The Yield of Multimodal Computed Tomography among Emergency Department Patients with Suspected Large Vessel Occlusion Stroke

Objectives: Endovascular therapy (EVT) improves outcomes for appropriately selected acute ischemic stroke patients. Guidelines suggest rapid acquisition of noninvasive vascular imaging to screen suspected ischemic stroke patients for large vessel occlusion (LVO) and candidacy for EVT. We sought to quantify the yield of an LVO stroke screening process in an undifferentiated emergency department (ED) suspected stroke population as well as identify predictors of successful EVT. Methods: We identified a cohort of consecutive ED patients who received CT angiography and brain perfusion (CTA/P) imaging to determine candidacy for EVT during 2016. In keeping with the guidelines at that time, hospital protocol directed physicians to obtain CTA/P studies if time from the onset of symptoms was less than or equal to 6 hours, and the National Institute of Health Stroke Scale (NIHSS) more than or equal to 6 or if recommended by the consulting stroke neurologist. Final discharge diagnoses, EVT attempts, and successful reperfusion (TICI 2b or better) were recorded. Yield of CTA/P was compared among patients based on NIHSS and duration of symptoms. Results: Over a 12-month period, 406 suspected stroke patients were screened with CTA/P; 273 (67%) received a final diagnosis of ischemic stroke. Among cases screened, 53 (13%) underwent attempted EVT; 35 (9%) achieved successful reperfusion. Only 1 of 113 (1%) patients with an NIHSS less than 6 was successfully treated with EVT compared to 34 of 285 (12%) with higher NIHSS (p = 0.001). The probability of successful EVT declined with increasing symptom duration (p = 0.009 for trend). In multivariable analysis, NIHSS more than or equal to 6 was associated with successful EVT (odds ratio [OR] 4.0 [1.6 to 9.9]) but presentation within 6 hours of onset was not (OR 2.3 [0.8 to 6.7]). Conclusions: EVT candidates were common among suspected stroke patients screened with CTA/P in the ED, however, patients with NIHSS less than 6 rarely received successful EVT.     

急性脑梗死患者多模式CT指导下的静脉溶栓治疗

目的 对发病3～9 h内的急性脑梗死患者,应用多模式CT指导下静脉rt-PA溶栓治疗,研究其疗效.方法 2007年8月至2009年5月于我院就诊,经多模式CT筛选出符合溶栓的患者27例.分为＞3～6 h组及7～9 h组,记录溶栓前、后的NIHSS、mRS及BI评分,症状性出血率和病死率.结果 27例样本中20例(74.1%)患者溶栓治疗有效,11例(40.7%)临床结局良好,5例(18.5%)血管完全再通,症状性出血1例(3.7%).其中＞3～6 h组有效率为92.3%(12/13,χ~2=4.34,P=0.037),血管冉通率38.5%(5/13,χ~2=6.608,P=0.010).结论 多模式CT指导下＞3～9 h溶栓是超过常规溶栓时间窗患者的一种可选择的治疗方法.     

Efficacy and safety assessment of alteplase in the treatment of stroke — gender differences

Abstract

Background:

Evidence for gender disparity in response to pharmacological thrombolysis for acute stroke treatment is inconclusive.

Objective:

To compare the effectiveness and safety of alteplase used in the treatment of male and female stroke patients.

Material and methods:

One thousand and seventy-seven patients who recently had their first-ever clinically apparent stroke (group I: 113 patients treated with intravenous alteplase and group II: 964 not treated with alteplase) were qualified. Groups I and II were divided into subgroups based on gender and were analysed based on: the age when they had a stroke, presence of key stroke risk factors (quantitatively: ≤ or >3), neurological state according to NIHSS in the first day of stroke, mortality rate, and the modified Rankin scale (mRS) at day 90 after the stroke. In group I, other determinants were additionally assessed: recent lesions as appeared on CT scans of the head in the first day of stroke and 24 hours after recombinant tissue plasminogen activator (rtPA), neurological state according to NIHSS in the second day of stroke, and the incidence of iatrogenic bleeding.

