Page 218 - Read Online
P. 218
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