off for improved efficacy. A comparative clinical outcome trial of thrombolysis and heparin treatment is warranted in patients with pulmonary embolism and selected for high risk of death and/or recurrence and low risk of bleeding.

Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis.

Abstract: Background and Purpose— The purpose of this study was to evaluate the safety and efficacy of direct percutaneous transluminal angioplasty (PTA) for patients with acute middle cerebral artery (MCA) trunk occlusion. Methods— Over the past 9 years, a total of 70 patients with acute MCA trunk occlusion were treated with intra-arterial reperfusion therapy. In the last 5 years, 34 patients were treated with direct PTA, and subsequent thrombolytic therapy was added if necessary for distal embolization. The other 36 patients, mainly in the first 4 years, were treated with thrombolytic therapy alone and were used as controls. Pretherapeutic neurological status was evaluated with National Institutes of Health Stroke Scale scores. The modified Rankin Scale (mRS) was used to assess clinical outcome at 90 days. Results— There were no significant differences in pretherapeutic National Institutes of Health Stroke Scale score and duration of ischemia between the 2 groups. The rate of partial or complete recanalization in...

New grading system for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke

Abstract: OBJECTIVE The Thrombolysis in Myocardial Infarction (TIMI) grading scheme and other classification systems are limited because they do not account for occlusion location or collateral circulation. A new scheme for angiographic classification of arterial occlusion and recanalization response to intra-arterial thrombolysis in acute ischemic stroke was designed because of limitations in existing grading systems. METHODS The proposed scheme assigns a score from 0 to 5 on the basis of occlusion site and collateral supply. The pre- and post-thrombolysis angiograms of 15 patients with acute ischemic stroke were independently graded by three neurointerventionists according to TIMI perfusion grade (0-3), a grading scheme developed by Mori et al. (Mori E, Tabuchi M, Yoshida T, Yamadori A: Intracarotid urokinase with thromboembolic occlusion of the middle cerebral artery. Stroke 19:802-812, 1988) (0-4), and the proposed scheme (0-5); and interobserver agreement was assessed. The effect of severity of initial arterial occlusion on outcomes of good recovery (National Institutes of Health Stroke Scale score of < or =4) or death at 7 days after thrombolysis according to the proposed and TIMI grading schemes was also assessed in 60 patients with acute ischemic stroke. Multivariate analyses were performed to assess these relationships after adjusting for patient age, sex, time interval between symptom onset and treatment, and thrombolytic agent used. RESULTS Interobserver agreement was higher for pre- and posttreatment grading of angiographic images using the new classification scheme (kappa = 0.73) than with either TIMI perfusion grade (kappa = 0.68) or Mori et al. grade (kappa = 0.68). The proposed grading scheme was inversely associated with good recovery at 7 days (odds ratio, 0.4; 95% confidence interval, 0.2-0.9) and directly associated with 7-day mortality (odds ratio, 2.0; 95% confidence interval, 1.1-3.6) after treatment. Initial TIMI grade did not correlate with either good recovery or death at 7 days. An inverse trend was observed between initial severity of angiographic occlusion as determined by the proposed scheme and complete recanalization after treatment (odds ratio, 0.6; 95% confidence interval, 0.4-1.02). CONCLUSION Application of the new classification scheme for assessing pretreatment occlusion and response to intra-arterial thrombolysis resulted in high interobserver agreement and correlated with 7-day outcomes. The six grades used in this scheme allowed precise angiographic evaluation of perfusion changes.

Hyperglycemia in Patients with Focal Cerebral Ischemia after Intravenous Thrombolysis: Influence on Clinical Outcome and Infarct Size

Abstract: The aim of the present prospective study was to investigate whether hyperglycemia influences the clinical outcome or the infarct size after intravenous thrombolysis of focal cerebral ischemia. A conse

Computed Tomographic Findings in Patients Undergoing Intra-arterial Thrombolysis for Acute Ischemic Stroke due to Middle Cerebral Artery Occlusion Results From the PROACT II Trial

Abstract: Background and Purpose— The purpose of this study was to evaluate the role of noncontrast CT in the selection of patients to receive thrombolytic therapy for acute ischemic stroke and to predict radiological and clinical outcomes. Methods— One hundred eighty patients with stroke due to middle cerebral artery (MCA) occlusion were randomized 2:1 within 6 hours of onset to receive intra-arterial recombinant prourokinase plus intravenous heparin or intravenous heparin only. Four hundred fifty-four CT examinations were digitized to calculate early infarct changes, infarct volumes, and hemorrhagic changes among the 162 patients treated as randomized (108 recombinant prourokinase–treated patients and 54 control patients). CT changes were correlated with baseline stroke severity, angiographic clot location, collateral vessels, and outcome at 90 days. Results— Baseline CT scans, 120 (75%) of 159, showed early infarct–related abnormalities. The baseline CT abnormality volume was not correlated with the baseline Nat...