Key result
Repeated IV tPA lowers NIHSS by 9 points without hemorrhage in early recurrent stroke.
Why the study?
Repeated intravenous tissue plasminogen activator is contraindicated in early recurrent stroke within 3 months due to increased intracranial hemorrhage risk, but safety in select cases is uncertain.
Does repeated IVtPA improve neurological outcomes without causing hemorrhagic transformation in patients with early recurrent stroke?
Case Report (n=1)
Does repeated IVtPA improve neurological outcomes without causing hemorrhagic transformation in patients with early recurrent stroke?
This case report suggests that repeated IVtPA may be safe and effective for early recurrent stroke in selected patients, despite current contraindications.
May support repeat IV tPA in selected early recurrent stroke; hypothesis-generating and should not change practice without prospective data.
INTRODUCTION: Intravenous thrombolysis within 4.5 hours from symptom onset improves functional outcome in acute ischemic stroke patients. Repeated intravenous tissue plasminogen activator (IVtPA) is contraindicated in patients presenting with early recurrent stroke (ERS) within 3 months from the initial stroke because of a greater risk of intracranial hemorrhage. CASE PRESENTATION: A 59-year-old man presented with ERS, National Institute of Health Stroke Scale of 16, 10 days after a previous stroke. Brain computed tomography (CT) showed a previous hypodensity with 4 cm volume. Angio-CT highlighted the left middle cerebral artery and left internal carotid occlusion. Perfusion CT showed small deep core and large penumbra. The patient underwent IVtPA. After 24 hours, the National Institute of Health Stroke Scale was 7, and CT scan showed an acute ischemic lesion in the left basal ganglia area and frontal lobe without hemorrhagic transformation. CONCLUSION: This case report suggests that further randomized studies may evaluate whether repeated IVtPA may be safe and effective in ERS occurring shortly after a previous stroke when patients experience a period of complete neurological regression, minor disability, and a small infarct volume. Should the hypothesis be confirmed, small volume core and wide volume penumbra at perfusion CT may support the decision of adopting IVtPA repetition.
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Caruso et al. (2019) conducted a case report in Early recurrent stroke (n=1). Repeated intravenous tissue plasminogen activator (IVtPA) was evaluated on Neurological improvement and absence of hemorrhagic transformation. Repeated intravenous tissue plasminogen activator in a 59-year-old man with early recurrent stroke reduced NIHSS from 16 to 7 at 24 hours without hemorrhagic transformation.
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