title: Safety and outcomes of intravenous thrombolysis in dissection-related ischemic stroke: an international multicenter study and comprehensive meta-analysis of reported case series.
abstract: The safety and efficacy of intravenous thrombolysis (IVT) in dissection-related ischemic stroke (DRIS) has not been established. We sought to determine safety and recovery rates of IVT in DRIS using prospective, international, multicenter data and by conducting a comprehensive meta-analysis of reported case series. We analyzed consecutive DRIS patients treated with IVT according to national guidelines during a 5-year period at six tertiary-care stroke centers, and also conducted a comprehensive review and meta-analysis of all available case series reporting safety outcomes in DRIS treated with IVT according to PRISMA guidelines. A total of 39 DRIS patients (mean age 60 ± 18 years; 59% men; median NIHSS 13 points, IQR 9-17) received IVT in our multicenter study. Symptomatic intracranial hemorrhage (sICH), in-hospital mortality, complete recanalization, favorable functional outcome (FFO; mRS-score of 0-1) and functional independence (FI; mRS-score of 0-2) were 0% (adjusted Wald 95% CI 0-8%), 10% (3-24%), 55% (40-70%), 61% (45-74%) and 68% (52-81%). The pooled sICH and mortality rates in meta-analysis including 10 case series (234 IVT-DRIS patients) were 2% (0-5%) and 4% (0-8%). The pooled recanalization, FFO and FI rates were 45% (26-67%), 41% (29-54%) and 61% (48-72%), respectively. Substantial heterogeneity was only found for FFO (I(2) = 61%; p = 0.006). Subsequent meta-regression analysis identified baseline NIHSS and dissection in the posterior circulation as independent predictors of FFO (p < 0.05), accounting for FFO variance across different studies. Our prospective, international data coupled with comprehensive meta-analysis results underscore IVT safety in DRIS, while further independent validation is required in larger observational registries or RCTs.
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA. tsivgoulisgiorg@yahoo.gr.|Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece. tsivgoulisgiorg@yahoo.gr.|Department of Neurology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece. tsivgoulisgiorg@yahoo.gr.|International Clinical Research Center, St. Anne's University Hospital in Brno, Brno, Czech Republic. tsivgoulisgiorg@yahoo.gr.
authors.forename: Georgios
authors.initials: G
authors.lastname: Tsivgoulis
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Ramin
authors.initials: R
authors.lastname: Zand
authors.affiliation: Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece.
authors.forename: Aristeidis H
authors.initials: AH
authors.lastname: Katsanos
authors.affiliation: Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.
authors.forename: Vijay K
authors.initials: VK
authors.lastname: Sharma
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Nitin
authors.initials: N
authors.lastname: Goyal
authors.affiliation: Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany.
authors.forename: Christos
authors.initials: C
authors.lastname: Krogias
authors.affiliation: Stroke Unit, Department of Neurology, Brugmann University Hospital, Brussels, Belgium.
authors.forename: Apostolos
authors.initials: A
authors.lastname: Safouris
authors.affiliation: Department of Neurology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Vadikolias
authors.affiliation: Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Voumvourakis
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.|Australian Catholic University, Sydney, Australia.
authors.forename: Anne W
authors.initials: AW
authors.lastname: Alexandrov
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Marc D
authors.initials: MD
authors.lastname: Malkoff
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Andrei V
authors.initials: AV
authors.lastname: Alexandrov
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000150:complications*; D002545:Brain Ischemia / Q000188:drug therapy* / Q000209:etiology; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Carotid artery dissection; Cervical artery dissection; Dissection-related ischemic stroke; Symptomatic intracranial hemorrhage; Thrombolysis; Tissue plasminogen activator; Vertebral artery dissection