Thrombolytic Treatment in Wake-Up Stroke: A Propensity Score-Matched Analysis of Treatment Effectiveness in the Norwegian Stroke Registry.

BACKGROUND: Previous clinical trials found improved outcome of thrombolytic treatment in patients with ischemic wake-up stroke (WUS) selected by advanced imaging techniques. The authors assessed the effectiveness of thrombolytic treatment in patients with WUS in a nationwide stroke registry. METHODS AND RESULTS: Using propensity score matching, the authors assessed the effectiveness and safety of thrombolytic treatment versus no thrombolytic treatment in 726 patients (363 matched pairs) with WUS in the Norwegian Stroke Registry in 2014 to 2019. Thrombolytic treatment in WUS versus known-onset stroke was compared in 730 patients (365 matched pairs). Functional outcomes were assessed by the modified Rankin Scale (mRS) at 3 months. A significant benefit of thrombolytic treatment in WUS was seen in ordinal analysis (odds ratio [OR], 1.48 [95% CI, 1.15-1.91]; P=0.003) and for mRS 0 to 2 (OR, 1.81 [95% CI, 1.29-2.52]; P=0.001) but not for mRS 0 or 1 (OR, 1.32 [95% CI, 1.00-1.74]; P=0.050). The proportion of patients with mRS 0 or 1 was lower in patients with WUS who underwent thrombolysis versus those with known-onset stroke (50.4% versus 59.5%; OR, 0.69 [95% CI, 0.52-0.93]; P=0.013), while outcomes were similar between groups for mRS 0 to 2 and ordinal analysis. Symptomatic intracranial hemorrhage after thrombolytic treatment occurred in 4.4% of patients with WUS and 3.9% of patients with known-onset stroke (OR, 1.14 [95% CI, 0.54-2.41]; P=0.726). CONCLUSIONS: Thrombolytic treatment in patients with WUS was associated with improved functional outcome compared with patients with no thrombolytic treatment and was not associated with increased rates of symptomatic intracranial hemorrhage compared with known-onset stroke. The results indicate that thrombolytic treatment is effective and safe in WUS in a real-life setting.

High average daily temperature in summer and the incidence of thrombolytic treatment for acute ischemic stroke.

INTRODUCTION: Meteorological factors can increase stroke risk; however, their impact is not precisely understood. Heat waves during summer increase total mortality. Therefore, we hypothesized that the average daily temperature in summer may correlate with the incidence of thrombolytic treatment for acute ischemic stroke in Budapest and Pest County, Hungary. METHODS: We analyzed the relationship between the average daily temperature in summer months and the daily number of thrombolytic treatments (TT) performed with the indication of acute ischemic stroke between 1st June and 31st August each year from 2007 to 2016. The analysis was also performed after the omission of the data of the last day of the months due to possible psychosocial impact reported in our previous study. Spearman's correlation was used for statistical analysis. RESULTS: No significant correlation was found between the average summer daily temperature and the number of TT in the entire sample of the 10-year period. When omitting the data of the last day of each month, positive correlations were suspected in 2014 (r=0.225, P=0.034) and 2015 (r=0.276, P=0.009). CONCLUSION: Our findings did not confirm an association between the average daily temperature in summer and the daily number of TT throughout the examined 10-year period. However, importantly, in 2014 and 2015, the years with the highest average daily temperatures in this period, a positive correlation was found. The level of correlation is modest, indicating that risk factors, both meteorological and non-meteorological, other than the average temperature, play equally important roles in determining the incidence of thrombolytic treatment for acute ischemic stroke on the population level.

