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Thrombolytic Therapy - Top 30 Publications

Comparison of triple antithrombotic therapy and dual antiplatelet therapy for patients with atrial fibrillation after percutaneous coronary stenting.

The aim of this study was to evaluate the safety and efficacy of triple antithrombotic therapy with warfarin, aspirin and clopidogrel in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI). We retrospectively reviewed clinical and follow-up data of 156 consecutive patients with atrial fibrillation after percutaneous coronary stenting. Patients were followed up at 2 and 12 months. A total of 156 consecutive patients were identified. There were 70 patients (dual antiplatelet therapy group, DAPT), warfarin was not used and 86 patients (triple antithrombotic therapy group, TT), both dual antiplatelet therapy and warfarin therapy were prescribed. The baseline data and PCI data were similar in the two groups. The outcome events were similar in the two groups except for bleeding events. There was a significant difference in bleeding risk in the two groups. In summary, triple antithrombotic therapy increases the bleeding risk. Dual antiplatelet therapy decreased this bleeding risk but tended to increase the risk of stroke.

Initial Assessment and Triage of the Stroke Patient.

Nearly 800,000 strokes occur in the United States each year, and stroke is the leading cause of preventable permanent disability. Timely recognition and treatment are imperative to reduce stroke-related morbidity and mortality. Given the evidence supporting intravenous thrombolysis and mechanical thrombectomy for ischemic stroke, stroke symptoms must be rapidly identified and mimics quickly excluded prior to therapeutic decisions. Intravenous tissue plasminogen activator is recommended for all qualified patients and patients with presentations suggesting large vessel occlusion should be evaluated for mechanical thrombectomy. Time to treatment is the most important prognostic factor for clinical outcome, highlighting the importance of reliable and efficient local and regional systems of care.

Endovascular therapy for ischemic stroke: Save a minute-save a week.

To quantify the patient lifetime benefits gained from reduced delays in endovascular therapy for acute ischemic stroke.

Sex differences in utilization and outcomes of catheter-directed thrombolysis in patients with proximal lower extremity deep venous thrombosis - Insights from the Nationwide Inpatient Sample.

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p<0.01, respectively). The rates of CDT increased between 2005 and 2011 for both women (2.1% to 5.9%, p<0.01) and men (2.5% to 7.5%, p<0.01). There was no significant difference in in-hospital mortality (1.2% vs 1.3%, p=0.76). Women were noted to have higher rates of blood transfusions (11.7% vs 8.8%, p<0.01), but lower rates of intracranial hemorrhage (0.5% vs 1.2%, p=0.03) and gastrointestinal bleeding (0.9% vs 2.2%, p<0.01) compared with men. Women were more likely to undergo inferior vena cava filter placement (37.0% vs 32.1%, p<0.01). In this large nationwide cohort, women with proximal DVT were less likely to receive CDT compared to men. Although mortality rates were similar, women were noted to have higher blood transfusion rates while men had more episodes of intracranial and gastrointestinal bleeding.

Thrombolysis in acute stroke without angiographically documented occlusion.

The aim of this study was to evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) using urokinase (UK) in acute stroke patients without angiographically-documented occlusion, and to define predictors of clinical outcome.

Risk Stratification for Patients in Cardiogenic Shock After Acute Myocardial Infarction.

Mortality in cardiogenic shock (CS) remains high. Early risk stratification is crucial to make adequate treatment decisions.

Intervention radiology for venous thrombosis: early thrombus removal using invasive methods.

The post thrombotic syndrome is one of the most dreaded complications of proximal deep vein thrombosis. This syndrome leads to pain and suffering with leg swelling, recalcitrant ulceration and venous claudication which greatly impairs mobility and quality of life. The prevalence can be high in patients with iliofemoral venous involvement particularly in the setting of a proximal venous stenosis, such as occurs in May Thurner syndrome. Anticoagulation alone does not reduce the likelihood of this outcome. Compression therapy may be effective but garment discomfort limits its implementation. Pharmacomechanical thrombectomy, which combines catheter-directed thrombolysis with mechanical thrombus dissolution, provides an attractive treatment strategy for such patients. The rationale and delivery of pharmacomechanical thrombectomy, including patient selection and adjunctive antithrombotic therapy, will be reviewed in addition to tips and tricks for managing difficult patient scenarios.

