Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy.

Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.

Thrombolysis in ischemic stroke without arterial occlusion at presentation.

BACKGROUND AND PURPOSE: None of the randomized trials of intravenous tissue-type plasminogen activator reported vascular imaging acquired before thrombolysis. Efficacy of tissue-type plasminogen activator in stroke without arterial occlusion on vascular imaging remains unknown and speculative. METHODS: We performed a retrospective, multicenter study to collect data of patients who presented to participating centers during a 5-year period with ischemic stroke diagnosed by clinical examination and MRI and with imaging evidence of no vascular occlusion. These patients were divided into 2 groups: those who received thrombolytic therapy and those who did not. Primary outcome measure of the study was excellent clinical outcome defined as modified Rankin Scale of 0 to 1 at 90 days from stroke onset. Secondary outcome measures were good clinical outcome (modified Rankin Scale, 0-2) and perfect outcome (modified Rankin Scale, 0). Safety outcome measures were incidence of symptomatic intracerebral hemorrhage and poor outcome (modified Rankin Scale, 4-6). RESULTS: A total of 256 patients met study criteria, 103 with thrombolysis and 153 without. Logistic regression analysis showed that patients who received thrombolysis had more frequent excellent outcomes with odds ratio of 3.79 (P<0.01). Symptomatic intracerebral hemorrhage was more frequent in thrombolysis group (4.9 versus 0.7%; P=0.04). Thrombolysis led to more frequent excellent outcome in nonlacunar group with odds ratio 4.90 (P<0.01) and more frequent perfect outcome in lacunar group with odds ratio 8.25 (P<0.01). CONCLUSIONS: This study provides crucial data that patients with ischemic stroke who do not have visible arterial occlusion at presentation may benefit from thrombolysis.

Thrombolysis in ischemic strokes with no arterial occlusion.

RATIONALE: Twelve million people develop ischemic stroke each year world over and 30-40% of them do not have arterial occlusions at presentation. Trials conducted to study the efficacy of thrombolytic drug reported better outcome with use of thrombolytic drug but none studied the subtypes of ischemic strokes specifically and adequately. The subgroups of patients with no arterial occlusion at presentation continue to receive thrombolytic therapy without proven benefit and with some risk. AIM: The aim of this article is to study whether intravenous thrombolysis with alteplase improves clinical outcome in ischemic stroke patients who do not have arterial occlusion at presentation. DESIGN: A retrospective medical record-based observational multicenter, multinational study. OUTCOMES: Primary outcome measure would be clinical outcome at three-months from stroke onset measured by modified Rankin Scale and National Institute of Health Stroke Scale. Secondary outcome measure will be frequency of intracerebral hemorrhage causing worsening of clinical deficit defined as increase in National Institute of Health Stroke Scale by >4.

Stand alone mechanical thrombectomy (with penumbra system) for acute ischemic stroke based on MR imaging: Single center experience.

BACKGROUND: There is dismal rate of recanalization following intravenous thrombolysis of large vessel occlusive ischemic stroke. Trials on use of mechanical clot retrievers in acute ischemic stroke have used time from onset and clinical deficit at presentation as the main indications for intervention. MATERIALS AND METHODS: Retrospective analysis of case records of acute stroke seen between May 2009 and October 2011 was done. It revealed 23 patients with acute ischemic stroke treated by mechanical thrombectomy using Penumbra system (PS). We used magnetic resonance (MR) imaging in correlation with clinical presentation to determine patients likely to benefit from recanalization and accordingly offered or at times deferred revascularization. A comparison of approach and outcomes was done with other relevant trials/reports. RESULTS: Recanalization was achieved in all but one patient. Median modified Rankin Scale (mRS) score at 90 days was 2. Good clinical outcome (mRS ≤ 2) was achieved in 56.5% compared with 25% in Penumbra pivotal trial and 36% in multi Mechanical Embolus Removal in Cerebral Ischemia (multi MERCI) trial. All cause mortality was 13.04%. Symptomatic intracerebral hemorrhage (ICH) occurred in two patients (8.6%). CONCLUSION: Analysis of our results suggests that PS is safe and effective (91.3%) in recanalizing cerebral vessels without concomitant thrombolytics.

Choroidal tubercles in neurotuberculosis: prevalence and significance.

PURPOSE: Neurotuberculosis is a relatively common form of tuberculosis and may be seen in 1-10% of patients of systemic tuberculosis and may present in several forms. Ocular lesions are frequently seen, most commonly optic nerve lesions. Limited data are available for choroidal tubercles. We conducted a prospective study 1) to determine the prevalence of choroidal tubercles in a cohort of patients of neurotuberculosis as well as its relative prevalence in the various morphological manifestations and 2) to study the role of co-existent systemic tuberculous infection. METHODS: IRB-approved prospective cross-sectional observational study. A hospital-based cohort of patients underwent a detailed physical, laboratory and ocular evaluation. RESULTS: A total of 52 (20 male, 32 female) patients were evaluated with tubercles being seen in 23 eyes (18 patients, 34.6%). Twenty four patients (46.12%, 16 female, 8 male) presented with intracranial granulomas and 28 (53.8%, 16 female, 12 male) presented with tuberculous meningitis. Tubercles were seen in 10 eyes of 8 (28.5%) patients with tuberculous meningitis and in 13 eyes of 10 patients (41.6%) with intracranial granulomas. This result is not statistically significant. Twenty seven patients (51.9%) had neurotuberculosis without systemic infection, whereas 25 (48.1%) patients had systemic foci. Tubercles were seen in 18 eyes (13 patients) with systemic foci and in 5 eyes (5 patients) of neurotuberculosis alone. The odds ratio for the presence of systemic tuberculosis when choroidal tubercles are present is 5.6 (95% confidence interval: 1.39-24.49, statistically significant [p = 0.005]). CONCLUSIONS: Tubercles were equally likely to occur in either manifestation of neurotuberculosis, and their presence was related to the presence of systemic focus of tuberculous infection. The presence of choroidal tubercles may serve as a diagnostic marker for the presence of an underlying systemic infection.