פוסט זה זמין גם ב: עברית
Seemant Chaturvedi, MD, reviewing
Thrombolysis was associated with higher rates of brain hemorrhage and deterioration in patients with mild strokes.
The potential role of intravenous thrombolysis (IVT) for patients with acute, mild ischemic strokes is controversial. With recent positive trials of dual antiplatelet therapy for mild stroke, comparative data are welcome. However, recent studies have excluded patients with mild but potentially disabling symptoms, such as aphasia or hemianopia (NEJM JW Neurol Jul 13 2023 and JAMA 2023; 329:2135).
These authors reviewed data from a prospective, nationwide registry in Austria to identify patients with mild stroke, defined as a NIH Stroke Scale (NIHSS) score of 3 or less. Patients with cardioembolic strokes or atrial fibrillation, those treated with antiplatelet monotherapy, and those missing 3-month outcome data were excluded. The authors compared IVT and DAPT for a variety of endpoints, including symptomatic intracerebral hemorrhage (sICH), early neurologic deterioration (END), increase in NIHSS score of 4 or more points, and functional outcome (modified Rankin Scale score) at 3 months.
During the years 2018 through 2021, 1616 patients were identified (mean age, 69 years; 38% women). Patients who received IVT were younger (mean, 68 vs. 71 years), were significantly less likely to have hypertension (73% vs. 84%) or diabetes (19% vs. 29%), and had a higher NIHSS score (median, 2 vs. 1) than those given DAPT. After propensity score adjustment, the rate of sICH was higher in the IVT group (1.4% vs. 0.1%). END was also higher in the IVT group (3.9% vs. 1.2%). The rate of mRS 0–1 outcome at 3 months was similar in the two groups (74.2% vs. 80.4%).
These data are mostly consistent with recent trials that have evaluated IVT for patients with mild, nondisabling strokes. For patients with very low NIHSS scores, as in this study, DAPT is preferred in most cases. For those with disabling deficits such as isolated hemianopia, IVT could be offered with shared decision making.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Sykora M et al. IV thrombolysis vs early dual antiplatelet therapy in patients with mild noncardioembolic ischemic stroke. Neurology 2023 Jul 5; [e-pub]. (https://doi.org/10.1212/WNL.0000000000207538. opens in new tab)