Caracterización clinicoepidemiológica, ecocardiográfica y terapéutica de pacientes con infarto agudo de miocardio / Clinical, epidemiological, echocardiographic and therapeutic characterization of patients with acute myocardial infarction i: en

Introducción: Aunque la incidencia general de infarto agudo de miocardio ha disminuido en muchos países desarrollados en las últimas décadas, aún genera números elevados de morbilidad y mortalidad en los de bajos ingresos; mostrando cifras mayores en tiempos de la pandemia por coronavirus. Objetivo: Caracterizar a pacientes con diagnóstico de infarto agudo de miocardio según variables clinicoepidemiológicas, ecocardiográficas y terapéuticas. Métodos: Se realizó una investigación descriptiva y retrospectiva, desde enero de 2018 hasta noviembre de 2022, de 263 pacientes con diagnóstico de infarto agudo de miocardio, atendidos en el Centro de Cardiología y Cirugía Cardiovascular de Santiago de Cuba. Entre las variables analizadas figuraron la edad, el sexo, la topografía del infarto, las complicaciones, las alteraciones ecocardiográficas y el tratamiento trombolítico. Resultados: En la serie predominaron el sexo masculino y el grupo etario menor o igual de 65 años. Se observó una mayor frecuencia del infarto en la topografía inferior (177, para 67,3 %); de estos afectados, 52,1 % tuvo complicaciones. Asimismo, la complicación de mayor frecuencia fue la fibrilación auricular paroxística, seguida del infarto de ventrículo derecho; mientras que la fracción de eyección menor de 45 %, el volumen de la aurícula izquierda y la motilidad parietal presentaron significación estadística. Conclusiones: Las características clinicoepidemiológicas, ecocardiográficas y terapéuticas de los pacientes con infarto agudo de miocardio en la provincia de Santiago de Cuba no difieren del contexto epidemiológico mundial.

Introduction: Although the general incidence of acute myocardial infarction has diminished in many developed countries in the last decades, it still generates high numbers of morbidity and mortality in those with low income; showing higher figures in times of coronavirus. Objective: To characterize patients with diagnosis of acute myocardial infarction according to clinical, epidemiological, echocardiographic and therapeutic variables. Methods: A descriptive and retrospective investigation was carried out from January, 2018 to November, 2022, of 835 patients with diagnosis of acute myocardial infarction, assisted in the Cardiology and Cardiovascular Surgery Center of Santiago de Cuba. Among the analyzed variables there were age, sex, topography of infarction, complications, echocardiographic disorders and thrombolytic treatment. Results: In the series there was a prevalence of the male sex and the 65 or less age group. A higher frequency of infarction in the lower topography (177, for 67.3 %) was observed; of these patients, 52.9 % had complications. Also, the complication of more frequency was the paroxysmal atrial fibrillation, followed by the infarction of the right ventricle; while the ejection fraction smaller than 45 %, the volume of the left auricle and the parietal motility presented statistical significance. Conclusions: Clinical, epidemiological, echocardiographic and therapeutic characteristics of patients with acute myocardial infarction in Santiago de Cuba province do not differ from the world epidemiological context.

Factors Influencing Early Hospital Arrival of Patients with Acute Ischemic Stroke, Cross-Sectional Study at Teaching Hospital in Mogadishu Somalia.

Background and Purpose: The low rates of thrombolysis for ischemic stroke in our country and other developing countries can be attributed to delays in arrival at the hospital. This study aims to investigate the factors that influence the early hospital arrival of patients with acute ischemic stroke to the hospital in Mogadishu, Somalia. Methods: This is a cross-sectional study conducted at a teaching hospital in Mogadishu, Somalia. Adult patients with acute ischemic stroke admitted to the emergency department (ED) between June 2021 and May 2022 were included in the study. A questionnaire-based interview was administered to adult patients or their relatives to assess the factors contributing to hospital delay. Results: Of the 212 patients in the study, 113 (53.3%) were male, while 99 (46.7%) were female. The mean age of the patients was 62±10. Hypertension was the most common risk factor among patients 121 (57%), followed by diabetes and hyperlipidemia. One hundred and forty (66%) patients lived in the city, while 72 (34%) lived outside of the city. About 53 (25%) of the patients were brought to the ED by ambulance, and only 32 (15%) reached the hospital in less than 4 hours. The majority of patients had no idea about stroke symptoms and thrombolytic treatment. In univariate and binary logistic regression analysis, delays in hospital arrivals were associated with a travel distance of more than 10 km, transportation via non-ambulance means, living alone, lack of recognition of stroke symptoms, night-time stroke onset, lack of knowledge about thrombolytic treatment, and non-hemiplegic presentation. Conclusion: This study demonstrates factors delaying early hospital arrivals of patients with ischemic stroke. Improving the modifiable factors through public education will prevent delays in the early hospital arrival of stroke patients and will improve early thrombolytic intervention and the overall outcome of these patients.

