Abstract
Background and Purpose
The presence of an intracranial aneurysm is listed as an exclusion criterion for the administration of recombinant tissue-plasminogen activator (rt-PA). This study was designed to test the hypothesis that the administration of rt-PA is safe in patients who have an unruptured intracranial aneurysm.
Methods
We performed a retrospective analysis of all acute ischemic stroke patients treated with rt-PA at our tertiary care academic medical center from June 2006 to June 2010 who also received intracranial vessel imaging. Baseline clinical characteristics were prospectively determined. Identification of hemorrhage and the presence of aneurysm were obtained from radiology report, and neuro-imaging findings were confirmed by study investigators. Symptomatic intracerebral hemorrhage (sICH) was defined according to National Institutes of Neurological Disorders and Stroke criteria.
Results
Five percent of patients (8/172) had at least one intracranial aneurysm on vessel imaging. A total of seven patients (4 %) had sICH. There was no significant difference in intracranial aneurysms between patients with or without sICH [1/7 (14 %) vs. 7/165 (4.2 %), p = 0.29]. In one patient with sICH and an intracranial aneurysm, the location of hemorrhage was distant from the aneurysm. The only predictors found for sICH in our cohort were atrial fibrillation (p = 0.03) and infarct size (p = 0.0004).
Conclusions
Incidental intracranial aneurysms are common in patients who were present with acute ischemic stroke and not associated with sICH in our population. The concern that these patients are at increased risk of hemorrhage after thrombolysis may not be warranted.
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References
The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke. 1997;28:2109–18.
Demchuk AM, Morgenstern LB, Krieger DW, Linda Chi T, Hu W, Wein TH, et al. Serum glucose level and diabetes predict tissue plasminogen activator-related intracerebral hemorrhage in acute ischemic stroke. Stroke. 1999;30:34–9.
Heuschmann PU, Kolominsky-Rabas PL, Roether J, Misselwitz B, Lowitzsch K, Heidrich J, et al. German Stroke Registers Study Group. Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy. JAMA. 2004;20:1831–8.
Tanne D, Kasner SE, Demchuk AM, Koren-Morag N, Hanson S, Grond M, et al. Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the multicenter rt-PA stroke survey. Circulation. 2002;105:1679–85.
Adams H, Adams R, Del Zoppo G, Goldstein LB, Stroke Council of the American Heart Association, American Stroke Association. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the stroke council of the american heart Association/American stroke association. Stroke. 2005;2005(36):916–23.
US Food and Drug Administration. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/ucm080432.htm (2011). Accessed 27 Aug 2011.
Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol. 2011;10:626–36.
Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT. American Heart Association Council on cardiovascular radiology and intervention, stroke council, and the interdisciplinary council on peripheral vascular disease. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke. 2009;40:3646–78.
Sims JR, Gharai LR, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, et al. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104–10.
Wardlaw JM, White PM. The detection and management of unruptured intracranial aneurysms. Brain. 2000;123:205–21.
Wiebers DO, Whisnant JP, Sundt TM Jr, O’Fallon WM. The significance of unruptured intracranial saccular aneurysms. J Neurosurg. 1987;66:23–9.
Wiebers DO, Whisnant JP, Huston J III, Meissner I, Brown RD Jr, Piepgras DG, et al. International study of unruptured intracranial aneurysms investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362:103–10.
Oh YS, Lee SJ, Shon YM, Yang DW, Kim BS, Cho AH. Incidental unruptured intracranial aneurysms in patients with acute ischemic stroke. Cerebrovasc Dis. 2008;26:650–3.
del Zoppo GJ, von Kummer R, Hamann GF. Ischemic damage of brain microvessels: inherent risks for thrombolytic treatment in stroke. J Neurol Neurosurg Psychiatry. 1998;65:1–9.
Kane I, Sandercock P, Thomas B. Can patients with unruptured intracranial aneurysms be treated with thrombolysis? Cerebrovasc Dis. 2005;20:51–2.
Sloan MA, Price TR, Petito CK, Randall AM, Solomon RE, Terrin ML, et al. Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: the thrombolysis in myocardial infarction (TIMI) II pilot and randomized clinical trial combined experience. Neurology. 1995;45:649–58.
Ogawa A, Mori E, Minematsu K, Taki W, Takahashi A, Nemoto S, et al. MELT Japan Study Group. Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic intervention trial (MELT). Stroke. 2007;38:2633–9.
Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant tissue-type plasminogen activator (alteplase) for ischemic stroke 3 to 5 hours after symptom onset. the ATLANTIS study: a randomized controlled trial. alteplase thrombolysis for acute noninterventional therapy in ischemic stroke. JAMA. 1999;282:2019–26.
Edwards NJ, Kamel H, Josephson SA. The safety of intravenous thrombolysis for ischemic stroke in patients with pre-existing cerebral aneurysms: a case series and review of the literature. Stroke. 2012;43:412–6.
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Sheth, K.N., Shah, N., Morovati, T. et al. Intravenous rt-PA is not Associated with Increased Risk of Hemorrhage in Patients with Intracranial Aneurysms. Neurocrit Care 17, 199–203 (2012). https://doi.org/10.1007/s12028-012-9734-9
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DOI: https://doi.org/10.1007/s12028-012-9734-9