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      MRI-based thrombolytic therapy in patients with acute ischemic stroke presenting with a low NIHSS

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          Abstract

          Objective

          Treatment of patients with stroke presenting with minor deficits remains controversial, and the recent Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) trial, which randomized patients to thrombolysis vs aspirin, did not show benefit. We studied the safety and efficacy of thrombolysis in a population of patients with acute stroke presenting with low NIH Stroke Scale (NIHSS) scores screened using MRI.

          Methods

          The NIH Natural History of Stroke database was reviewed from January 2006 to December 2016 to identify all patients with an initial NIHSS score ≤5 who received thrombolysis within 4.5 hours of symptom onset after being screened with MRI. The 24-hour postthrombolysis MRIs were reviewed for hemorrhagic transformation. Primary outcomes were symptomatic intracranial hemorrhage (sICH) and favorable 90-day outcome modified Rankin Scale score 0–1. Subgroup analysis was performed on patients who would have been eligible for the PRISMS trial, which enrolled patients with a nondisabling neurologic deficit.

          Results

          A total of 121 patients were included in the study with a median age of 65 and an NIHSS score of 3; 63% were women. The rate of any hemorrhagic transformation was 13%, with 11% of them being limited to petechial hemorrhage. The rate of sICH was <1%. Sixty-six patients had 90-day outcome data; of those, 74% had a favorable outcome. For the subgroup of 81 PRISMS-eligible patients, none experienced sICH. Fifty of these patients had 90-day outcome data; of these, 84% had a favorable outcome.

          Conclusions

          Thrombolytic therapy was safe in our patients with stroke with minor deficits who were initially evaluated by MRI. Future studies of this population may benefit from MRI selection.

          Classification of evidence

          This study provides Class IV evidence that for patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe.

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          Most cited references16

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          Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility.

          Thrombolytic therapy for acute stroke (<3 hours) will not have a major impact on death and dependency unless it is accessible to more patients. To determine why patients with ischemic stroke did not receive IV TPA and assess the availability of this therapy to patients with ischemic stroke. Consecutive patients with acute ischemic stroke were prospectively identified at a university teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke were identified that were admitted to one of three other hospitals in the Calgary region during the study period. The Oxford Community Stroke Programme Classification was used to record type and side of stroke. Of 2165 stroke patients presenting to the university hospital, 1168 (53.9%) were diagnosed with ischemic stroke, 31.8% with intracranial hemorrhage (intracerebral, subarachnoid, or subdural), and 13.9% with TIA. Delay in presentation to emergency department beyond 3 hours excluded 73.1% (854/1168). Major reasons for delay included uncertain time of onset (24.2%), patients waited to see if symptoms would improve (29%), delay caused by transfer from an outlying hospital (8.9%), and inaccessibility of treating hospital (5.7%). Twenty-seven percent of patients with ischemic stroke (314/1168) were admitted within 3 hours of sympton onset and of these 84 (26.7%) patients received IV TPA. The major reasons for exclusion in this group of patients (<3 hours) were mild stroke (13.1%), clinical improvement (18.2%), perceived protocol exclusions (13.6%), emergency department referral delay (8.9%), and significant comorbidity (8.3%). Of those patients who were considered too mild or were documented to have had significant improvement, 32% either remained dependent at hospital discharge or died during hospital admission. Throughout the region there was a total of 1806 ischemic stroke patients (admitted to all four Calgary hospitals). During this study period, 4.7% received IV TPA. The majority of patients are unable to receive TPA for acute ischemic stroke because they do no not reach the hospital soon enough. Of those patients presenting within 3 hours, 27% received the therapy but a further 31% were excluded because their symptoms were either considered too mild or were rapidly improving. Subsequently, a third of these patients were left either dependent or dead, bringing into question the initial decision not to treat.
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            Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits

            More than half of patients with acute ischemic stroke have minor neurologic deficits (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) at presentation. Although prior major trials of alteplase included patients with low NIHSS scores, few without clearly disabling deficits were enrolled.
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              Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis.

              Randomised trials have shown that alteplase improves the odds of a good outcome when delivered within 4·5 h of acute ischaemic stroke. However, alteplase also increases the risk of intracerebral haemorrhage; we aimed to determine the proportional and absolute effects of alteplase on the risks of intracerebral haemorrhage, mortality, and functional impairment in different types of patients.
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                Author and article information

                Journal
                Neurology
                Neurology
                Ovid Technologies (Wolters Kluwer Health)
                0028-3878
                1526-632X
                October 14 2019
                October 15 2019
                October 15 2019
                September 13 2019
                : 93
                : 16
                : e1507-e1513
                Article
                10.1212/WNL.0000000000008312
                8c399768-b221-41a7-baf3-d03bbcf7e661
                © 2019
                History

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