Application of emerging technologies to improve access to ischemic stroke care.

During the past 20 years, the traditional supportive treatment for stroke has been radically transformed by advances in catheter technologies and a cohort of prominent randomized controlled trials that unequivocally demonstrated significant improvement in stroke outcomes with timely endovascular intervention. However, substantial limitations to treatment remain, among the most important being timely access to care. Nonetheless, stroke care has continued its evolution by incorporating technological advances from various fields that can further reduce patients' morbidity and mortality. In this paper the authors discuss the importance of emerging technologies-mobile stroke treatment units, telemedicine, and robotically assisted angiography-as future tools for expanding access to the diagnosis and treatment of acute ischemic stroke.

Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion.

OBJECTIVE The goals of this study were to describe the authors' recent institutional experience with the transradial approach to anterior circulation large-vessel occlusions (LVOs) in acute ischemic stroke patients and to report its technical feasibility. METHODS The authors reviewed their institutional database to identify patients who underwent mechanical thrombectomy via a transradial approach over the 2 previous years, encompassing their experience using modern techniques including stent retrievers. RESULTS Eleven patients were identified. In 8 (72%) of these patients the right radial artery was chosen as the primary access site. In the remaining patients, transfemoral access was initially attempted. Revascularization (modified Treatment in Cerebral Ischemia [mTICI] score ≥ 2b) was achieved in 10 (91%) of 11 cases. The average time to first pass with the stent retriever was 64 minutes. No access-related complications occurred. CONCLUSIONS Transradial access for mechanical thrombectomy in anterior circulation LVOs is safe and feasible. Further comparative studies are needed to determine criteria for selecting the transradial approach in this setting.

Thrombolysis and thrombectomy for acute ischaemic stroke.

The likelihood of disability-free recovery after acute ischemic stroke is significantly improved by reperfusion either by intravenous thrombolytic drug treatment or with endovascular mechanical thrombectomy in selected cases. The use of intravenous thrombolysis is limited by the short treatment window and you need to assess individual balance of benefit and risk of symptomatic intracranial haemorrhage. Benefit is greater for shorter onset-to-reperfusion time intervals, requiring optimisation of pre-hospital and in-hospital pathways. Symptomatic haemorrhage is more likely with more severe strokes, but a greater proportion of patients are left free of disability than suffer a treatment-related haemorrhage at all levels of severity. Extracranial haemorrhage and orolingual angioedema are less common complications. Endovascular mechanical thrombectomy can be used in selected patients with imaging-proven large artery occlusion. Successful therapy depends on well-organised services that can deliver treatment within a short time window at centres with adequate expertise to perform the procedure.

Long-Term Prognosis in Ischemic Stroke Patients Treated with Intravenous Thrombolytic Therapy.

It remains unclear if intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator has an impact on the survival and maintenance of a favorable effect on functional recovery over a long follow-up period. The aim of this study was to assess whether or not IVT treatment has a favorable effect on functional recovery and survival less than 1 year after a stroke.

Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism.

The long-term effect of thrombolytic treatment of pulmonary embolism (PE) is unknown.

Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke.

Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome.

Evaluation of functional outcome measured by modified Rankin scale in rtPA treated patients with acute ischemic stroke.

Aim of our study was to assess functional outcome measured by modified Rankin scale (mRS) in patients that were treated with thrombolytic therapy-recombinant tissue plasminogen activator (rtPA) after acute ischemic stroke. The study included 100 participants that were treated after acute ischemic stroke. Analyzed parameters included: gender; age groups: age 54 and below (Groupup to-54), 55-64 (Group55-64), 65-74 (Group65-74), and 75 and above (Group75-up); cerebral blood flow (CBF) and cerebral blood volume (CBV). Considering time of rtPA administration, we analyzed 3 groups: between 1-2 hours from stroke onset (Time1-2h), 2-3 hours (Time2-3h) and 3-4.5 hours (Time3h-up). NIHSS scores were analyzed: NIHSS 1-at admission and NIHSS 2-at discharge from hospital; and mRS values: RANKIN 1-at admission and RANKIN 2-at discharge from hospital. There is significant reduction in NIHSS and mRS scores between two measurements for all groups of evaluated parameters. CBF, CBV and NIHSS values at admission significantly correlated with mRS scores at admission (p<0.01), as well as with mRS scores at discharge except for CBF where statistical significance was (p=0.019). Significantly lower values of NIHSS at admission (p<0.01), CBF values (p<0.01) and CBV values (p<0.01) are noticed in the group with mRS≤2. Early induction of rtPA treatment in patients with acute ischemic stroke within first 4.5 hours significantly increases positive treatment outcome in both genders and for all evaluated age groups. Favorable outcome (mRS≤2) at the time of discharge from hospital is significantly associated with lower NIHSS values at admission.

