Thrombolytic therapy for acute ischemic stroke after recent transient ischemic attack

Stroke Unit, Department of Neurology, University Hospital Ramón y Cajal, IRYCIS, Universidad de Alcalá de Henares, Madrid, Spain.
International Journal of Stroke (Impact Factor: 3.83). 11/2011; 7(3):213-8. DOI: 10.1111/j.1747-4949.2011.00690.x
Source: PubMed


Safety and efficacy of intravenous thrombolysis in stroke patients with recent transient ischemic attack are hotly debated. Patients suffering transient ischemic attack may present with diffusion-weighted imaging lesions, and although normal computed tomography would not preclude thrombolysis, the concern is that they may be at higher risk for hemorrhage post-thrombolysis treatment. Prior ipsilateral transient ischemic attack might provide protection due to ischemic preconditioning. We assessed post-thrombolysis outcomes in stroke patients who had prior transient ischemic attack.
Multicentered prospective study of consecutive acute stroke patients treated with intravenous tissue plasminogen activator (tPA). Ipsilateral transient ischemic attack, baseline characteristics, risk factors, etiology, and time-lapse to treatment were recorded. National Institutes of Health Stroke Scale at seven-days and modified Rankin Scale at three-months, symptomatic intracranial hemorrhage, and mortality were compared in patients with and without transient ischemic attack.
There were 877 patients included, 60 (6·84%) had previous ipsilateral transient ischemic attack within one-month prior to the current stroke (65% in the previous 24 h). Transient ischemic attack patients were more frequently men (70% vs. 53%; P = 0·011), younger (63 vs. 71 years of age; P = 0·011), smokers (37% vs. 25%; P = 0·043), and with large vessel disease (40% vs. 25%; P = 0·011). Severity of stroke at onset was similar to those with and without prior transient ischemic attack (median National Institutes of Health Stroke Scale score 12 vs. 14 P = 0·134). Those with previous transient ischemic attack were treated earlier (117 ± 52 vs. 144 ± 38 mins; P < 0·005). After adjustment for confounding variables, regression analysis showed that previous transient ischemic attack was not associated with differences in stroke outcome such as independence (modified Rankin Scale 0-2) (odds ratios: 1·035 (0·57-1·93) P = 0·91), mortality (odds ratios: 0·99 (0·37-2·67) P = 0·99), or symptomatic intracranial hemorrhage (odds ratios: 2·04 (0·45-9·32) P = 0·36).
Transient ischemic attack preceding ischemic stroke does not appear to have a major influence on outcomes following thrombolysis. Patients with prior ipsilateral transient ischemic attack appear not to be at higher risk of bleeding complications.

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    • "Increased incidence of intracerebral bleeding complication in our study sample can be explained in two ways. First of all, our patients with a history of TIA were older (mean age 68) than in similar studies (63) [6] [7]. Older age has been shown to be an important risk factor for SICH in some studies [15,28–31]. "
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    ABSTRACT: Background Intravenous thrombolysis (iv-thrombolysis) with use of rt-PA in patients after recent transient ischaemic attack (TIA) is an important clinical problem. The aim of the study was to assess the impact of TIA within 24 h preceding acute ischaemic stroke (AIS) on the safety and efficacy of iv-thrombolysis. Methods We retrospectively evaluated the clinical and demographic data of 400 patients with AIS who were consecutively treated with iv-thrombolysis from September 2006 to May 2011 in three stroke centres. Results At three-month follow-up, 58.0% of patients were independent (modified Rankin Scale; mRS 0–2), 17.8% had died, 17.0 % suffered haemorrhagic transformation (HT) and 4.3% experienced Symptomatic Intracerebral Haemorrhage (SICH). There were 29 patients (7.3%) who had a previous ipsilateral TIA within 24 h before established stroke. In the TIA subgroup, there was no significant higher percentage of favourable outcome (p = 0.07) and higher SICH rate (p = 0.15). Multivariate analysis showed the impact of prior TIA within 24 h before stroke onset on the presence of SICH (p = 0.01), no impact of TIA on unfavourable outcomes after three months (p = 0.25) and on the mortality rate within three months (p = 0.41). Conclusion TIA within 24-hours prior to ischaemic stroke can portend severe intracerebral bleeding in patients qualified to iv-thrombolysis with use of rt-PA.
    Full-text · Article · May 2014 · Journal of the neurological sciences
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    ABSTRACT: The following perspective represents our summary of questions, ideas, concerns, and recommendations expressed by speakers and discussants at the second Biennial Translational Preconditioning Workshop held in Miami in December 2011.
    No preview · Article · Feb 2013
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    ABSTRACT: Currently, intravenous thrombolysis is by far the most effective treatment of acute ischemic stroke, and its use can independently strongly increase the proportion of stroke patients surviving. While the use of recombinant tissue plasminogen activator in accordance to licensed criteria has continuously risen, off-label use is also frequent. In this review the most important reasons to transcend current license criteria are discussed and evidence is summarized from new studies, such as IST-3, contributing to the balance of increased benefit as opposed to possible harm in situations of off-label use of recombinant tissue plasminogen activator in stroke. In addition, several scores to predict risk and outcome in patients undergoing thrombolysis are compared.
    No preview · Article · Feb 2013 · Expert Review of Neurotherapeutics
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