Disclosures: Maximo C. Kiok, M.D. Medical Director of Stroke Program Trinity Health System

1. Disclosures: Maximo C. Kiok, M.D. Medical Director of Stroke Program Trinity Health System

2. Therapy Options for Acute Ischemic Stroke Trinity Stroke Nursing Symposium Feb 18, 2012 By Maximo C. Kiok, M.D.

3. Overview of Treatment Options • IV thrombolytic therapy (0-3 hrs) • IV thrombolytic therapy (3-4.5 hrs) • IA thrombolytic therapy • Endovascular mechanical thrombectomy (Merci, Penumbra, Solitaire, etc.) • Balloon angioplasty with stenting • Anti-platelet agents for non-thrombolytic Rx • Anticoagulants for atrial fibrillation

4. IV Thrombolytic Therapy • NINDS Stroke Trial (1995): 0-3 hrs window. • Benefit at 90 days • Risk of symptomatic cerebral hemorrhage within first 36 hours • Mortality Rate at 90 days • Exclusion criteria for administration of I.V. t-PA

6. The trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. No benefit found for IV t-PA. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS. Benefit found!

7. BENEFIT of IV t-PA Treatment at 0-3 Hours As compared with patients given placebo, patients treated with t-PA were at least 30 percentmore likely to have minimal or no disability at three monthson the assessment scales.

8. Risk of Symptomatic Intracerebral Hemorrhage (sICH) within 36 hours after the onset of stroke

9. Mortality Rate at 3 Months After Onset of Stroke

17. IV Thrombolytic Therapy • European Cooperative Acute Stroke Study III (ECASS-III) 2008: 3-4.5 hrs window. • Benefit at 90 days • Risk of symptomatic cerebral hemorrhage within first 36 hours • Mortality Rate at 90 days • Additional exclusion criteria for administration of I.V. t-PA

19. BENEFIT of IV t-PA Treatment at 3-4.5 Hours As compared with patients given placebo, patients treated with t-PA were 16 percent more likely to have minimal or no disability at three monthson the assessment scales. Absolute improvement of 7.2% only. In the alteplase group, 52.4% had a favorable outcome (defined as a score of 0 or 1 on the modified Rankin scale), compared to the placebo group (45.2%), representing an absolute improvement of 7.2 percentage points (odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; relative risk, 1.16; 95% CI, 1.01 to 1.34; P=0.04).

20. Risk of Symptomatic Intracerebral Hemorrhage (sICH) within 36 hours after the onset of stroke There were more cases of intracranial hemorrhage in the alteplase group than in the placebo group (27.0% vs. 17.6%, P=0.001).

21. Definition of Symptomatic Intracranial Hemorrhage • In the ECASS III protocol, symptomatic intracranial hemorrhage was defined as: • Any extravascular blood in the brain or within the cranium • Identified as the cause of any neurologic deterioration, and • With a magnitude of • 4 points or more in the NIHSS, or • That led to death.

22. Mortality Rate at 3 Months After Onset of Stroke

30. Thank you!