Acute Coronary Syndrome: Current Treatment.

Acute coronary syndrome continues to be a significant cause of morbidity and mortality in the United States. Family physicians need to identify and mitigate risk factors early, as well as recognize and respond to acute coronary syndrome events quickly in any clinical setting. Diagnosis can be made based on patient history, symptoms, electrocardiography findings, and cardiac biomarkers, which delineate between ST elevation myocardial infarction and non-ST elevation acute coronary syndrome. Rapid reperfusion with primary percutaneous coronary intervention is the goal with either clinical presentation. Coupled with appropriate medical management, percutaneous coronary intervention can improve short- and long-term outcomes following myocardial infarction. If percutaneous coronary intervention cannot be performed rapidly, patients with ST elevation myocardial infarction can be treated with fibrinolytic therapy. Fibrinolysis is not recommended in patients with non-ST elevation acute coronary syndrome; therefore, these patients should be treated with medical management if they are at low risk of coronary events or if percutaneous coronary intervention cannot be performed. Post-myocardial infarction care should be closely coordinated with the patient's cardiologist and based on a comprehensive secondary prevention strategy to prevent recurrence, morbidity, and mortality.

Individual and System Contributions to Race and Sex Disparities in Thrombolysis Use for Stroke Patients in the United States.

Intravenous thrombolysis (IVT) is underutilized in ethnic minorities and women. To disentangle individual and system-based factors determining disparities in IVT use, we investigated race/sex differences in IVT utilization among hospitals serving varying proportions of minority patients.

Declotting the Thrombosed Access.

Because a patent access is the lifeline for a dialysis patient, access declotting is extremely important. Before embarking on a declot, it is important to evaluate the patient for potential contraindications such as pulmonary hypertension, right-to-left shunts and access infection in order to be able to avoid potential complications such as symptomatic pulmonary embolism, stroke, and sepsis. Multiple methods to perform a percutaneous declot exist. Four common methods are described here. We also discuss how to avoid causing an arterial embolism and how to treat it if it does occur.

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis.

To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance.

Plasma fibrinogen level as a potential predictor of hemorrhagic complications after catheter-directed thrombolysis for peripheral arterial occlusions.

The benefit of catheter-directed thrombolysis for peripheral arterial occlusions is limited by hemorrhagic complications. Plasma fibrinogen level (PFL) has been suggested as a predictor of these hemorrhagic complications, but the accurateness of prediction is unknown. We summarized the available evidence on the predictive value of PFL for hemorrhagic complications after catheter-directed thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions.

Absent Filling of Ipsilateral Superficial Middle Cerebral Vein Is Associated With Poor Outcome After Reperfusion Therapy.

Our aim was to study the effect of drainage of cortical veins, including the superficial middle cerebral vein (SMCV), vein of Trolard, and vein of Labbé on neurological outcomes after reperfusion therapy.

Surveys of Stroke Patients and Their Next of Kin on Their Opinions towards Decision-Making and Consent for Stroke Thrombolysis.

Early initiation of stroke thrombolysis is associated with improved outcomes. Procurement of consent is a key factor in prolonging the door-to-needle duration. This study aimed to determine the attitudes and preferences of stroke patients and their next of kin (NOK) towards decision-making for stroke thrombolysis in Singapore.

Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges.

In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.

Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke.

Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes.

Thrombolysis with intravenous recombinant tissue plasminogen activator during early postpartum period: a review of the literature.

