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Meenakshi-Sundaram et al.                                                                                                                                    Stroke thrombolysis in a patient on prasugrel

           to be associated with complications, importantly   Ethics approval
           intracerebral hemorrhage . However, many of the    Ethics committee approval was obtained for publishing
                                   [5]
           contraindications  have  proven  to  be  unnecessarily   the case report.
           restrictive  in  real-world  clinical  practice,  and
           patients  have  been  thrombolysed  off-label  with   REFERENCES
           consistent  benefits [4,6] . Our patient had a recent
           myocardial infarction, traditionally considered as a   1.   Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk
           contraindication for intravenous thrombolysis. Since   BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA,
           the preferred  option of  mechanical thrombectomy     Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart
           is available only in a few select centers with such   Association Stroke Council;  Council  on Cardiovascular  Nursing;
           expertise,  we  opted  for  intravenous  thrombolysis   Council  on Peripheral  Vascular  Disease;  Council  on Clinical
                                                                 Cardiology. Guidelines for the  early  management  of patients  with
           which has the inherent risks of myocardial rupture,   acute ischemic stroke: a guideline for healthcare professionals from
           pericardial  hemorrhage  and  cardiac  tamponade.     the American Heart Association/American Stroke Association. Stroke
           Fortunately, these complications are less likely to occur   2013;44:870-947.
           with inferior wall myocardial infarction in contrast to   2.   Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau-Sepulveda MV,
           anterior, and patients have undergone thrombolysis in   Pan  W, Olson DM, Hernandez  AF, Peterson  ED, Schwamm  LH.
           this situation with benefits . Also, we did not consider   Time to treatment with intravenous tissue plasminogen activator and
                                  [7]
           the percutaneous intervention, done 3 days prior, as a   3.   outcome from acute ischemic stroke. JAMA 2013;309:2480-8.
                                                                 Demaerschalk  BM, Kleindorfer  DO,  Adeoye  OM, Demchuk
           specific contraindication for therapy. Traditionally, an   AM, Fugate  JE, Grotta  JC, Khalessi  AA, Levy  EI,  Palesch  YY,
           NIHSS of more than 20 or 25 has been considered       Prabhakaran  S, Saposnik  G, Saver  JL, Smith  EE; American  Heart
           as an exclusionary criterion for administration of    Association  Stroke  Council  and  Council  on  Epidemiology  and
           alteplase.  However  mounting  evidence  has  shown   Prevention.  Scientific  rationale  for  the  inclusion  and  exclusion
           the  benefits  of  intravenous  thrombolysis,  despite   criteria for intravenous alteplase in acute ischemic stroke: a statement
           high NIHSS [1,8] .  The occurrence of stroke while in   for healthcare  professionals from the American  Heart Association/
           the hospital allowed us to institute treatment within   American Stroke Association. Stroke 2016;47:581-641.
           one hour, a factor that could have contributed to the   4.   Fugate JE, Rabinstein AA. Absolute and relative contraindications to
                                                                 IV rt-PA for acute ischemic stroke. Neurohospitalist 2015;5:110-21.
           dramatic recovery in our patient [9,10] . Prior antiplatelet   5.   Lopez-Yunez AM, Bruno A, Williams LS, Yilmaz E, Zurrú C, Biller
           therapy is not considered a contraindication for stroke   J. Protocol violations in community-based rTPA stroke treatment
           thrombolysis.  While  thrombolysis  has  been  reported   are associated with symptomatic  intracerebral  hemorrhage.  Stroke
           in patients on aspirin or clopidogrel or both, this is the   2001;32:12-1.
           first report of thrombolysis in a patient on prasugrel.  6.   Meretoja  A, Putaala  J,  Tatlisumak  T,  Atula  S,  Artto  V, Curtze  S,
                                                                 Häppölä O, Lindsberg PJ, Mustanoja S, Piironen K, Pitkäniemi  J,
           In conclusion, stroke thrombolysis has to be          Rantanen K, Sairanen T, Salonen O, Silvennoinen H, Soinne L, Strbian
           considered  on  a  case-to-case  basis  after  careful   D, Tiainen M, Kaste M. Off-label thrombolysis is not associated with
                                                                 poor outcome in patients with stroke. Stroke 2010;41:1450-8.
           consideration of the risks-to-benefits ratio and must   7.   De Silva  DA, Manzano  JJ, Chang HM, Wong MC. Reconsidering
           be pursued where benefits outweigh the risks.         recent  myocardial  infarction  as a contraindication  for IV stroke
                                                                 thrombolysis. Neurology 2011;76:1838-40.
           DECLARATIONS                                       8.   Sylaja  PN, Dong  W, Grotta JC, Miller  MK,  Tomita  K, Hamilton
                                                                 S, Semba C,  Hill MD. Safety outcomes of Alteplase  among acute
           Authors’ contributions                                ischemic stroke patients with special characteristics. Neurocrit Care
           All the authors were part of  the treating team.  The   9.   2007;6:181-5.
                                                                 Lansberg MG, Schrooten M, Bluhmki E,  Thijs  VN, Saver JL.
           manuscript was prepared by the corresponding author,   Treatment time-specific number needed to treat estimates for tissue
           and later read and acknowledged by all the authors.   plasminogen activator therapy in acute stroke based on shifts over the
                                                                 entire range of the modified rankin scale. Stroke 2009;40:2079-4.
           Financial support and sponsorship                  10.  Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E,
           None.                                                 Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste
                                                                 M, Koga M, von Kummer R, Lansberg M, Lindley RI, Murray G,
           Conflicts of interest                                 Olivot JM,  Parsons M,  Tilley B,  Toni D,  Toyoda K,  Wahlgren N,
           There are no conflicts of interest.                   Wardlaw J,  Whiteley  W, del Zoppo GJ, Baigent  C, Sandercock  P,
                                                                 Hacke  W;  Stroke  Thrombolysis  Trialists’  Collaborative  Group.
           Patient consent                                       Effect of treatment delay, age, and stroke severity on the effects of
                                                                 intravenous thrombolysis with alteplase for acute ischaemic stroke:
           Patient consent was obtained for publishing the case   a meta-analysis of individual patient data from randomised trials.
           report.                                               Lancet 2014;384:1929-35.





            218                                                                 Neuroimmunology and Neuroinflammation ¦ Volume 4 ¦ October 19, 2017
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