Ezgi Yılmaz1, Elıf Sarıönder Gencer2, Ethem Murat Arsava1, Mehmet Akif Topcuoğlu1

1Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey
2University of Health Sciences Turkey, Antalya Training and Research Hospital, Clinic of Neurology, Antalya, Turkey

Keywords: Homocysteine, tissue plasminogen activator, acute ischemic stroke


Objective: Hyperhomocysteinemia is an independent risk factor for cardiovascular diseases. It has paradoxically both antifibrinolytic and pro-hemorrhagic effects. In the study, we investigated the effect of homocysteine (Hcy) levels on thrombolytic therapy in patients with acute ischemic stroke.

Materials and Methods: Patients who received intravenous (iv) tissue plasminogen activator (tPA) between 2005 and 2021 and had Hcy levels measured within the first 3 days were reviewed in terms of tPA efficacy, prognosis and intracerebral hemorrhage. The efficacy of tPA treatment was categorized as effective response (decrease of at least 4 points or a decrease in score to zero) and dramatic response (decrease of at least 8 points or a decrease in score to either zero or one) according to NIHSS score at 24 hours. Scores of 0 and 1 were classified as “excellent outcome”, and scores of 0, 1, and 2 were classified as “good outcome” on the modified Rankin scale evaluated at 3 months. Hemorrhagic transformation was evaluated according to Fiorelli’s classification.

Results: Effective response was observed in 46.7% of the 182 patients (mean age 71±14 years; 99 women) included in the study, and dramatic response in 31.3%. Excellent outcome was reported in 33% of the patients, and good outcome in 53.3%. Cerebral hemorrhage of any severity was detected in 15.9% of the patients, and parenchymal hematoma type 2 in 5.5%. In the analyses made for assessing iv tPA response and cerebral hemorrhage status, no difference was found in terms of Hcy level and between the subgroups formed with different cut-off values of Hcy level.

Conclusion: In our study, hyperhomocysteinemia, which is known to have negative effects on fibrinolysis and vascular integrity, did not show a significant effect on iv tPA efficacy, prognosis and complications. Prospective and large-sample sized studies are needed to better demonstrate these effects.

Ethics Committee Approval

Ethical approvals were obtained from the Hacettepe University Non-Invasive Clinical Research Ethics Committee for the stroke database and the project (decision no: 2022/07-48, date: 19.04.2022).

Peer Review

Externally and internally peer-reviewed.

Author Contributions

Surgical and Medical Practices: E.Y., E.S.G., E.M.A., M.A.T., Concept: E.Y., E.S.G., E.M.A., M.A.T., Design: E.Y., E.S.G., E.M.A., M.A.T., Data Collection or Processing: E.Y., E.S.G., E.M.A., M.A.T., Analysis or Interpretation: E.Y., E.S.G., E.M.A., M.A.T., Literature Search: E.Y., E.S.G., E.M.A., M.A.T., Writing: E.Y., E.S.G., E.M.A., M.A.T.

Conflict of Interest

No conflict of interest was declared by the authors.

Financial Disclosure

The authors declared that this study received no financial support.