Successful intravenous thrombolysis in acute ischaemic stroke in a patient on rivaroxaban treatment
Araceli Alonso-CanovasAlicia de Felipe MimbreraSusana Sainz de la MazaRodrigo Álvarez‐VelascoBeatriz ZarzaJaime MasjuánMichal Maciej Kawiorski
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Successful intravenous thrombolysis in acute ischaemic stroke in a patient on rivaroxaban treatment -Keywords:
Ischaemic stroke
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There have been considerable advances in stroke research leading to translation of drug therapy for stroke into the clinical arena. Thrombolysis for ischaemic stroke is a key advance that significantly reduces disability. This has revolutionized the manner in which acute stroke is treated as a medical emergency. The use of advanced imaging techniques and adjuncts to thrombolysis could potentially improve selection of patients who may benefit from reperfusion therapy such as mechanical thrombectomy and allow treatment decisions to be based on individual brain pathophysiology, rather than arbitrary time windows. It is likely that reconfiguration of stroke services may be required to accommodate further delivery of hyperacute interventions for acute stroke.
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Ischaemic stroke is a treatable medical emergency. In an era of time-dependent reperfusion techniques, it is crucial that an accurate and prompt diagnosis is made. Approximately 30% of patients admitted to hyperacute stroke units are subsequently found not to have a final diagnosis of acute stroke although some of these patients do have incidental or previously symptomatic cerebrovascular disease. These patients do not benefit from thrombolysis and may require the input of other specialists or treatments. Meanwhile, a proportion of patients with acute stroke have unusual presentations and are sometimes initially admitted to general medical admissions units prior to accessing stroke unit care. It is important that atypical presentations of stroke are recognised so that patients are not denied the benefits of stroke unit care and secondary prevention. This article describes some characteristics of common stroke mimics and chameleons, considers how to avoid diagnostic mistakes and discusses the contributory role of imaging.Stroke
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Abstract There have been considerable advances in stroke research leading to translation of drug therapy for stroke into the clinical arena. Thrombolysis for ischaemic stroke is a key advance that significantly reduces disability. This has revolutionized the manner in which acute stroke is treated as a medical emergency. The use of advanced imaging techniques and adjuncts to thrombolysis could potentially improve selection of patients who may benefit from reperfusion therapy such as mechanical thrombectomy and allow treatment decisions to be based on individual brain pathophysiology, rather than arbitrary time windows. It is likely that reconfiguration of stroke services may be required to accommodate further delivery of hyperacute interventions for acute stroke.
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Developments in acute stroke therapy have followed advances in the understanding of the evolving pathophysiology in both ischaemic stroke and intracerebral haemorrhage (ICH). In ischaemic stroke, rapid reperfusion of the ischaemic penumbra with thrombolysis within 3 h of symptom onset is of proven benefit, but few patients currently receive therapy, mainly due to the short-time window and lack of stroke expertise. In ICH, a recent study indicated that a haemostatic agent can limit ongoing bleeding and improve outcomes when administered within 4 h of stroke onset. These advances in acute stroke therapy underlie the concept that 'time is brain' and that urgent intervention can limit cerebral damage. Neuroprotective therapy could offer the prospect of a greater proportion of stroke patients receiving treatment, potentially before imaging and even in the ambulance setting. Virtually all stroke patients would benefit from receiving multidisciplinary care in acute stroke units.
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Despite huge global burden, stroke disease has traditionally received little attention in the general medical press. We review a series of four acute stroke research articles published in a themed issue of the Lancet. Claiborne-Johnston and coworkers presented a scoring system to stratify risk of stroke following transient ischaemic attack. Chalela and colleagues demonstrated that magnetic resonance imaging is superior to computed tomography in detecting acute ischaemic stroke and that fears of missing intracranial haemorrhage are unfounded. The SITS-MOST (Safe Implementation of Thrombolysis in Stroke - Monitoring Study) group reported positive experience of translating acute stroke thrombolysis trials into routine clinical practice in Europe, and the PROSIT (Project on Stroke Services in Italy) group studied acute effects of admission to a dedicated stroke unit. The message from all of these reports is that evidence-based, successful management of acute stroke is possible, and that investment in health infrastructure and changing mind sets of health practitioners to improve stroke care will deliver benefits.
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Stroke is an important cause of death and disability throughout the world. Most strokes are ischaemic, caused by thrombotic or embolic occlusion of blood vessels. The advent of thrombolysis for acute ischaemic stroke has revolutionised the treatment of acute stroke in the developed world. The benefit of thrombolysis in acute stroke is very time-dependent, with the greatest benefit achieved when administered within 90 minutes of ictus, but trials demonstrating some benefit up to 4.5, and possibly 6 hours. This has revolutionised stroke treatment, with redesign of clinical pathways to try to ensure patients with suspected stroke reach a hospital with a thrombolysis service as quickly as possible. Clinical stroke services need to ensure that all acute stroke patients can be scanned, treated and admitted to stroke units without delay. Future research needs to address the prevention and better management of complications, such as secondary intracerebral haemorrhage and angioedema. In addition, the evidence base for direct intra-arterial intervention such as thrombectomy needs to be established.Stroke
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