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Table of Contents    
EDITORIAL
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 371-372

Intravenous thrombolysis in acute ischemic stroke in the elderly


Department of Neurology, Institute of Neurological Sciences, CARE Hospital, Nampally, Hyderabad, India

Date of Submission02-Aug-2012
Date of Decision02-Aug-2012
Date of Acceptance02-Aug-2012
Date of Web Publication6-Sep-2012

Correspondence Address:
J. M. K. Murthy
Department of Neurology, The Institute of Neurological Sciences, CARE Hospital, Nampally, Hyderabad 500 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.100715

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How to cite this article:
Murthy J. Intravenous thrombolysis in acute ischemic stroke in the elderly. Neurol India 2012;60:371-2

How to cite this URL:
Murthy J. Intravenous thrombolysis in acute ischemic stroke in the elderly. Neurol India [serial online] 2012 [cited 2019 Sep 17];60:371-2. Available from: http://www.neurologyindia.com/text.asp?2012/60/4/371/100715


Intravenous recombinant tissue plasminogen activator (rt-PA) given within 4.5 hours in patients with acute ischemic stroke aged 80 years or younger who have no severe ischemic changes on computed tomography and no general contraindication, increases the odds of survival without dependency. [1],[2],[3] Systematic reviews and meta-analysis of the trials suggest that rt-PA given up to 6 hours after ischemic stroke might benefit some patients. [4],[5],[6] The third International Stroke Trial (IST3) compared the efficacy and safety of intravenous rt-PA versus placebo in the 0-6 hours' time window in patients with acute ischemic stroke who were not eligible for thrombolysis according to the license. There were more deaths within 7 days in the rt-PA group than in the control group. However, case fatality rates were similar in both the groups at 6 months follow-up and more patients had Oxford Handicap Score (OHS) scores of 0-2 in the rt-PA group than control group. The IST3 data do not support any restriction of treatment on the basis of stroke severity or the presence of early ischemic changes on the baseline brain scan. [7] The recent updated systematic review and meta-analysis suggests that rt-PA when administered within 6 hours of symptom onset significantly increases the odds of being alive and independent (modified Rankin Scale 0-2) at the end of the follow-up compared with controls. [8] However, the magnitude of the effect is greatest in patients treated within 3 hours of onset of stroke.

Intravenous rt-PA has not been licensed for use in patients aged over 80 years. In the IST3 half of all patients were older than 80 years of age and a significant difference was observed in the adjusted effect of treatment between patients older than 80 years and in patients 80 years or younger ( p0 =0.027), suggesting greater benefit in those older than 80 years. [7] The recent updated systematic review and meta-analysis showed that relative and absolute benefits of rt-PA are at least as larger in older as in younger individuals. Among patients treated within 6 hours with rt-PA, an increase of 38 per 1000 individuals were alive and independent ( p0 =0.07) at the last follow-up and for patients treated within 3 hours with rt-PA, an increase of 96 per 1000 individuals were alive and independent ( p0 =0.003) at the last follow-up. Therefore, efforts to reduce treatment delays should continue, particularly for older people. [8] In this issue of Neurology India Kim and colleagues [9] report their experience with thrombolysis in 22 patients (intravenous rt-PA in 14, intra-arterial reperfusion therapy in 4, and combined intravenous and intra-arterial therapy in 4) aged >80 years with acute ischemic stroke (National Institute of Health Stroke Scale score >10). Of the 22 patients, 19 patients had stroke due to large artery occlusion (both anterior and posterior circulation). The mean interval from onset-to-treatment was 146.2+73.3 minutes. Of the 22 patients who received thrombolysis, 18 patients survived to discharge, 4 (22.2%) of them had mRS 0-2 at 3-months while none in the control group. Fourteen patients were treated with intravenous rt-PA alone, 2 (14.3%) patients had mRS 0-2 at 3-months. This study suggests that in the elderly with large artery occlusive stroke, thrombolysis is associated with increase in odds of survival without dependency. However, there are several limitations to the study, it is a retrospective study and the patient population was a heterogeneous (both circulations) group with small number of patients in each arterial sub-group.

 
  References Top

1.The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-7.   Back to cited text no. 1
    
2.Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-29.  Back to cited text no. 2
    
3.Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS and EPITHET trials. Lancet 2010;375:1695-703.  Back to cited text no. 3
[PUBMED]    
4.Wardlaw JM, Sandercock PA, Berge E. Thrombolytic therapy with recombinant tissue plasminogen activator for acute ischemic stroke. Where do we go from here? A cumulative meta-analysis. Stroke 2003;34:1437-42.  Back to cited text no. 4
    
5.Wardlaw JM, del Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischemic stroke. Cochrane Database Syst Rev 2003;60:CD000213.  Back to cited text no. 5
    
6.Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74.  Back to cited text no. 6
[PUBMED]    
7.The IST-3 collaborative group: The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 hours of acute ischemic stroke (the third international stroke trial [IST-3]): A randomized controlled trial. Lancet 2012;379:2352-63.   Back to cited text no. 7
    
8.Wardlaw JM, Murry V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischemic stroke: An updated systematic review and meta-analysis. Lancet 2012;379:2364-72.   Back to cited text no. 8
    
9.Kim SC, Cho YJ, Cho JY, Park HK, Song P, Hong KS. Efficacy and safety of thrombolysis in patients aged 80 or more with major ischemic stroke. Neurol India 2012;60;373-8.  Back to cited text no. 9
    




 

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