Current guidelines recommended providing lytics in acute stroke within 3 hours of symptom onset (guidelines). However, 2 new studies provide evidence for extending that window to 4.5 hours. The first observational study found similar 30 day mortality, 30 day functional status, and 24 hour ICH in patients who recieved lytics in <3 hours compared to those in the 3-4.5 hour window (abstract). The second was a RCT of patients presenting between 3-4.5 hours with acute stroke. The lytic group (compared to placebo) had a slightly higher % favorable 90 day functional score and non-significantly fewer deaths, but significantly more ICH (OR 1.73) (abstract) As an accompanying editorialist notes, “how long do you have to initiate thrombolytic therapy? The correct answer is 1 minute”, indicating that any delay, however short, is too long (editorial). However, in patients presenting between 3-4.5 hours with acute stroke, evidence suggests they should still be evaluated for lytics, as some of them may benefit.
In this large multicenter trial, patients with minor stroke or TIA were randomized to clopidogrel+ASA or ASA alone; 90-day stroke occurred in 8% vs 12% respectively, and rates of hemorrhage or hemorrhagic stroke were the same (abstract).
These guidelines provide an evidence based for the use of periprocedural antithrombotics in patients with cerebrovascular disease. They recommend continuing ASA-warfarin for dental procedures, and most other minor procedures. There is little evidence to support the use of procedural bridging with heparin, and it does increase the risk of bleeding. Cessation of therapy for 7 […]
A large analysis from a stroke registry found better outcomes with earlier thrombolytics for acute ischemic stroke; every 15 minutes earlier was associated with an odds ratio of 0.96 for in-hospital death or intracranial hemorrhage, and an odds ratio of 1.03 for being discharged home and 1.04 for walking independently at discharge (abstract).