Dual thrombolytic therapy with mutant pro-urokinase and small bolus alteplase for ischemic stroke (DUMAS): study protocol for a multicenter randomized controlled phase II trial.

BACKGROUND: The effectiveness of alteplase for ischemic stroke treatment is limited, partly due to the occurrence of intracranial and extracranial hemorrhage. Mutant pro-urokinase (m-proUK) does not deplete fibrinogen and lyses fibrin only after induction with alteplase. Therefore, this treatment has the potential to be safer and more efficacious than treatment with alteplase alone. The aim of this study is to assess the safety and efficacy of thrombolytic treatment consisting of a small bolus alteplase followed by m-proUK compared with standard thrombolytic treatment with alteplase in patients presenting with ischemic stroke. METHODS: DUMAS is a multicenter, phase II trial with a prospective randomized open-label blinded end-point (PROBE) design, and an adaptive design for dose optimization. Patients with ischemic stroke, who meet the criteria for treatment with intravenous (IV) alteplase can be included. Patients eligible for endovascular thrombectomy are excluded. Patients are randomly assigned (1:1) to receive a bolus of IV alteplase (5mg) followed by a continuous IV infusion of m-proUK (40 mg/h during 60 min) or usual care with alteplase (0.9 mg/kg). Depending on the results of interim analyses, the dose of m-proUK may be revised to a lower dose (30 mg/h during 60 min) or a higher dose (50 mg/h during 60 min). We aim to include 200 patients with a final diagnosis of ischemic stroke. The primary outcome is any post-intervention intracranial hemorrhage (ICH) on neuroimaging at 24 h according to the Heidelberg Bleeding Classification, analyzed with binary logistic regression. Efficacy outcomes include stroke severity measured with the National Institutes of Health Stroke Scale (NIHSS) at 24 h and 5-7 days, score on the modified Rankin scale (mRS) assessed at 30 days, change (pre-treatment vs. post-treatment) in abnormal perfusion volume, and blood biomarkers of thrombolysis at 24 h. Secondary safety endpoints include symptomatic intracranial hemorrhage, death, and major extracranial hemorrhage. This trial will use a deferred consent procedure. DISCUSSION: When dual thrombolytic therapy with a small bolus alteplase and m-proUK shows the anticipated effect on the outcome, this will lead to a 13% absolute reduction in the occurrence of ICH in patients with ischemic stroke. TRIAL REGISTRATION: NL7409 (November 26, 2018)/NCT04256473 (February 5, 2020).

Intravenous Thrombolysis for Acute Ischemic Stroke during the COVID-19 Pandemic-Polish Single-Center Retrospective Cohort Study.

