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*Only for medical professionals to read for reference to dissolve and insoluble, this is a problem
.
The incidence of acute cerebral infarction remains high and tends to be younger, and the disability rate and fatality rate are extremely high.
With the continuous improvement of thrombolytic technology, the thrombolytic treatment of acute cerebral infarction has also been greatly promoted.
Some patients benefit
.
Some patients lose the chance of recanalization due to relative or absolute contraindications
.
This patient is not only a super-aged patient, but also received adequate intravenous thrombolysis when there is contraindication to gastrointestinal bleeding, and good results have been achieved.
The summary is as follows
.
1.
Case report Li, male, 90 years old
.
The patient was hospitalized in the Department of Cardiology due to coronary heart disease and heart failure.
Due to "sudden speech slurred and weakness of the right lower extremity for 35 minutes, please consult the neurology department for emergency consultation.
Physical examination: Consciousness, poor speech, right upper extremity muscle strength V-level, Muscle strength of the right lower limb is grade III, and the right Pap sign is positive
.
The National Institutes of Health Stroke Scale (NIHSS) score is 7 points (question 2 + upper right 1 + lower right 2 + speech 2)
.
Past history of hypertension, long-term black History of stool, chronic anemia
.
Hb 81 g/L before thrombolysis, fecal occult blood (+)
.
Video 1: Head CT before thrombolysis Head CT excludes cerebral hemorrhage, combined with upper gastrointestinal hemorrhage, high risk of thrombolysis, but family attitudes Positive, agree to intravenous thrombolysis, give Alteplase (rt-PA) 0.
9 mg/kg intravenous thrombolysis after signing, and score 0 on the National Institutes of Health Stroke Scale (NIHSS) after thrombolysis
.
Figure 1: Immediately after thrombolysis, head MRI+MRA showed that: Pontine subacute cerebral infarction after thrombolysis, the Hb and stool conditions were basically the same as before
.
Video 2: 24 hours after thrombolysis, there is no bleeding on CT of the skull.
2.
Discussion on contraindications for gastrointestinal bleeding.
The guidelines clearly point out that gastrointestinal bleeding in the past 3 weeks is a contraindication for intravenous thrombolysis.
The patient has a long history of melena for about 20 years.
, The reason is unknown, considering non-acute gastrointestinal mucosal injury, and family members have a strong desire for thrombolysis, so intravenous thrombolysis is given
.
There has been a case report of a 54-year-old man with recent upper gastrointestinal bleeding who was given adequate rt-PA thrombolysis and obtained a good prognosis.
The cause of this patient’s bleeding was extensive and diffuse acute gastric mucosal injury after heavy drinking half a month ago.
Ulcers appeared, severe vomiting caused cardiac mucosa torn and bleeding.
After active treatment, the patient's acutely injured gastric mucosa had been repaired before this thrombolytic treatment
.
3.
The guidelines gradually abolish the age limit, and there is no upper limit for those over 80.
Figure 3: Chinese guidelines for acute ischemic stroke recommends thrombolytic therapy for elderly patients with ischemic stroke Figure 4: Chinese guidelines for clinical management of cerebrovascular disease for elderly ischemic Thrombolytic therapy recommendations for stroke patients IV.
Study on elderly patients (over 80 years old) Table 1: NINDS study and ECASS Ⅲ study 1) The 1995 NINDS study included 302 intravenous thrombolytic patients and 302 non-thrombolytic patients.
Only 42 patients were older than 80 years old
.
The ages of Part1 thrombolysis group and control group were 67±10 years old and 66±11 years old, Part2 were 69±12 years old and 66±13 years old
.
It can be seen that most of the patients enrolled in the group are relatively young, and the proportion of patients older than 80 years is quite low.
It is not appropriate to extend the NINDS study conclusions to ultra-elderly patients 80 or even 90 years old
.
The 2008 ECASS III study did not include patients older than 80 years of age
.
2) The update of the guidelines relies on the results of a large clinical trial-the Third International Stroke Trial (IST-3)
.
This international multi-center, randomized, open treatment trial included a total of 3,035 patients from 156 hospitals in 12 countries, of which 1,617 (53%) patients were older than 80 years old.
The results of the study showed that despite the early risks, But over time, by six months, there was no difference in mortality between the two groups
.
And after analyzing the elderly patients, it is found that the benefits of elderly patients are not reduced
.
This study provides a basis for relaxing the age limit for patients in the guidelines
.
3) In 2017, Karolinska Institute in Sweden explored the comparison of the results and risks of intravenous thrombolysis within 3 h and 3-4.
5 h thrombolysis in patients with acute ischemic stroke over 80 years of age
.
The results of the study show that although thrombolysis with a 3-4.
5 h time window increases the risk of bleeding, elderly patients should not reject intravenous thrombolysis with a time window (3-4.
5 h) only because of their age when there are no other contraindications
.
V.
