Intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage: a meta-analysis.

BACKGROUND: The history of intracranial hemorrhage (ICrH) is considered a contraindication for intravenous thrombolysis (IVT) among patients with acute ischemic stroke (AIS). Objective: This study aimed at comparing the safety of IVT among patients with and without a history of ICrH. METHODS: We performed a systematic review of the literature. Data regarding all AIS patients with prior ICrH who received IVT were retrieved. Meta-analysis was performed to compare the rate of symptomatic hemorrhagic transformation (sHT), death within 90 days, and favorable and unfavorable 90-day functional outcomes based on modified Rankin Scale (mRS) among stroke patients with and without prior ICrH. RESULTS: Out of 13,032 reviewed records, 7 studies were included in the systematic review and meta-analysis. Quantitative synthesis of data regarding the rate of sHT (5068 patients) revealed no significant difference between the two groups [odds ratio, OR: 1.55 (0.77, 3.12); p = 0.22]. However, a significantly higher risk of death within 90 days [OR: 3.91 (2.16, 7.08); p < 0.00001] and a significantly higher 90-day poor functional outcomes (mRS, 4-6) [OR: 1.57 (1.07, 2.30); p = 0.02] were observed among patients with prior ICrH. Likewise, the percentage of 90-day good functional outcomes (mRS, 0-1) was lower in the prior ICrH group [OR: 0.54 (0.35, 0.84); p = 0.06]. Subgroup analyses in patients with a history of ICrH (based on both patients' medical history and imaging confirmation) revealed no significant between-group differences in rates of sHT. Also, sensitivity analysis consisting of only studies using standard-dose IVT showed no difference in sHT rates and 90-day outcomes between the two groups. There was no evidence of heterogeneity (I 2 >50%) among included studies. CONCLUSION: The results of this study indicated that prior history of ICrH does not increase the risk of sHT post-IVT, but it is associated with a higher risk of death and poor functional outcomes in 90 days.

Short-term glycemic variability and hemorrhagic transformation after successful endovascular thrombectomy.

BACKGROUND: Glycemic variability (GV) is a risk factor for poor outcomes after ischemic stroke. However, its effect on hemorrhagic transformation after endovascular recanalization therapy (ERT) remains to be elucidated. METHODS: Patients with acute ischemic stroke due to large vessel occlusion with successful recanalization after ERT (modified thrombolysis in cerebral infarction 2b or 3) were enrolled between January 2013 and November 2019. Blood glucose level data were obtained during the first 36 h after ERT, and ten GV parameters including time rate (TR) of glucose variation were assessed. The TR of glucose variation reflects the speed of glucose fluctuations over time (mg/dL/hour) during the monitoring period. Symptomatic intracerebral hemorrhage (sICH) and unfavorable outcomes at 3 months after ERT were analyzed. The sICH was defined as parenchymal hematoma type 2 with a neurological deterioration of 4 points or more on the National Institute of Health Stroke Scale. Moreover, a modified Rankin Scale of 3-6 at 3 months was considered an unfavorable outcome. RESULTS: Among all patients (n = 176; mean age, 69.3 years; 47.7 % female), sICH developed after successful ERT in 16 (9.1%) patients. In addition, 54% (n = 95) patients had an unfavorable outcome at 3 months. Patients with sICH and unfavorable outcome had higher the TR of glucose variation. After adjusting for potential confounders, the TR of glucose (per 1 mg/dL/h increase) variation was independently associated with sICH (odds ratio, 1.17; 95% confidence interval [CI], 1.012-1.343) and 3-month unfavorable outcome (OR 1.14, 95% CI, 1.000-1.297). CONCLUSIONS: Time-related GV during the first 36 h after successful ERT has a stronger correlation with sICH and poor functional outcomes compared to any GV parameters. This suggests that maintaining stable glucose may be an important factor in the prevention of sICH after undergoing successful ERT.

[The efficacy of systemic thrombolysis in patients with cardioembolic stroke]. / Éffektivnost' sistemnoi tromboliticheskoi terapii u bol'nykh s kardioémbolicheskim insul'tom.

AIM: To compare the efficacy and safety of systemic thrombolytic therapy (STLT) in patients with cardioembolic stroke (CE) versus other pathogenic subtypes of ischemic stroke (IS). MATERIAL AND METHODS: The study included 147 patients, 62 women and 85 men (mean age - 62.9±0.8 years) including 37 patients (25.2%) with CE subtype of IS (group 1) and 110 patients with other pathogenetic subtypes of IS (group 2). NIHSS and Rankin scale were used to assess patient's neurological status. RESULTS: One hundred and twenty-six patients were discharged, 21 (14.3%) died. In 11 patients, the cause of death was the development of symptomatic hemorrhagic transformation (SHT). There were no significant differences in the lethality between groups 1 and 2. Tolerability to STLT in these groups did not differ as well. As a result of treatment, the condition of patients surviving to the end of the hospital stay improved, which was reflected in a significant decrease in the NIHSS scores, despite the higher NIHSS scores in group 1. CONCLUSION: The results confirm the efficacy of STLT in patients with CE IS and indicate the increase in the frequency of favorable functional recovery in these patients.

Should we exclude acute stroke patients with previous intracerebral hemorrhage from receiving intravenous thrombolysis?