COVID-19 has affected the entire world and has had a great impact on healthcare, influencing the treatment of patients with acute ischemic stroke (AIS). The aim of this study was to determine the impact of the COVID-19 pandemic on the care of patients with AIS. We performed a retrospective analysis of 1599 patients diagnosed with AIS and hospitalized in the authors' institution from January 2018 to December 2021. The final sample consisted of 265 patients treated with thrombolysis without a diagnosis of COVID-19. The initiation of thrombolytic treatment during the pandemic was delayed (2:42 ± 0:51 vs. 2:25 ± 0:53; p = 0.0006). The delay was mainly related to the pre-hospital phase (1:41 ± 0:48 vs. 1:26 ± 0:49; p = 0.0014), and the door-to-needle time was not affected. There were no differences in stroke severity and patients' outcomes. Patients with AIS were less likely to have previously been diagnosed with atrial fibrillation (16.9% vs. 26.7%; p = 0.0383), ischemic heart disease (25.3% vs. 46.5%; p = 0.0003) and hyperlipidemia (31.2% vs. 46.5%; p = 0.0264). Patients treated during the pandemic had higher glycemia (149.45 ± 54. vs. 143.25 ± 60.71 mg/dL; p= 0.0012), while no significant differences in their lipid profiles were found. Conclusions: The COVID-19 pandemic affected the treatment of AIS patients locally at our stroke center. It caused treatment delay and hindered the recognition of risk factors prior to the occurrence of AIS.

Comparison of tenecteplase versus alteplase in STEMI patients treated with ticagrelor: A cross-sectional study.

BACKGROUND: The effectiveness and safety of administration of ticagrelor simultaneously with fibrinolytic agents in STEMI patients remain unclear. OBJECTIVE: This study aimed to investigate the effectiveness and safety of tenecteplase against alteplase in patients with STEMI receiving a loading dose of ticagrelor. METHODS: We conducted a cross-sectional study in patients with STEMI who were reperfused with fibrinolytic. The study included 150 patients (ages 18 to 75 years) administered tenecteplase or alteplase and concomitantly given ticagrelor [180 mg loading dose, 90 mg bid (bis in die)]. Patients who had active major bleeding, died, and who were decided to have a CABG surgery as a result of coronary angiography were excluded. Patients who underwent facilitated-PCI with fibrinolysis continued to receive ticagrelor without switching to clopidogrel. The MACE (in-hospital death, TIMI flow grade, major bleeding) rates of the two groups were compared. RESULTS: The study consisted of 150 patients, comprising 99 (66%) men and 51 women (34%) with a mean age of 60,33 ± 13,83 years. Patients were divided into two groups according to the thrombolytic therapy: alteplase (n = 60) and tenecteplase (n = 90). The major adverse cardiac events (MACE) (45% vs 22.2%), bleeding (11.7% vs 2.2%), hypertension (51.7% vs 30%), atrial fibrillation (26.7% vs 12.2%), left ventricular hypertrophy (26.7% vs 10%), CRP (p < 0.001) were significantly higher and the recanalization (66.7% vs 85.4%), hematocrit (p = 0.03) were significantly lower in the alteplase group compared to the tenecteplase group. No significant differences were found between the two groups about in-hospital mortality (p = 0.151). Kaplan Meier analysis was performed in terms of MACE (TIMI flow grade 1, major bleeding, in-hospital mortality) rates during the follow-up period (Log-rank test, p = 0.032). Patients who received tenecteplase treatment had a lower MACE, according to a Kaplan-Meier analysis. CONCLUSIONS: The administration of tenecteplase in STEMI patients who received a loading dose with ticagrelor resulted in a significant reduction in MACE compared to alteplase. Larger multi-center studies are warranted to investigate the effect of tenecteplase treatment on clinical results.

Cerebral edema in acute stroke: Effect of thrombolytic treatment.