Research on ultra-elderly patients (over 90 years old) 1) The most detailed study of intravenous thrombolysis in (ultra-)elderly patients comes from BMJ published in one of the four major journals in 2010.
Cases are from SITS-ISTR and VISTA.
In the major stroke registration database, the former is a thrombolytic case (n=23334), and the latter is a control case (n=6166).
The age is divided into 10 grades (21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90 and 91-100 years old)
.
Figure 5: The effect of age on the prognosis of patients with intravenous thrombolysis.
Effectiveness: For elderly patients (>80 years old), intravenous thrombolysis is still effective, but the risk of bleeding increases; however, for very elderly patients (>90 years old), intravenous thrombolysis is still effective.
Thrombolysis is ineffective
.
Safety: The incidence of symptomatic intracranial hemorrhage transformation is significantly increased
.
2) In 2016, an article published by Hofstra University on Stroke discussed the effect evaluation of rt-PA used by people over 90 years old
.
A total of 35708 patients were enrolled, of which 2585 (7.
2%) were over 90 years old
.
The use of rt-PA and the results were compared between patients over 90 years old, 18-64 years old, 65-79 years old, and 80-89 years old
.
The results of the study show that the risk of sICH in people over 90 years old is not higher than that in people 65-89, but the mortality rate is high and the functional outcome is poor
.
3) In 2015, Taiwan's Changhua Hospital published a document in Oxford Academic that showed that for elderly patients over 90 years old, the proportion of symptomatic intracranial hemorrhage caused by rt-PA thrombolysis increased, but there was no difference in mortality
.
A study conducted by the University of Texas published in the Journal of Stroke&Cerebrovascular Diseases in 2018 showed that for stroke patients over 90 years old, the 90-day modified Rankin score, the thrombolytic group is still better than the non-thrombolytic group
.
6.
Conclusions on whether the elderly and super-aged patients are intravenous thrombolysis According to some research results, the overall prognosis of the elderly patients with acute ischemic stroke is poor, and the bleeding risk and mortality are higher than those of younger patients, but rt-PA thrombolysis in elderly patients The benefit of treatment is clear, and the earlier the time, the more obvious the benefit
.
Thrombolysis should not be rejected simply because of advanced age .
Thrombolysis is recommended within 3 hours of onset, and the risk of bleeding should be combined within 3 to 4.
5 hours of onset
.
Thrombolysis for ultra-elderly patients can also benefit.
Whether or not to choose thrombolysis for ultra-elderly patients is currently controversial, and it is necessary to comprehensively evaluate their overall situation before making a judgment
.
.
The incidence of acute cerebral infarction remains high and tends to be younger, and the disability rate and fatality rate are extremely high.
With the continuous improvement of thrombolytic technology, the thrombolytic treatment of acute cerebral infarction has also been greatly promoted.
Some patients benefit
.
Some patients lose the chance of recanalization due to relative or absolute contraindications
.
This patient is not only a super-aged patient, but also received adequate intravenous thrombolysis when there is contraindication to gastrointestinal bleeding, and good results have been achieved.
The summary is as follows
.
1.
Case report Li, male, 90 years old
.
The patient was hospitalized in the Department of Cardiology due to coronary heart disease and heart failure.
Due to "sudden speech slurred and weakness of the right lower extremity for 35 minutes, please consult the neurology department for emergency consultation.
Physical examination: Consciousness, poor speech, right upper extremity muscle strength V-level, Muscle strength of the right lower limb is grade III, and the right Pap sign is positive
.
The National Institutes of Health Stroke Scale (NIHSS) score is 7 points (question 2 + upper right 1 + lower right 2 + speech 2)
.
Past history of hypertension, long-term black History of stool, chronic anemia
.
Hb 81 g/L before thrombolysis, fecal occult blood (+)
.
Video 1: Head CT before thrombolysis Head CT excludes cerebral hemorrhage, combined with upper gastrointestinal hemorrhage, high risk of thrombolysis, but family attitudes Positive, agree to intravenous thrombolysis, give Alteplase (rt-PA) 0.
9 mg/kg intravenous thrombolysis after signing, and score 0 on the National Institutes of Health Stroke Scale (NIHSS) after thrombolysis
.
Figure 1: Immediately after thrombolysis, head MRI+MRA showed that: Pontine subacute cerebral infarction after thrombolysis, the Hb and stool conditions were basically the same as before
.
Video 2: 24 hours after thrombolysis, there is no bleeding on CT of the skull.
2.
Discussion on contraindications for gastrointestinal bleeding.
The guidelines clearly point out that gastrointestinal bleeding in the past 3 weeks is a contraindication for intravenous thrombolysis.
The patient has a long history of melena for about 20 years.
, The reason is unknown, considering non-acute gastrointestinal mucosal injury, and family members have a strong desire for thrombolysis, so intravenous thrombolysis is given
.
There has been a case report of a 54-year-old man with recent upper gastrointestinal bleeding who was given adequate rt-PA thrombolysis and obtained a good prognosis.
