Outcomes of intravenous thrombolytic therapy in cardioembolic strokes

Year 2021, Volume: 5 Issue: 2, 111 - 114, 01.02.2021

Mustafa Çetiner , Murat Seyit , Neslihan Eşkut , Gönül Akdağ , Fatma Akkoyun Sibel Canbaz Kabay

https://doi.org/10.28982/josam.801301

Abstract

Background/Aim: It is controversial whether intravenous recombinant tissue plasminogen activator (IV r-tPA) treatment outcomes in cardioembolic strokes differ from other types of strokes. This study aims to investigate the clinical data of patients with cardioembolic and large-vessel atherosclerosis who received IV r-tPA treatment and compare and discuss the results according to the literature.
Methods: The data of the patients who were admitted within the first 4.5 hours following the onset of symptoms, diagnosed with acute ischemic stroke in the Neurology clinic of Kütahya Evliya Çelebi Training and Research Hospital and underwent IV r-tPA were evaluated in this retrospective cohort study. Demographic data, clinical and functional results of patients were compared between the two groups (cardioembolic and large vessel atherosclerosis).
Results: Eighty-five patients with ischemic stroke who received IV r-tPA treatment due to cardioembolism and large-vessel atherosclerosis were included in the study. There were 51 patients (60%) in the cardioembolic stroke group and 34 patients (40%) in the large vascular atherosclerotic group. There was no significant difference in terms of functional results between the groups (62.7% vs 44.1%; P=0.09). While symptomatic intracerebral hemorrhage was not detected in the large-vessel atherosclerosis group, it occurred in 3.9% of the cardioembolic stroke group.
Conclusion: This study proved that functional and clinical results are similar between cardioembolic and large-vessel atherosclerosis patients who were treated with IV r-tPA treatment. Regardless of the etiology, all suitable patients with acute ischemic stroke should be treated with thrombolytic therapy.

