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Population Health and Systems of Neurological Care
Published in Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw, Hankey's Clinical Neurology, 2020
Philip B. Gorelick, Jong S. Kim, Hee-Joon Bae
In the United States, organized stroke systems of care are established around a stroke center for the diagnosis of acute stroke and the delivery of intravenous alteplase (tissue plasminogen activator [tPA]). A major goal has been to deliver alteplase as soon as possible as more timely administration of alteplase has been associated with better functional outcomes and lower mortality. The stroke center has been organized to include such components as a team to meet the patient in the emergency department to initiate diagnostic processes, care pathways for treatment, time awareness (“time is brain” adage) to allow provision of treatment as soon as possible, proper diagnosis followed by proper acute and recurrent stroke preventatives, a stroke unit, and other aspects. Over time, with the advent of new treatments such as stroke stent retrievers and aspiration devices for treatment of acute ischemic stroke and perfusion diagnostic software, stroke center certification programs have surfaced and stroke centers are designated based on the complexity of care that can be provided: Acute Stroke Ready HospitalPrimary Stroke Center (PSC)Comprehensive Stroke CenterThrombectomy-Capable Stroke Center
General Medical Emergencies
Published in Anthony FT Brown, Michael D Cadogan, Emergency Medicine, 2020
Anthony FT Brown, Michael D Cadogan
Refer the patient to the medical team or stroke unit for admission and definitive management. Give aspirin 300 mg orally daily or via NGT within 48 h, once CT scan has excluded haemorrhage, unless thrombolysis is used (withold for 24 h).Select patients suitable for thrombolysis if symptom onset is less than 4.5 h, there is a measurable and clinically significant deficit on NIH Stroke Scale examination, CT scan excludes haemorrhage or non-vascular cause, and age is over 18 years: NIH Stroke Scale is a 15-item neurologic examination to evaluate and document neurological status, determine appropriate treatment and predict patient outcome.Get senior ED doctor help and carefully follow local thrombolysis guidelines such as ‘Code Stroke’.Give alteplase 0.9 mg/kg up to 90 mg i.v. over 1 h, with 10% as an initial bolus, having excluded absolute contraindications (see Table 2.12) and considered relative contraindications.
The science of biotechnology
Published in Ronald P. Evens, Biotechnology, 2020
Protein manipulation for enzyme proteins can serve as a good example of several possible different manipulations and new products. Alteplase is an enzyme protein used for thrombolysis and to prevent death in acute myocardial infarction related to preventing clot formation. The protein is fairly complex with 527 amino acids, 14 disulfide bridges, glycosylation at 3 amino acid sites, and 5 peptide domains, as demonstrated with rectangles in Figure 5.2.
Analysis of risk factors for the efficacy of tirofiban in the treatment of acute ischemic stroke
Published in Neurological Research, 2023
Chong Liu, Lu Yin, Yinqin Hu, Zhizhen Shi, Qiaoyan Zhu, Qian Xiao, Guoyi Li, Jiwei Cheng, Yangbo Hou
Acute ischemic stroke, also known as acute cerebral infarction (ACI), is one of the most common diseases in neurology. ACI is characterized by high morbidity, disability and mortality, and poses a serious threat to human health [1]. The main purpose of treating acute ischemic stroke is to restore the blood perfusion of patients with cerebral infarction timely to rescue the ischemic penumbra. At present, intravenous thrombolysis is considered to be an effective method for treating acute ischemic stroke in the hyperacute stage, but the strict treatment time window and numerous contraindications limit the clinical application of this technique. Clinically, only a small number of patients are candidates for treatment with alteplase [2]. Patients in the acute stage of ischemic stroke are prone to neurological deterioration, resulting in irreversible damage. Therefore, finding safe and effective drug treatment is the most important step in improving the prognosis of acute ischemic stroke.
Endovascular treatment for ischemic stroke patients with and without atrial fibrillation, and the effects of adjunctive pharmacotherapy: a narrative review
Published in Expert Opinion on Pharmacotherapy, 2023
Muath Alobaida, Gregory Y H Lip, Deirdre A Lane, Dimitrios Sagris, Andrew Hill, Stephanie L Harrison
Although, alteplase remains the standard-of-care in IVT, tenecteplase may be a safe and effective alternative in patients undergoing both IVT and EVT[13]. One small randomized controlled trial including 202 patients with anterior and basilar ischemic stroke eligible for EVT showed higher recanalization rate, borderline association with better functional outcomes, and similar proportions of sICH in patient treated tenecteplase compared to alteplase[19]. Further, pooled subgroup analysis of two randomized controlled trials demonstrated higher rates of recanalization and functional outcomes in patient treated with tenecteplase compared to alteplase[20]. Accordingly, a meta-analysis of post-hoc pooled subgroup analysis of randomized controlled trials based on non-clinical primary outcomes showed better functional outcomes (modified Rankin Scale; mRS, 0–2) with tenecteplase compared to alteplase (OR: 2.09, 95% CI: 1.16–3.76)[13].
Investigational drugs for ischemic stroke: what’s in the clinical development pipeline for acute phase and prevention?
Published in Expert Opinion on Investigational Drugs, 2022
Maria Giulia Mosconi, Maurizio Paciaroni, Walter Ageno
Despite significant advances in early diagnosis and the development of protocols for reducing the door-to-needle time, only alteplase has been approved for thrombolytic treatment of acute ischemic stroke. However, this agent is only accessible for a minority of AIS patients, and it has been associated with bleeding complications. This could contribute to an undertreatment of patients who are otherwise eligible for thrombolysis. Alternative thrombolytic agents are under investigation in several trials and tenecteplase, in preliminary results, suggest that it has a similar efficacy but safer profile, when compared to alteplase. The recent extension of the time window for IVT ± EVT for selected cases of patients with AIS with unknown onset time or wake-up stroke, with a neuroimaging-guided approach, allows to treat a greater number of patients. Patients treated with alteplase can also run a non-negligible risk of re-occlusion and clinical worsening, which are associated with poorer outcomes. So far, antiplatelet and anticoagulants have been generally contraindicated in the post-acute phase of revascularization, due to a higher risk of hemorrhagic transformation. To reduce the risk of re-occlusion, as well as the risk of bleeding complications, several novel antiplatelets and anticoagulants are under investigation for their administration in the acute phase of post-revascularization treatments.