The cause of this patient’s bleeding was extensive and diffuse acute gastric mucosal injury after heavy drinking half a month ago.
Ulcers appeared, severe vomiting caused cardiac mucosa torn and bleeding.
After active treatment, the patient's acutely injured gastric mucosa had been repaired before this thrombolytic treatment
.
3.
The guidelines gradually abolish the age limit, and there is no upper limit for those over 80.
Figure 3: Chinese guidelines for acute ischemic stroke recommends thrombolytic therapy for elderly patients with ischemic stroke Figure 4: Chinese guidelines for clinical management of cerebrovascular disease for elderly ischemic Thrombolytic therapy recommendations for stroke patients IV.
Study on elderly patients (over 80 years old) Table 1: NINDS study and ECASS Ⅲ study 1) The 1995 NINDS study included 302 intravenous thrombolytic patients and 302 non-thrombolytic patients.
Only 42 patients were older than 80 years old
.
The ages of Part1 thrombolysis group and control group were 67±10 years old and 66±11 years old, Part2 were 69±12 years old and 66±13 years old
.
It can be seen that most of the patients enrolled in the group are relatively young, and the proportion of patients older than 80 years is quite low.
It is not appropriate to extend the NINDS study conclusions to ultra-elderly patients 80 or even 90 years old
.
The 2008 ECASS III study did not include patients older than 80 years of age
.
2) The update of the guidelines relies on the results of a large clinical trial-the Third International Stroke Trial (IST-3)
.
This international multi-center, randomized, open treatment trial included a total of 3,035 patients from 156 hospitals in 12 countries, of which 1,617 (53%) patients were older than 80 years old.
The results of the study showed that despite the early risks, But over time, by six months, there was no difference in mortality between the two groups
.
And after analyzing the elderly patients, it is found that the benefits of elderly patients are not reduced
.
This study provides a basis for relaxing the age limit for patients in the guidelines
.
3) In 2017, Karolinska Institute in Sweden explored the comparison of the results and risks of intravenous thrombolysis within 3 h and 3-4.
5 h thrombolysis in patients with acute ischemic stroke over 80 years of age
.
The results of the study show that although thrombolysis with a 3-4.
5 h time window increases the risk of bleeding, elderly patients should not reject intravenous thrombolysis with a time window (3-4.
5 h) only because of their age when there are no other contraindications
.
V.
Research on ultra-elderly patients (over 90 years old) 1) The most detailed study of intravenous thrombolysis in (ultra-)elderly patients comes from BMJ published in one of the four major journals in 2010.
Cases are from SITS-ISTR and VISTA.
In the major stroke registration database, the former is a thrombolytic case (n=23334), and the latter is a control case (n=6166).
The age is divided into 10 grades (21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90 and 91-100 years old)
.
Figure 5: The effect of age on the prognosis of patients with intravenous thrombolysis.
Effectiveness: For elderly patients (>80 years old), intravenous thrombolysis is still effective, but the risk of bleeding increases; however, for very elderly patients (>90 years old), intravenous thrombolysis is still effective.
Thrombolysis is ineffective
.
Safety: The incidence of symptomatic intracranial hemorrhage transformation is significantly increased
.
2) In 2016, an article published by Hofstra University on Stroke discussed the effect evaluation of rt-PA used by people over 90 years old
.
A total of 35708 patients were enrolled, of which 2585 (7.
2%) were over 90 years old
.
The use of rt-PA and the results were compared between patients over 90 years old, 18-64 years old, 65-79 years old, and 80-89 years old
.
The results of the study show that the risk of sICH in people over 90 years old is not higher than that in people 65-89, but the mortality rate is high and the functional outcome is poor
.
3) In 2015, Taiwan's Changhua Hospital published a document in Oxford Academic that showed that for elderly patients over 90 years old, the proportion of symptomatic intracranial hemorrhage caused by rt-PA thrombolysis increased, but there was no difference in mortality
.
A study conducted by the University of Texas published in the Journal of Stroke&Cerebrovascular Diseases in 2018 showed that for stroke patients over 90 years old, the 90-day modified Rankin score, the thrombolytic group is still better than the non-thrombolytic group
.
6.
Conclusions on whether the elderly and super-aged patients are intravenous thrombolysis According to some research results, the overall prognosis of the elderly patients with acute ischemic stroke is poor, and the bleeding risk and mortality are higher than those of younger patients, but rt-PA thrombolysis in elderly patients The benefit of treatment is clear, and the earlier the time, the more obvious the benefit
.
Thrombolysis should not be rejected simply because of advanced age .
Thrombolysis is recommended within 3 hours of onset, and the risk of bleeding should be combined within 3 to 4.
5 hours of onset
.
Thrombolysis for ultra-elderly patients can also benefit.
Whether or not to choose thrombolysis for ultra-elderly patients is currently controversial, and it is necessary to comprehensively evaluate their overall situation before making a judgment
.