Keywords

Acute ischemic stroke, Cardioembolic stroke, Intravenous thrombolytic therapy

References

• 1. Ois A, Cuadrado-Godia E, Rodriguez-Campello A, Giralt-Steinhauer E, Jiménez-Conde J, Lopez-Cuiña M, et al. Relevance of stroke subtype in vascular risk prediction. Neurology. 2013;81:571-80.
• 2. Wei W, Li S, San F, Zhang S, Shen Q, Guo J, et al. Retrospective analysis of prognosis and risk factors of patients with stroke by TOAST. Medicine (Baltimore). 2018:97:e0412.
• 3. The National Institute of Neurological Disorder and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-7.
• 4. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998;352:1245-51.
• 5. Timsit SG, Sacco RL, Mohr JP, Foulkes MA, Tatemichi TK, Wolf PA, et al. Brain infarction severity differs according to cardiac or arterial embolic source. Neurology. 1993;43:728-33.
• 6. Molina CA, Montaner J, Arenillas JF, Ribo M, Rubiera M, Sabín JA. Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes. Stroke. 2004;35:486-90.
• 7. Rocha S, Pires A, Gomes J, Rocha J, Sousa F, Pinho J, et al. Intravenous thrombolysis is more effective in ischemic cardioembolic strokes than in non-cardioembolic? Arq Neuro psiquiatr. 2011;69:905-9.
• 8. Nam HS, Lee KY, Kim YD, Choi HY, Cho HJ, Cha MJ, et al. Failure of complete recanalization is associated with poor outcome after cardioembolic stroke. Eur J Neurol. 2011;18:1171-8.
• 9. Kimura K, Iguchi Y, Shibazaki K, Iwanaga T, Yamashita S, Aoki J. IV t-PA therapy in acute stroke patients with atrial fibrillation. J Neurol Sci. 2009;276:6-8.
• 10. Güneş M. Relationship between blood pressure levels during thrombolytic therapy and functional outcomes in patients with middle cerebral artery infarction. J Surg Med. 2020;4:378-82.
• 11. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke. A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947.
• 12. Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, E Fugate JE, Grotta JC, et al. American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47:581-641.
• 13. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24:35-41.
• 14. Vaclavik D, Vilionskis A, Jatuzis D, Karlinski MA, Gdovinova Z, Kõrv J, et al. Clinical outcome of cardioembolic stroke treated by intravenous thrombolysis. Acta Neurol Scand. 2018;137:347-55.
• 15. Mustanoja S, Meretoja A, Putaala J, Viitanen V, Curtze S, Atula S, et al. Outcome by stroke etiology in patients receiving thrombolytic treatment: Descriptive subtype analysis. Stroke. 2011;42:102–6.
• 16. Tan YF, Zhan LX, Chen XH, Guo JJ, Qin C , En Xu E. Risk Factors, Clinical Features and Prognosis for Subtypes of Ischemic Stroke in a Chinese Population. Curr Med Sci. 2018;38:296-303.
• 17. Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Ischemic stroke subtypes: a population-based study of functional outcome, survival, and recurrence. Stroke. 2000;31:1062-8.
• 18. Wang XG, Zhang LQ, Liao XL, Pan YS, Shi YZ, Wang CJ, et al. Thrombolysis Implementation and Monitoring of acute ischemic Stroke in China (TIMS-China) Investigators. Unfavorable Outcome of Thrombolysis in Chinese Patients with Cardioembolic Stroke: a Prospective Cohort Study. CNS Neurosci Ther. 2015;21:657-61.
• 19. Schmitz ML, Simonsen CZ, Svendsen ML, Larsson H, Madsen MH, Mikkelsen IK, et al. Ischemic stroke subtype is associated with outcome in thrombolyzed patients. Acta Neurol Scand. 2017;135:176-82.
• 20. Boeckh-Behrens T, Kleine JF, Zimmer C, Neff F, Scheipl F, Pelisek J, et al. Thrombus Histology Suggests Cardioembolic Cause in Cryptogenic Stroke. Stroke. 2016;47:1864-71.
• 21. Yeo LL, Paliwal P, Teoh HL, Seet RC, Chan BPL, Wakerley B, et al. Early and continuous neurologic improvements after intravenous thrombolysis are strong predictors of favorable long-term outcomes in acute ischemic stroke. J Stroke Cerebrovasc Dis. 2013;22:e590-6.
• 22. Fuentes B, Martínez-Sánchez P, Alonso de Leciñana M, Egido J, Reig-Roselló G, Díaz-Otero F, et al. Madrid Stroke Network. Efficacy of intravenous thrombolysis according to stroke subtypes: the Madrid Stroke Network data. Eur J Neurol. 2012;19:1568-74.
• 23. Paciaroni M, Agnelli G, Corea F, Ageno W, Alberti A, Lanari A, et al. Early hemorrhagic transformation of brain infarction: Rate, predictive factors, and influence on clinical outcome: Results of a prospective multicenter study. Stroke. 2008;39:2249–56.
• 24. Liu M, Pan Y, Zhou L, Wang Y. Predictors of post-thrombolysis symptomatic intracranial hemorrhage in Chinese patients with acute ischemic stroke. PLoSOne. 2017;12:e0184646.
• 25. Ge WQ, Chen J, Pan H, Chen F, Zhou CY. Analysis of Risk Factors Increased Hemorrhagic Transformation after Acute Ischemic Stroke.J Stroke Cerebrovasc Dis. 2018;27:3587-90.
• 26. Shon SH, Heo SH, Kim BJ, Choi HY, Kwon Y, Yi SH, et al. Predictors of Hemorrhage Volume after Intravenous Thrombolysis. J Stroke Cerebro vasc Dis. 2016;25:2543-8.
• 27. Tan S, Wang D, Liu M, Zhang S, Wu B, Liu B. Frequency and predictors of spontaneous hemorrhagic transformation in ischemic stroke and its association with prognosis. J Neurol. 2014;261:905-12.
• 28. Dang H, Ge WQ, Zhou CF, Zhou CY. The Correlation between Atrial Fibrillation and Prognosis and Hemorrhagic Transformation. Eur Neurol. 2019;82:9-14.
• 29. Wen L, Zhang S, Wan K, Zhang H, Zhang X. Risk factors of haemorrhagic transformation for acute ischaemic stroke in Chinese patients receiving intravenous thrombolysis: A meta-analysis. Medicine (Baltimore). 2020;99:e18995.