Cerebral edema (CED) is a common complication of ischemic stroke in Intensive Care Unit. Although frequently observed in patients undergoing intravenous thrombolytic (IVT) treatment, the pathogenic role of recombinant tissue plasminogen activator (rtPA) in CED induction has not yet been definitively clarified. The aim of our study is to verify the relationship between CED and rtPA in patients affected by acute ischemic stroke, without reperfusion signs, evaluating the CED growth rate in the first week after stroke onset. In this single-center, retrospective observational study, we included all consecutive patients with acute stroke undergone multi-parameter monitoring of vital signs in the sub-intensive care Unit. We included both patients undergoing systemic IVT and standard medical treatment (n-IVT) with the following time of CT scan: within 4.5 h onset, 24 ± 12 h, 72 ± 24 h and 120 ± 24 h from the stroke onset. Of 1753 with acute ischemic stroke patients screened, 810 patients were included in the study (218 IVT and 592 n-IVT). No significant difference was observed at baseline in age, gender, NIHSS score or infarcted area, while hemorrhagic transformation rate was significantly higher in IVT than in n-IVT group. We observed a significant increase of CED growth rate in IVT patients compared to n-IVT patients only between 24 and 72 h from the ischemic event (respectively 1.85cm3/h and 0.89cm3/h; p = 0.031) regardless of the presence of HT. No significant difference was observed in growth rate between 3 and 5 days following rtPA administration or in overall growth rate. Although the pathogenetic mechanism of rtPA determining CED remains uncertain, our data suggests rtPA can act as a "trigger" of edema onset and progression. Therefore, drugs interfering with specific molecular pathways, such as kallikrein-kinin cascade, could constitute an effective strategy to reduce the risk of development and progression of rtPA-related cerebral edema in patients with acute stroke. Further studies are needed to define the molecular pathways involved in the genesis of CE in humans and to verify the efficacy of specific drugs.

Imaging for Predicting Hemorrhagic Transformation of Acute Ischemic Stroke-A Narrative Review.

Hemorrhagic transformation is caused by extravasation of blood products from vessels after acute ischemic stroke. It is an undesirable and potentially devastating complication, which occurs in 10%-40% of clinical cases. Hemorrhagic transformation is classified into four subtypes based on European cooperative acute stroke study II. Predicting hemorrhagic complications at presentation can be useful life saving/altering decisions for the patient. Also, understanding the mechanisms of hemorrhagic transformation can lead to new treatments and intervention measures. We highlighted various imaging techniques that have been used to predict hemorrhagic transformation. Specifically, we looked at the usefulness of perfusion and permeability imaging for hemorrhagic transformation. Use of imaging to predict hemorrhagic transformation could change patient management that may lead to the prevention of hemorrhagic transformation before it occurs. We concluded that the current evidence is not strong enough to rely on these imaging parameters for predicting hemorrhagic transformation and more studies are required.

Dual-Targeting Glycol Chitosan/Heparin-Decorated Polypyrrole Nanoparticle for Augmented Photothermal Thrombolytic Therapy.

Near-infrared (NIR)-light-modulated photothermal thrombolysis has been investigated to overcome the hemorrhage danger posed by clinical clot-busting substances. A long-standing issue in thrombosis fibrinolytics is the lack of lesion-specific therapy, which should not be ignored. Herein, a novel thrombolysis therapy using photothermal disintegration of a fibrin clot was explored through dual-targeting glycol chitosan/heparin-decorated polypyrrole nanoparticles (GCS-PPY-H NPs) to enhance thrombus delivery and thrombolytic therapeutic efficacy. GCS-PPY-H NPs can target acidic/P-selectin high-expression inflammatory endothelial cells/thrombus sites for initiating lesion-site-specific thrombolysis by hyperthermia using NIR irradiation. A significant fibrin clot-clearance rate was achieved with thrombolysis using dual-targeting/modality photothermal clot disintegration in vivo. The molecular level mechanisms of the developed nanoformulations and interface properties were determined using multiple surface specific analytical techniques, such as particle size distribution, zeta potential, electron microscopy, Fourier-transform infrared spectroscopy (FTIR), wavelength absorbance, photothermal, immunofluorescence, and histology. Owing to the augmented thrombus delivery of GCS-PPY-H NPs and swift treatment time, dual-targeting photothermal clot disintegration as a systematic treatment using GCS-PPY-H NPs can be effectively applied in thrombolysis. This novel approach possesses a promising future for thrombolytic treatment.

Additional factors to corelate with a more than 30% NIHSS score improvement in patients 7 days after fibrinolytic and/or endovascular treatment for ischemic stroke.

