Thrombolytic therapy acute stroke

Wildermuth S, Knauth M, Brandt T, Winter R, Sartor K, Hacke W. Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke. Stroke 1998 29 935-938 [see comment]. 

O Connor RE, McGraw P, Edelsohn L. Thrombolytic therapy for acute ischemic stroke why the majority of patients remain ineligible for treatment. Ann Emerg Med 1999 33 9-14. 

Stroke is the leading cause of major long-term disability in adults and the third leading cause of death in the United States. On average, a new stroke occurs every 45 seconds. Thrombolytic therapy with intravenous recombinant tissue-plasminogen activator (IV rt-PA) is the most effective treatment for acute ischemic stroke. In this chapter, we review the rationale for thrombolysis in acute ischemic stroke, clinical evidence supporting the use of thrombolytics, and the application of thrombolysis in practice. 

Clark WM, Albers GW, Madden KR Hamilton S. The rtPA (alteplase) 0- to 6-hour acute stroke trial, part a (a0276g) results of a double-bhnd, placebo-controlled, multicenter study. Thrombolytic Therapy in Acute Ischemic Stroke Study Investigators. Stroke. 2000 31 811-816. 

Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial-Europe study group. N Engl J Med. 1996 335 145-150. 

Practice advisory Thrombolytic therapy for acute ischemic stroke-summary statement. Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 1996 47 835-839. 

Heuschmann PU, Berger K, Misselwitz B, Hermanek P, Leffmann C, Adelmann M, Buecker-Nott HI, Rother J, Neundoerfer B, Kolominsky-Rabas PL. Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality The German Stroke Registers Study Group. Stroke. 2003 34 1106-1113. 

Schriger DL, Kalafut M, Starkman S, Krueger M, Saver JL. Cranial computed tomography interpretation in acute stroke physician accuracy in determining eligibility for thrombolytic therapy. JAMA. 1998 279 1293-1297. 

Saver JL. Number needed to treat estimates incorporating effects over the entire range of clinical outcomes novel derivation method and application to thrombolytic therapy for acute stroke. Arch Neurol 2004 61 1066-1070. 

Combination GP Ilb/IIIa and rt-PA Therapy for Acute Stroke The combination of antiplatelet and thrombolytic drugs has proven efficacy in the setting of myocardial ischemia where an additive effect is seen. In acute stroke thrombolysis with a very narrow time window and less than 50% optimal reperfusion rates,adjunctive therapy with antiplatelets may be a promising approach. However, MAST-I concluded that the group of patients receiving streptokinase plus aspirin had a marked increase in 10-day mortality. 

Von Rummer R, Allen KL, Holle R, Bozzao L, Bastianello S, Manelfe C, Bluhmki E, Ringleb P, Meier DH, Hacke W. Acute stroke usefulness of early CT findings before thrombolytic therapy. Radiology 1997 205 327-333. 

Determine whether thrombolytic therapy is indicated in a patient with acute ischemic stroke. 

Acute neurologic events, such as stroke, will require hospitalization and close monitoring. Patients should have physical and neurologic examinations every 2 hours.27 Acute treatment may include exchange transfusion or simple transfusion to maintain hemoglobin at around 10 g/dL (100 g/L or 6.2 mmol/L) and HbS concentration at less than 30%. Patients with a history of seizure may need anticonvulsants, and interventions for increased intracranial pressure should be initiated if necessary. Children with a history of stroke should be initiated on chronic transfusion therapy. Adults presenting with ischemic stroke should be considered for thrombolytic therapy if it has been less than 3 hours since the onset of symptoms.6,27... 

Schelhnger PD, Kaste M, Hacke W. An update on thrombolytic therapy for acute stroke. Curr Opin Neurol 2004 17 69-77. 

The evolution of the mismatch model of the penumbra has led to a number of studies examining the response of acute DWI/PI patterns to thrombolytic therapy, particularly with respect to treatment beyond 3 h after stroke onset (Jansen et al. 1999 Kidwell et al. 2000 Parsons et al. 2002a Schellinger et al. 2000). These studies supported the mismatch-penumbra hypothesis by demonstrating that thrombolysis rescues mismatch tissue... 

Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ (1988) Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke 19 1216-1222... 

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... 

Preventing misdiagnosis of stroke is increasingly important in the acute stage of the disease when thrombolytic or interventional therapies with potential adverse effects are considered. Misdiagnosis may have serious consequences A misdiagnosed patient may be subject to unjustified thrombolytic therapy and encounter an elevated bleeding risk. Or, another serious nonvascular disorder maybe misclassified as stroke and treatment options maybe missed. 

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