Early recurrent ischemic stroke can complicate thrombolysis

2 September 2010

MedWire News: UK researchers have found that early recurrent ischemic stroke (ERIS) after the use of intravenous recombinant tissue-type plasminogen activator (iv rtPA) may be more common than previously thought.

Their case series showed similar levels of early neurological deterioration after acute stroke treatment, but a higher incidence of ERIS than had been reported previously.

The team says: “Although the incidence of ERIS was low and certainly should not delay thrombolysis in suitable patients, ERIS accounted for a significant proportion of deterioration and was only slightly less frequent than symptomatic intracerebral hemorrhage (SICH).”

Keith Muir (University of Glasgow) and colleagues studied all 228 consecutive acute stroke patients treated with iv rtPA at a single center between January 2006 and December 2008.

In total, 34 (15%) patients developed early neurologic deterioration, defined as a drop of at least 4 points on the National Institutes of Health Stroke Scale within 72 hours.

This was due to SICH in 10 (4.4%) patients, and ERIS in six (2.6%), with 18 (8%) having neither and neurological deterioration therefore attributed to the evolution of the incident stroke.

Five of the six patients with ERIS had documented atrial fibrillation on admission, which was paroxysmal in four and permanent in one.

The single case without atrial fibrillation had a recurrent, contralateral, middle cerebral artery stroke during iv rtPA infusion and multiple high-signal emboli detected by transcranial Doppler.

All six patients with ERIS died between 2 days and 2 weeks after their first stroke. In four patients, deterioration occurred suddenly during or immediately after iv alteplase infusion and in two it occurred 3 days later.

Early recurrent ischemic stroke accounted for five (42%) of 12 cases of early neurologic deterioration in patients with atrial fibrillation.

Reporting in the journal Stroke, the authors conclude: “Awareness of second embolic stroke may allow clinicians to consider interventional treatment approaches in individual cases, which may be justified in the light of a poor prognosis.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Stroke 2010; 41: 1990–1995