BACKGROUND: Our objective was to find which additional factors can influence the favorable result in stroke patients after receiving fibrinolytic and/or endovascular treatment, quantified as a more than 30% improvement of the NIHSS score at 7 days. METHODS: This is a retrospective study to find factors that could influence a favorable evolution of patients with stroke that underwent fibrinolytic and or thrombectomy using the NIHSS score changes. At the admission in the hospital, blood glucose, blood count, coagulation time, INR, aPTT, PT, platelet count, NIHSS questionnaire and ASPECTS score were collected. NIHSS was assessed at the admission, after 1 h, after 2 h, after 24 h and after 7 days. RESULTS: As compared to the initial evaluation, at 7 days after admission 59% (72) of patients have improved with more than 30% the NIHSS. Higher levels of systolic blood pressure, glycemia and lower ASPECTS score at admission were observed in non-achievers. The value of INR contributed to model: for every unit increase of INR, the chance of better outcome decreases by 90,1%. High glycemia has also a negative impact: for every unit increase, the chance of better outcome decreases by 24%. Higher initial ASPECTS score is associated with better outcomes: each point increase of ASPECTS score at initial evaluation, increases the chance of better outcome by 154.2%. CONCLUSION: Males, older age, diabetes, and hyperglycemia correlate with a worse outcome after cerebral stroke regardless of the benefit yielded fibrinolytic and/or thrombectomy therapy. In this study, patients with the above-mentioned factors did not improve more than 30% of baseline NIHSS score from admission to the 7th day.

Thrombolytic treatment of prosthetic valve thrombosis: a study using Urokinase.

OBJECTIVE: We analysed the efficacy and safety of thrombolytic therapy with urokinase in patients with prosthetic valve thrombosis. METHODS: Twenty-three patients with valve thrombosis received thrombolytic treatment using urokinase. First, a 250,000 IU intravenous bolus injection was administered as a loading dose, followed by intravenous infusion of 100,000 IU/h for 10 h and anticoagulation with low molecular weight heparin every day. The maximum treatment time was 5 days, i.e., until the transvalvular pressure gradient was normal or close to normal. Transthoracic echocardiography (TTE) was used every 12 h to monitor whether the thrombus was reduced and whether there was haemodynamic improvement. Routine blood tests, the prothrombin time (PT), international normalized ratio (INR) and complications were observed every day. RESULTS: Sixteen (69.6%) patients were successfully treated with thrombolytic therapy: 2/2 (100%) aortic valves and 14/21 (66.7%) mitral valves. The partial success rate of this study was 13.0% (3/23). Four patients did not show any improvement in haemodynamics. Two cases had slight urine haemorrhage. One patient died of severe cerebral haemorrhage and shock. The overall mortality was 13.0% (3/23), including two patients who died after subsequent surgery. CONCLUSION: Urokinase is more convenient and successful in the treatment of PVT. More experience may make TT the optimal treatment for PVT, especially in high-risk surgical situations.

Diffuse alveolar hemorrhage following intravenous thrombolytic treatment in acute ischemic stroke: a case series.

Diffuse alveolar hemorrhage (DAH) following fibrinolytic therapy is a rare but a life-threatening complication. In acute ischemic stroke (AIS), DAH as a complication was not reported following intravenous thrombolytic therapy (ITT). The demographic, clinical, radiologic, and prognostic data of 4 patients with AIS who developed DAH after ITT are presented in this case series, along with a literature review.

Comparison of urokinase and reteplase thrombolytic treatment in patients with high-risk pulmonary embolism.

