Stroke ischaemic, thrombolytics

Although ongoing trials may modify the following treatment algorithm, a possible role of combined PI and DWI as part of a multimodal MRI protocol in the near future for the selection of acute ischaemic stroke patient for thrombolysis is presented below. Indeed, many centres do use stroke MRI to select patients for thrombolysis beyond 3 h (Schellinger et al. 2003). At present, as the evidence is not conclusive, we prefer to randomise post-3-h patients to thrombolytic trials. 

Hacke W, Kaste M, Fieschi C (1998) Randomised double-blind placebo controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet 352 1245-1251... 

Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, Larrue V, Bluhmki E, Davis S, Donnan G, Schneider D, Diez-Tejedor E, TroiuUas P. Randomised double-blind placebo-controUed trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ecass II). Second emopean-australasian acute stroke study investigators. Lancet. 1998 352 1245-1251... 

Wardlaw J M, Warlow C P, Counsell C (1997). Systematic review of evidence on thrombolytic therapy for acute ischaemic stroke. Eancet. 350 607-614. 

Hacke, W., Kaste, M., Fieschi, C., von Kummer, R., Daveilos, A., Meier, D., Larrue, V., Bluhmki, E., Davis, S., Donnan, G., Schneider, D., Diez-Tejedor, E., and TrouUlas, P. (1998) Randomised double-blind placebo-controlled tried of thrombolytic therapy with intravenous edteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet, 352 1245-1251. 

Cardiovascular A meta-analysis and systemic review were performed to ascertain the relationship between prior warfarin use with subtherapeutic international normalized ratio (INR) and outcome after intravenous or intraarterial thrombolytic therapy in acute ischaemic stroke patients The outcomes were symptomatic intracranial haemorrhage, modified Rankin scale score and mortality. The risk of symptomatic intracranial haemorrhage after thrombolytic therapy was increased in patients using warfarin with subtherapeutic INR levels. However, there was no association between prior warfarin therapy and worsened fxmctional outcome or all-cause death. 

Miedema I, Luijckx G-J, De Keyser J, Koch M, Uyttenboogaart M. Thrombolytic therapy for ischaemic stroke in patients using warfarin a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2012 83(5) 537-40. 

Much debate exists over the accuracy of the acute DWI lesion identifying the ischaemic core, that is, tissue that is irreversibly damaged. There is no doubt that diffusion lesions may be partially reversed with early reperfusion. This has been demonstrated in both animal and human stroke (Chalela et al. 2003 Kidwell et al. 2000 Li et al. 1999,2000). However, in humans these lesion reversals in most instances are only minor or partial, and are quite often not permanent. Indeed, in our thrombolytic series, less than 5% of patients had what would be considered any significant reduction in ischaemic lesion volume between the pre-treatment DWI and outcome T2-weighted... 

---