BACKGROUND: Current guidelines have contraindicated history of intracerebral hemorrhage for intravenous recombinant tissue plasminogen activator. AIM: This study aimed to investigate the safety and effectiveness of intravenous recombinant tissue plasminogen activator for patients who had previous intracerebral hemorrhage on history or initial brain magnetic resonance imaging. METHODS: Using a prospective multicenter stroke registry database, we identified acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 4.5 h of onset. Previous intracerebral hemorrhage was defined as having a clinical history or evidence of old intracerebral hemorrhage on initial brain magnetic resonance imaging. Associations of previous intracerebral hemorrhage with symptomatic hemorrhagic transformation during hospitalization and functional outcome and mortality at discharge and three months were analyzed. RESULTS: Among 1495 patients who were treated with intravenous recombinant tissue plasminogen activator, 73 (4.9%) had previous intracerebral hemorrhage; 9 on history only, 61 on magnetic resonance imaging only and 3 on both. Of those 1495 patients, 71 (4.7%) experienced symptomatic hemorrhagic transformation; 6.8% in patients with previous intracerebral hemorrhage and 4.6% in those without previous intracerebral hemorrhage. Multivariable logistic regression analysis showed that previous intracerebral hemorrhage did not significantly increase the risk of symptomatic hemorrhagic transformation (odds ratio 1.08, 95% confidence interval 0.39-2.96) mortality, and most of functional outcome measures CONCLUSIONS: Previous intracerebral hemorrhage may neither increase the risk of symptomatic hemorrhagic transformation nor alter major clinical outcomes in acute ischemic stroke patients receiving intravenous recombinant tissue plasminogen activator. This study suggests reconsideration of prior history of intracerebral hemorrhage as an exclusion criterion for intravenous recombinant tissue plasminogen activator administration in acute ischemic stroke.

Statins in Acute Ischemic Stroke: A Systematic Review.

BACKGROUND AND PURPOSE: Statins have pleiotropic effects of potential neuroprotection. However, because of lack of large randomized clinical trials, current guidelines do not provide specific recommendations on statin initiation in acute ischemic stroke (AIS). The current study aims to systematically review the statin effect in AIS. METHODS: From literature review, we identified articles exploring prestroke and immediate post-stroke statin effect on imaging surrogate markers, initial stroke severity, functional outcome, and short-term mortality in human AIS. We summarized descriptive overview. In addition, for subjects with available data from publications, we conducted meta-analysis to provide pooled estimates. RESULTS: In total, we identified 70 relevant articles including 6 meta-analyses. Surrogate imaging marker studies suggested that statin might enhance collaterals and reperfusion. Our updated meta-analysis indicated that prestroke statin use was associated with milder initial stroke severity (odds ratio [OR] [95% confidence interval], 1.24 [1.05-1.48]; P=0.013), good functional outcome (1.50 [1.29-1.75]; P<0.001), and lower mortality (0.42 [0.21-0.82]; P=0.0108). In-hospital statin use was associated with good functional outcome (1.31 [1.12-1.53]; P=0.001), and lower mortality (0.41 [0.29-0.58]; P<0.001). In contrast, statin withdrawal was associated with poor functional outcome (1.83 [1.01-3.30]; P=0.045). In patients treated with thrombolysis, statin was associated with good functional outcome (1.44 [1.10-1.89]; P=0.001), despite an increased risk of symptomatic hemorrhagic transformation (1.63 [1.04-2.56]; P=0.035). CONCLUSIONS: The current study findings support the use of statin in AIS. However, the findings were mostly driven by observational studies at risk of bias, and thereby large randomized clinical trials would provide confirmatory evidence.

Statins in Acute Ischemic Stroke: A Systematic Review / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Statins have pleiotropic effects of potential neuroprotection. However, because of lack of large randomized clinical trials, current guidelines do not provide specific recommendations on statin initiation in acute ischemic stroke (AIS). The current study aims to systematically review the statin effect in AIS. METHODS: From literature review, we identified articles exploring prestroke and immediate post-stroke statin effect on imaging surrogate markers, initial stroke severity, functional outcome, and short-term mortality in human AIS. We summarized descriptive overview. In addition, for subjects with available data from publications, we conducted meta-analysis to provide pooled estimates. RESULTS: In total, we identified 70 relevant articles including 6 meta-analyses. Surrogate imaging marker studies suggested that statin might enhance collaterals and reperfusion. Our updated meta-analysis indicated that prestroke statin use was associated with milder initial stroke severity (odds ratio [OR] [95% confidence interval], 1.24 [1.05-1.48]; P=0.013), good functional outcome (1.50 [1.29-1.75]; P<0.001), and lower mortality (0.42 [0.21-0.82]; P=0.0108). In-hospital statin use was associated with good functional outcome (1.31 [1.12-1.53]; P=0.001), and lower mortality (0.41 [0.29-0.58]; P<0.001). In contrast, statin withdrawal was associated with poor functional outcome (1.83 [1.01-3.30]; P=0.045). In patients treated with thrombolysis, statin was associated with good functional outcome (1.44 [1.10-1.89]; P=0.001), despite an increased risk of symptomatic hemorrhagic transformation (1.63 [1.04-2.56]; P=0.035). CONCLUSIONS: The current study findings support the use of statin in AIS. However, the findings were mostly driven by observational studies at risk of bias, and thereby large randomized clinical trials would provide confirmatory evidence.