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Intravenous thrombolysis in acute ischaemic stroke: from trial exclusion criteria to clinical contra-indications. An international Delphi study
  1. Maaike Dirks (m.dirks{at}erasmusmc.nl)
  1. Erasmus MC, University Medical Center, Netherlands
    1. Louis w Niessen (l.niessen{at}erasmusmc.nl)
    1. Erasmus MC, University Medical Center, Netherlands
      1. Peter J Koudstaal (p.j.koudstaal{at}erasmusmc.nl)
      1. Erasmus MC, University Medical Center, Netherlands
        1. Cornelius L Franke (c.franke{at}atriummc.nl)
        1. Atrium Medical Center Heerlen, Netherlands
          1. Robert J van Oostenbrugge (r.vanoostenbrugge{at}neurologie.azm.nl)
          1. University Hospital Maastricht, Netherlands
            1. Diederik W J Dippel (d.dippel{at}erasmusmc.nl)
            1. Erasmus MC, University Medical Center, Netherlands

              Abstract

              Objective: Several studies indicate that only a small proportion of patients with acute ischaemic stroke is treated with intravenous thrombolysis. Indications and contraindications for this treatment are usually based on the inclusion and exclusion criteria of randomised clinical trials. The trial-context of these criteria hampers implementation in real-life settings. We therefore aimed to obtain specialist opinion in a Delphi consensus on these contraindications.

              Methods: We used the Delphi approach in an international group of specialists in the field of thrombolysis. Inclusion and exclusion criteria were reworded into 18 quantitatively phrased propositions. Feedback consisted of the median score, the interquartile range and the panellist’s own score in the previous round. For each item, we defined consensus as the achievement of an interdecile range within two prespecified clinically relevant units.

              Results: Thirty-one specialists participated in the first round and 30 of them completed all three rounds. Consensus was reached on 12 of the 18 propositions: Previous ischaemic stroke, head trauma and gastro-intestinal tract bleeding should not have taken place earlier than 1½ months, 2 months and 14 days, respectively; The severity of the neurological deficit is defined as an NIHSS score of 2-3 or more, and blood pressure level should be at most 185/110 mmHg. Platelet count should be over 90 x 1012/l, glucose levels between 2.7 - 22 mmol/l, INR less than 1.5 and APTT less than 50 seconds. No consensus was reached on propositions concerning the stroke onset-to-treatment time, patient’s age, recent medical procedures, spontaneous improvement rate and blood pressure treatment.

              Conclusions: We present specialists’ opinion on contra-indications for intravenous thrombolysis in ischaemic stroke. The results of this study may be relevant for routine clinical practice, since they may help to increase the number of treated patients.

              • acute ischaemic stroke
              • contraindications
              • delphi study
              • thrombolysis

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