Post haemodialysis stroke thrombolysis, to give or not to give?

Abstract

With every increment of glomerular filtration rate (GFR) by 10%, there is an elevated risk of stroke by 7%. Stroke death is also 9 times higher in end stage renal failure (ESRF) patients as compared to the general population. Certain studies have described that intravenous thrombolysis in ESRF patients with acute ischaemic stroke has no added benefit with increased risk of bleeding while some still recommend intravenous thrombolysis (IVT) as it improves neurological outcome. We describe two cases of acute ischaemic stroke at 0 hours post haemodialysis (HD) and 3.5 hours post HD. A 62-year- old gentleman with underlying hypertension and ESRF, presented 3.5 hours after haemodialysis with National Institute of Health Stroke Scale (NIHSS) of 7. Computed Tomography Angiography (CTA) showed a right distal M1 non occlusive thrombus and IV Alteplase 40mg was given. NIHSS post IVT at 6hours showed improvement to 3 and 0 upon discharge. Current mRS is 0. Upon undergoing 3hours of haemodialysis, a 66-year-old gentleman with underlying Hepatitis C and ESRF had an acute stroke with NIHSS of 10. CTA showed left M2 occlusion and IV Alteplase 50mg was given. NIHSS 6hours post IVT is 7 and 4 upon discharge. Complications include, oozing over his left BCF and minimal sulcal subarachnoid haemorhage. Current mRS is 1. In conclusion, post dialysis patients who suffer from an acute stroke, may be given intravenous thrombolysis as to improve their clinical outcome. In this study, both patients were given a lower dose of Alteplase (0.6mg/kg) and had favourable outcomes.