Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

Intravenous thrombolysis for acute ischemic stroke in centenarians.

PURPOSE: The benefit of intravenous alteplase is well established for patients with disabling stroke symptoms regardless of age, although data on outcomes in centenarian patients are scarce. We present our experience in patients beyond 100 years. METHODS: Descriptive study including centenarians from our single-centre prospective registry who underwent intravenous thrombolysis with alteplase for acute ischemic stroke in our tertiary university hospital. Clinical variables and functional outcome at 3 months were collected. RESULTS: Four patients, all women, functionally independent (mRS ≤ 2) were included. Treatment with alteplase was applied within 4.5 h of stroke onset. One patient complicated with pneumonia and died. Two patients were functionally independent (mRS ≤ 2) at discharge, while the third was partially dependent (mRS of 3 at discharge), improving after 3 months, (mRS 2). No serious hemorrhagic or systemic adverse events were registered. CONCLUSION: In our experience, intravenous thrombolysis may be beneficial and should be considered in patients over 100 years old with no previous disability.

[Cerebral venous thrombosis: when etiology makes the difference]. / Trombosis venosa cerebral: cuando la etiología marca la diferencia.

OBJECTIVES: To make a retrospective study of the clinical, etiological, diagnostic and prognostic features of cerebral vein and sinus thrombosis (CVST) diagnosed at our University Hospital. METHODS: We performed a systematic research of the clinical records of our University Hospital's electronic database (1977-2009) using the key words <>. RESULTS: Ninety-five possible cases were found, and 16 were excluded due to alternative or uncertain diagnosis. Seventy-nine patients (43 females), median age of 46 years (2-82), were studied. Hereditary or acquired thrombophilia was detected in 22 patients (27.8%): prothrombin G20210A mutation (10), factor V Leyden (3), protein C deficiency (2), homozygous MTHFR C677T mutation (1), antiphospholipid syndrome (7) and hematological conditions (3). CVST was associated with infection in 17 cases, intracranial neoplasm in 9, malignancy in 13, treatment with prothrombotic drugs in 20 (including substitutive/antineoplastic hormones and oral contraceptives) and other causes in 8. Thirteen cases were idiopathic. Clinical presentation was intracranial hypertension in 83.5%, focal deficits in 45.6% and seizures in 12.6 %. Transverse (57%) and superior sagittal sinus (49.4%) were the most commonly involved. Seizures occurred in 25.3%, venous infarction in 41% and severe intracranial hypertension in 22.8 %. Up to 31.6 % required surgical drainage, decompressive craniectomy or ventricular drainage. Nine cases associated peripheral venous thromboembolism and 4 CVST recurred. Evolution was favorable (modified Rankin scale 0-2 at 3 months) in 74.7%. Mortality rate was 13.9% (11 patients). Neoplastic and infectious origin was significantly associated with mortality and disability. CONCLUSION: We describe a large retrospective series of CVST where infectious and neoplastic etiologies were linked to an unfavorable outcome.