Thrombolytic treatment is recommended for patients with high-risk pulmonary embolism. The present study compared thrombolytic therapy with urokinase and reteplase. A total of 37 patients presenting with acute high-risk pulmonary embolism at the Intensive Care Unit of Weinan Central Hospital of Shaanxi Province (Weinan, China) between June 2013 and January 2017 were retrospectively analyzed. According to their treatment, these subjects were assigned to the reteplase group (n=16) or the urokinase group (n=21). Systolic blood pressure (SBP), heart rate (HR) and respiratory rate (RR) were recorded prior to, and at 2, 4, 24 and 48 h after thrombolytic therapy. Complications, including bleeding, were closely monitored. Changes in blood gas analysis, troponin-T (TNT), pro-B-type natriuretic peptide (pro-BNP) and D-dimer (D-D) were observed. In the reteplase and urokinase group, 11 and 13 cases exhibited marked improvement, treatment was rated as effective in 4 and 6 cases, and 1 and 2 mortalities occurred, resulting in an overall effective rate of 93.8 and 90.5%, respectively (P>0.05). In the reteplase group, one patient was unsuccessfully resuscitated and died. In the urokinase group, one patient died of gastric hemorrhage after 22 h of thrombolysis, while another patient died of brain failure resuscitation. The treatment improved the SBP in each of the two groups (P<0.05), and this outcome was similar between these two groups (P>0.05). HR and RR were similar prior to and after thrombolytic therapy (P>0.05). In contrast to the urokinase group, TNT was significantly decreased after thrombolyis compared with the baseline in the reteplase group. Complications in the reteplase group were higher, but in contrast to the urokinase group, no life-threatening bleeding occurred. Although reteplase is as effective as urokinase in treating high-risk pulmonary embolism, reteplase may reduce myocardial damage.

CT-guided thrombolytic treatment of patients with wake-up strokes.

BACKGROUND: Observational studies of thrombolysis outcomes in wake-up acute ischemic stroke patients selected based on non-contrast brain CT criteria suggested that treated patients did as well as or better than those not treated, after adjustment for baseline characteristics. We began offering thrombolytic treatment (IVTPA) to patients presenting with wake-up strokes and normal non-contrast brain CTs, who could be treated within 4.5 h of being found. DESIGN/METHODS: A retrospective chart review was performed in patients presenting with AIS between November 2014 and December 2017 who received IVTPA. A planned subgroup analysis compared patients with wake-up strokes and normal non-contrast brain CTs to patients with witnessed stroke treated within 4.5 h of being found, or of witnessed onset, respectively. RESULTS: Three hundred and six patients were treated, 279 with witnessed-onset and 27 with wake-up strokes. The latter were not candidates for endovascular intervention. Efficacy and safety were similar in both groups. Discharges home, respectively, were 143(53%) and 13(48%); facility discharges were 112(40.1%) and 11(40.7%) and in-hospital mortality was 19 (6.8%) and 3 (11%). Treatment-related symptomatic bleeds were: 5(1.8%) and 1 (3.7%), respectively. CONCLUSIONS: The findings affirm, in a new clinical series reflecting routine practice, that it is safe to treat with IVTPA patients with wake-up strokes and a normal brain CT scan, who are not candidates for endovascular intervention. We hypothesize, that when the non-contrast brain CT scan is normal, it may be safe to extend beyond 4.5 h the IVTPA treatment eligibility window in similar patients with witnessed-onset stroke.

Successful treatment of massive thrombosis in different locations with prolonged thrombolytic therapy: A life-saving intervention.

Venous thrombosis is recognized as one of the most important complications of nephrotic syndrome (NS). In patients with NS, venous thrombosis may develop in the renal veins, the deep veins of the lower limb, and the inferior vena cava. Here, we describe a case report of an NS patient with multiple venous thrombosis in the right renal vein, the left iliac vein, the vena cava inferior, the right atrium, and the pulmonary arteries. Moreover, we describe the successful treatment of multiple venous thrombosis with prolonged thrombolytic treatment in spite of an increased risk of bleeding due to renal biopsy.

Assessment of the Efficiency of Stroke Awareness Campaigns in Hungary.

