renal function and tpa

IV thrombolysis and renal function.

Gensicke H1, Zinkstok SM, Roos YB, Seiffge DJ, Ringleb P, Artto V, Putaala J, Haapaniemi E, Leys D, Bordet R, Michel P, Odier C, Berrouschot J, Arnold M, Heldner MR, Zini A, Bigliardi G, Padjen V, Peters N, Pezzini A, Schindler C, Sarikaya H, Bonati LH, Tatlisumak T, Lyrer PA, Nederkoorn PJ, Engelter ST.

 

Abstract
OBJECTIVE: To investigate the association of renal impairment on functional outcome and complications in stroke patients treated with IV thrombolysis (IVT).

METHODS: In this observational study, we compared the estimated glomerular filtration rate (GFR) with poor 3-month outcome (modified Rankin Scale scores 3-6), death, and symptomatic intracranial hemorrhage (sICH) based on the criteria of the European Cooperative Acute Stroke Study II trial. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Patients without IVT treatment served as a comparison group.

RESULTS: Among 4,780 IVT-treated patients, 1,217 (25.5%) had a low GFR (<60 mL/min/1.73 m(2)). A GFR decrease by 10 mL/min/1.73 m(2) increased the risk of poor outcome (OR [95% CI]): (ORunadjusted 1.20 [1.17-1.24]; ORadjusted 1.05 [1.01-1.09]), death (ORunadjusted 1.33 [1.28-1.38]; ORadjusted 1.18 [1.11-1.249]), and sICH (ORunadjusted 1.15 [1.01-1.22]; ORadjusted 1.11 [1.04-1.20]). Low GFR was independently associated with poor 3-month outcome (ORadjusted 1.32 [1.10-1.58]), death (ORadjusted 1.73 [1.39-2.14]), and sICH (ORadjusted 1.64 [1.21-2.23]) compared with normal GFR (60-120 mL/min/1.73 m(2)). Low GFR (ORadjusted 1.64 [1.21-2.23]) and stroke severity (ORadjusted 1.05 [1.03-1.07]) independently determined sICH. Compared with patients who did not receive IVT, treatment with IVT in patients with low GFR was associated with poor outcome (ORadjusted 1.79 [1.41-2.25]), and with favorable outcome in those with normal GFR (ORadjusted 0.77 [0.63-0.94]).

CONCLUSION: Renal function significantly modified outcome and complication rates in IVT-treated stroke patients. Lower GFR might be a better risk indicator for sICH than age. A decrease of GFR by 10 mL/min/1.73 m(2) seems to have a similar impact on the risk of death or sICH as a 1-point-higher NIH Stroke Scale score measuring stroke severity.

ESCAPE, SWIFT PRIME and EXTEND -1A tirals

ESCAPE trial  (" Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times")

 

120 patients with proximal anterior circulation occlusion were randomized to alteplase v. alteplase + embolectomy.  Study was stopped early due to positive results.  Outcome measure was mrs at 90 days.  The study used CT and CT-A and multiphase CT angiogram. mrs of 0-2 was achieved in 53 % v. 29.2 % (p<0.001).

 

SWIFT PRIME ("Solitaire with the intention for thrombectomy as primary endocascular treatment"). 98 patienrs were randomized in each arm within 4.5 hours to tpa and 6 hours of symptom onset to Solitaire.  Outcome was mrs 0-2 at 90 days 60.2 % with endovascular treatment v. 35.5 % without (p= 0.0002)

 

For every 100 patients treated, 39 would have a better outcome with endovascular than with just tpa, and an additional 25 % would reach functional independence. Study was led by Dr. Saver.  He notes that whether to perform the procedure after six hours is not answered.

 

For MRS of 0, 17 % of patients achieved who got alteplase + procedure v. 8.6 % of alteplase only

For MRS of 1, 25.5 % v. 10.8 % 

For MRS of 2, numbers wwere 17.3 % v. 17.2 %

 

Overall good outcome occurred in 60.1 % of patients with embolectomy v. 35.5 % of patients with T-pa alone.

 

EXTEND 1A: ("Extending the time for thrombolysis in emergency neurological deficits-intraarterial").  35 patients were randomized to tpa alone, 33 to embolectomy but only 27 underwent embolectomy.  37 % of tpa patients achieved early reperfusion v. 100 % of embolectomy patients (p<0.0001).  37 % of patients on tpa achieved early neurological recovery v. 80 % of patients receiving embolectomy (p=0.0002).  They used the Solitaire stent and a 4.5 hour tpa window.  Endovascular was initiated within 210 minutes after onset of stroke.  Study was led by Dr. Bruce Campbell in Austrailia.