Why do some patients with acute ischemic stroke after intravenous thrombolytic therapy fail to improve? A case-control study
DOI:
https://doi.org/10.36311/jhgd.v33.15284Keywords:
epidemiology, NIHSS, stroke, thrombolysis, thrombolytic therapyAbstract
Introduction: thrombolytic therapy is the primary saving measure adopted in ischemic cerebrovascular accident (ICVA) victims, adequate for most of them. However, some patients do not show clinical progress, worsening the prognosis, which constitutes an essential scientific gap.
Objective: to analyze the determinants of clinical non-improvement in stroke patients who used rt-PA thrombolytic agentes.
Methods: retrospective observational case-control study, carried out from 2014 to 2017 through an active search of medical records of CVA patients undergoing thrombolytic therapy in a reference hospital in Ceará. Clinical failure was characterized as no reduction in the National Institutes of Health Stroke Scale-Score (NIHSS).
Results: a total of 139 patients enrolled in the study in a single CVA unit. The mean age was 66.14 years (range 34 to 95). The 24-hour follow-up was completed in 100% of patients. A favorable result 24 hours post-thrombolysis was observed in 113 patients (81.29%), and there was no clinical improvement in 26 (18.7%). Post-thrombolysis hemorrhagic transformation was a strong predictor of no improvement (p=0.004), and diabetes was the main modifiable risk factor found (p=0.040).
Conclusion: diabetes and hemorrhagic transformation after thrombolysis were identified as risk factors for clinical non-improvement in patients with acute stroke undergoing thrombolytic therapy.
Downloads
References
da Silva Paiva L, Oliveira FR, de Alcantara Sousa LV, dos Santos Figueiredo FW, de Sá TH, Adami F. Decline in Stroke Mortality Between 1997 and 2012 by Sex: Ecological Study in Brazilians Aged 15 to 49 Years. Scientific Reports 2019; 9. DOI: https://doi.org/10.1038/s41598-019-39566-8
De Santana NM, Dos Santos Figueiredo FW, De Melo Lucena DM, Soares FM, Adami F, De Carvalho Pádua Cardoso L, et al. The burden of stroke in Brazil in 2016: An analysis of the Global Burden of Disease study findings 11 Medical and Health Sciences 1117 Public Health and Health Services. BMC Research Notes 2018; 11. DOI: https://doi.org/10.1186/s13104-018-3842-3
Selim M, Fink JN, Kumar S, Caplan LR, Horkan C, Chen Y, et al. Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume. Stroke. 2002; 33: 2047–52.
Ortiz GA, L. Sacco R. National institutes of health stroke scale (nihss). Wiley StatsRef: Statistics Reference Online 2014.
Lyden PD, Lu M, Levine S, Brott TG, Broderick J. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials. Stroke 2001; 32: 1310–7.
Lyden P. Using the national institutes of health stroke scale: a cautionary tale. Stroke 2017; 48: 513–9.
Cooray C, Fekete K, Mikulik R, Lees KR, Wahlgren N, Ahmed N. Threshold for NIH stroke scale in predicting vessel occlusion and functional outcome after stroke thrombolysis. International Journal of Stroke 2015; 10: 822–9.
Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Annals of Internal Medicine 2007; 147: 573–7.
Figueiredo FW dos S, Adami F. Steps for the decision making based on the statistical analyses. Journal of Human Growth and Development 2017; 27: 350–2. DOI: https://doi.org/10.7322/jhgd.141278
He Y, Yang Q, Liu H, Jiang L, Liu Q, Lian W, et al. Effect of blood pressure on early neurological deterioration of acute ischemic stroke patients with intravenous rt-PA thrombolysis may be mediated through oxidative stress induced blood-brain barrier disruption and AQP4 upregulation. Journal of Stroke and Cerebrovascular Diseases 2020; 29: 104997.
Yu WM, Abdul-Rahim AH, Cameron AC, Kõrv J, Sevcik P, Toni D, et al. The incidence and associated factors of early neurological deterioration after thrombolysis: results from SITS registry. Stroke 2020; 51: 2705–14.
Ong C-T, Wong Y-S, Wu C-S, Su Y-H. Outcome of stroke patients receiving different doses of recombinant tissue plasminogen activator. Drug Design, Development and Therapy 2017; 11: 1559.
Tanaka K, Matsumoto S, Furuta K, Yamada T, Nagano S, Takase K, et al. Differences between predictive factors for early neurological deterioration due to hemorrhagic and ischemic insults following intravenous recombinant tissue plasminogen activator. Journal of Thrombosis and Thrombolysis 2019: 1–6.
Lee S-J, Hong JM, Lee SE, Kang DR, Ovbiagele B, Demchuk AM, et al. Association of fibrinogen level with early neurological deterioration among acute ischemic stroke patients with diabetes. BMC Neurology 2017; 17: 1–7.
Ferreira DB. Transformação Hemorrágica pós-rtPA Endovenoso: frequência e fatores de risco em Unidade de AVC de um hospital terciário. Hospital Geral de Fortaleza, 2017.
Tong X, George MG, Yang Q, Gillespie C. Predictors of in-hospital death and symptomatic intracranial hemorrhage in patients with acute ischemic stroke treated with thrombolytic therapy: Paul Coverdell Acute Stroke Registry 2008–2012. International Journal of Stroke 2014; 9: 728–34.
Boehme AK, Siegler JE, Mullen MT, Albright KC, Lyerly MJ, Monlezun DJ, et al. Racial and gender differences in stroke severity, outcomes, and treatment in patients with acute ischemic stroke. Journal of Stroke and Cerebrovascular Diseases 2014; 23: e255–61.
Savitz SI, Schlaug G, Caplan L, Selim M. Arterial occlusive lesions recanalize more frequently in women than in men after intravenous tissue plasminogen activator administration for acute stroke. Stroke 2005; 36: 1447–51.
de Carvalho JJF, Alves MB, Viana GÁA, Machado CB, dos Santos BFC, Kanamura AH, et al. Stroke epidemiology, patterns of management, and outcomes in Fortaleza, Brazil: a hospital-based multicenter prospective study. Stroke 2011; 42: 3341–6.
Eissa A, Krass I, Bajorek B V. Barriers to the utilization of thrombolysis for acute ischaemic stroke. Journal of Clinical Pharmacy and Therapeutics 2012; 37: 399–409.
Engelter ST, Bonati LH, Lyrer PA. Intravenous thrombolysis in stroke patients of≥ 80 versus< 80 years of age—a systematic review across cohort studies. Age and Ageing 2006; 35: 572–80.
Henon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre P, et al. Early predictors of death and disability after acute cerebral ischemic event. Stroke 1995; 26: 392–8.
Puetz V, Sylaja PN, Coutts SB, Hill MD, Dzialowski I, Mueller P, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 2008; 39: 2485–90.
Puetz V, Dzialowski I, Hill MD, Demchuk AM. The Alberta Stroke Program Early CT Score in clinical practice: what have we learned? International Journal of Stroke 2009; 4: 354–64.
Caso V, Paciaroni M, Venti M, Palmerini F, Silvestrelli G, Milia P, et al. Determinants of outcome in patients eligible for thrombolysis for ischemic stroke. Vascular Health and Risk Management. 2007; 3: 749.
Downloads
Published
Issue
Section
License
Copyright (c) 2023 Filho HLM, Figueiredo FWS, Costa AVF, Albuquerque CNB, Diógenes RC, Rafael GV, Correa JA
This work is licensed under a Creative Commons Attribution 4.0 International License.