BACKGROUND: The critical period of stroke management lies between the disease onset and the time of the emergency call, relying on stroke-related knowledge of the population. Public campaigns play a role in spreading relevant health information. Due to the substantial expenses of these campaigns, the assessment of their efficiency is reasonable. METHODS: We assessed the number of thrombolytic treatments performed in Hungary, subjected to national media coverage and in particular in Budapest, being the location of the Stroke Day campaign, in the period between 2008 and 2015. We compared the change in the daily mean number of thrombolytic treatments performed during the preceding and following day, week, and month. Data were also compared with annual means. RESULTS: No meaningful changes can be seen in the number of thrombolytic treatments on the days immediately following Stroke Days, and casual differences can be seen in the following week. The comparison of the numbers of thrombolytic treatments performed in the postcampaign months with the monthly means in the corresponding years revealed a positive effect in each year except for 2012, 2014, and 2015. Regarding the whole examined period, however, the effect is not statistically significant, neither for data obtained from Hungary nor from Budapest. CONCLUSIONS: Better outcomes were observed 1 month after a campaign than more immediately. This can be partly explained by ongoing media coverage in a given period rather than exposure of the public on a single Stroke Day.

Acute massive pulmonary embolism associated with olanzapine.

Treatment with low-potency anti-psychotic agents is an important risk factor in the development of pulmonary embolism (PE). We report a case of 74years old female patient receiving olanzapine for psychotic depression admitted to the emergency service with the complaints of chest pain and shortness of breath. She had tachypnea, hypotension and tachycardia. Arterial blood gas analysis showed hypoxemia-hypocapnia and D-dimer level was high. Computed tomographic pulmonary angiography (CTPA) demonstrated pulmonary embolism in both main pulmonary arteries, through lobar and segmental branches. Tissue plasminogen activator (t-PA) was administered in intensive care unit. As the only possible risk factor for PE was olanzapine, olanzapine treatment was terminated with pyschiatry consultation. During the 12-month follow-up of the patient; malignancy was not observed. Diagnosis and prevention of PE are the important goals to reduce morbidity and mortality in subjects receiving olanzapine.

Thrombolytic treatment in a patient with antiphospholipid syndrome : APS developing renal infarction.

Antiphospholipid syndrome (APS), a leading entity in acquired thrombophilia, is characterized by recurrent thrombosis, morbidity in pregnancy and presence of antiphospholipid antibodies (APA). Although the etiopathogenesis is unclear, APA against negatively charged phospholipids and phospholipid-protein complexes are held responsible for the clinical picture. In case of acute thrombosis due to APS, thrombolytic therapy is not a commonly administered treatment option. Here, we present a case with acute thrombosis in the left renal artery showing partial response to thrombolytic therapy.

Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis.

The treatment options for high risk acute pulmonary embolism (PE) patients with failed systemic thrombolytic treatment (STT) is limited. The clinical use of catheter directed thrombolysis with the EkoSonic Endovascular System (EKOS) in this population has not been evaluated before. Catheter directed thrombolysis is an effective treatment modality for high risk PE patients with failed STT. Thirteen consecutive patients with failed STT were included in the study. EKOS catheters were placed and tissue plasminogen activator (t-PA) in combination with unfractionated heparin were given. Clinical and echocardiographic properties of the patients were collected before EKOS, at the end of EKOS and during the follow-up visit 6 months after discharge. The duration of EKOS treatment was 21.8 ± 3.8 h and the total dose of tPA was 31.2 ± 15.3 mg. One patient who presented with cardiac arrest died and the clinical status of the remaining subjects improved significantly. Any hemorrhagic complication was not observed. EKOS resulted in significant improvement of right ventricular functions and decrease of systolic pulmonary artery pressure. During a follow-up period of 6 months none of the patients died or suffered recurrent PE. In addition, echocardiographic parameters or right ventricular function significantly got better compared to in-hospital measurements. EKOS is an effective treatment modality for high risk PE patients with failed STT and can be applied with very low hemorrhagic complications.