Thromboembolic events are one of the leading causes of maternal death during the postpartum period. Postpartum thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is controversial because the treatment may lead to massive bleeding. Data centralization may be beneficial for analyzing the safety and effectiveness of systemic thrombolysis during the early postpartum period. We performed a computerized MEDLINE and EMBASE search. We collected data for 13 cases of systemic thrombolytic therapy during the early postpartum period, when limiting the early postpartum period to 48 hours after delivery. Blood transfusion was necessary in all cases except for one (12/13; 92%). In seven cases (7/13; 54%), a large amount of blood was required for transfusion. Subsequent laparotomy to control bleeding was required in five cases (5/13; 38%), including three cases of hysterectomy and two cases of hematoma removal, all of which involved cesarean delivery. In cases of transvaginal delivery, there was no report of laparotomy. The occurrence of severe bleeding was high in relation to cesarean section, compared with vaginal deliveries. Using rt-PA in relation to cesarean section might be worth avoiding. However, the paucity of data in the literature makes it difficult to assess the ultimate outcomes and safety of this treatment.

Endovascular therapy for Angio-seal(TM) -related acute limb ischemia: Perioperative and long-term results.

To investigate the perioperative and long-term outcomes of endovascular therapy for Angio-seal(TM) -related acute limb ischemia.

The effects of pharmaceutical thrombolysis and multi-modal therapy on patients with acute posterior circulation ischemic stroke: Results of a one center retrospective study.

The treatment method for acute ischemic stroke is rapidly developing, and the effects of endovascular modalities, when used alone or in combination, needs to be studied. We aimed to identify the difference between pharmaceutical thrombolysis and multi-modal therapy (MMT) used in acute posterior circulation ischemic stroke (APCIS) patients and also to detect the predictors for successful recanalization and favorable outcomes.

Thrombolysis in peripheral artery disease.

Peripheral artery disease (PAD) has been associated with severe morbidity and mortality worldwide, affecting the quality of life for millions of patients. Acute thrombosis has been identified as a major complication of PAD, with proper management including both open as well as endovascular techniques. Thrombolysis has emerged as a reasonable option in the last decades to treat such patients although data produced by randomized trials have been limited. This review aims to present major aspects of thrombolysis in PAD regarding its indications and contraindications, technique tips as well as to review literature data in order to produce useful conclusions for everyday clinical practice.

Remote Evaluation of the Patient With Acute Stroke.

This article describes advances related to the successful remote evaluation of the patient with acute stroke. Telestroke is a connected care approach that brings expert stroke care to remote, neurologically underserved urban or rural locations. Recent findings reveal strong evidence showing that telestroke is equivalent to in-person care. Time is critical in treating patients with acute stroke, and telestroke networks must assure that technology improves-not delays-delivery of care. The stroke center and the spoke site must work collaboratively to develop and institute protocols and policies to ensure that eligible patients are identified, assessed, and treated swiftly. Adverse outcomes, such as intracranial hemorrhage and mortality, must be monitored to assess safety metrics. An additional goal of telestroke networks is to screen patients who might be candidates for potential endovascular or neurosurgical therapy and transfer these patients for these procedures.

Treatment of Acute Ischemic Stroke.

This article provides an update on the state of the art of the emergency treatment of acute ischemic stroke with particular emphasis on the alternatives for reperfusion therapy.

Acute Ischemic Stroke Therapy Overview.

The treatment of acute ischemic stroke has undergone dramatic changes recently subsequent to the demonstrated efficacy of intra-arterial (IA) device-based therapy in multiple trials. The selection of patients for both intravenous and IA therapy is based on timely imaging with either computed tomography or magnetic resonance imaging, and if IA therapy is considered noninvasive, angiography with one of these modalities is necessary to document a large-vessel occlusion amenable for intervention. More advanced computed tomography and magnetic resonance imaging studies are available that can be used to identify a small ischemic core and ischemic penumbra, and this information will contribute increasingly in treatment decisions as the therapeutic time window is lengthened. Intravenous thrombolysis with tissue-type plasminogen activator remains the mainstay of acute stroke therapy within the initial 4.5 hours after stroke onset, despite the lack of Food and Drug Administration approval in the 3- to 4.5-hour time window. In patients with proximal, large-vessel occlusions, IA device-based treatment should be initiated in patients with small/moderate-sized ischemic cores who can be treated within 6 hours of stroke onset. The organization and implementation of regional stroke care systems will be needed to treat as many eligible patients as expeditiously as possible. Novel treatment paradigms can be envisioned combining neuroprotection with IA device treatment to potentially increase the number of patients who can be treated despite long transport times and to ameliorate the consequences of reperfusion injury. Acute stroke treatment has entered a golden age, and many additional advances can be anticipated.