Results:

The age of the onset of stroke was older in women both in group I and group II. Apart from lipid disorders, no statistically significant differences in the distribution of other risk factors for stroke between groups I and II were found. The neurological state (according to the NIHSS scale) on the first day of the disease was significantly more severe in women both in group I and group II. In group II, the level of functioning according to the mRS scale at day 90 day after the onset of the disease was significantly more severe in women; there was no significant difference in group I. Among patients from group I, a significantly greater improvement, according to the NIHSS scale, was found in women 24 hours after rtPA administration in comparison with men. The presence of focal ischemia, responsible for the occurrence of stroke, on the CTs of the head performed 24 hours after rtPA administration, was also significantly more often found in women (in group I). No statistically significant differences in the incidence of complications after rtPA between women and men in group I were observed. In multivariate methods, we did not find any impact of factors other than gender on the outcome after stroke.

Conclusions:

The use of alteplase in women during the treatment of stroke is associated with a greater and faster improvement in their neurological state in comparison with men. Treating stroke with alteplase in women improves long-term prognosis regarding self-efficacy in everyday functioning. Finally, there are no gender-related differences regarding the safety of intravenous thrombolytic therapy.     

Acute stroke management in the elderly

BACKGROUND AND PURPOSE: Though the proportion of elderly stroke patients is increasing, patients >80 years are often excluded from clinical stroke trials. We reviewed the management of older patients presenting with acute ischemic stroke (AIS) and assessed the safety and efficacy of recombinant tissue plasminogen activator (rtPA) administration in a community-based setting. METHODS: A retrospective review of patients >80 years (n = 341) admitted to a community stroke center with AIS were compared to their younger counterparts (n = 690) using the stroke center database from April 2003 to December 2005. Parameters that were measured included admission and discharge NIH Stroke Scale (NIHSS), rate of thrombolytic treatment, the frequency and etiology of thrombolytic exclusion criteria and complications from rtPA for the different aged populations. Additional data were collected for Barthel Index at 12 months. RESULTS: A total of 166 patients underwent thrombolysis. Older patients were not delayed in reaching the hospital within 3 h of stroke onset (182/690, 26%, in the <80 cohort vs. 98/341, 29%, in the > or = 80 cohort). Although the overall rates of tPA use were similar in both the young and aged cohort, older patients were less likely to be treated with rtPA because of reasons not listed as exclusion criteria (17% in the <80 cohort vs. 32% in the > or = 80 cohort).The older group did not have an excess risk of intracranial hemorrhage following rtPA infusion despite equivalent NIHSS on admission (13.5 in the <80 cohort vs. 12.4 in the > or = 80 cohort). Both groups showed improvement in NIHSS following thrombolytic treatment with a drop of 7.7 points in the younger age group and 5.6 points in the older group. Elderly patients treated with rtPA had a comparable 12-month modified Barthel Index score to younger cohorts. CONCLUSIONS: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age.     

Obstructive Sleep Apnea before Ischemic Stroke: Clinical Relevance to Infarction Volume and Neurological Recovery

Background: Obstructive sleep apnea (OSA) is a probable risk factor with speculative roles in the induction or aggravation of acute ischemic stroke (AIS). Methods: The association between OSA and AIS severity was retrospectively analyzed using clinical data of first-onset AIS patients, admitted to our hospital between January 2013 and September 2016. Eligible patients were categorized based on the presence of OSA prior to stroke. Stroke severity and functional outcomes were evaluated using the National Institute of Health Stroke Severity Scale (NIHSS) and the modified Rankin scale (mRS), respectively. Results: No significant differences were observed among OSA and non-OSA groups for infarction volume, NIHSS at admission and discharge, or mRS at discharge and at the 3-month follow-up (all P > .05). OSA prior to stroke negatively correlated with infarction volume (P = .008), NIHSS at discharge (P = .006), and the 3-month mRS (P = .015). In addition to OSA, it was also found that infarction volume significantly correlated with large artery occlusion (LAO), anterior circulation involvement, neutrophil count, and fibrinogen level; NIHSS at discharge significantly correlated with LAO, transient ischemia attack (TIA), neutrophil count, and thrombolysis; and the 3-month mRS significantly correlated with LAO, TIA, age, neutrophil count, and thrombolysis. Conclusions: OSA before AIS does not increase the severity of stroke. The negative association between OSA and infarction volume, stroke severity, and clinical outcomes suggests an endogenous neuroprotective effect.     

高龄急性轻型缺血性卒中早期阿替普酶静脉溶栓疗效观察

目的 探讨高龄轻型缺血性卒中3 h内行阿替普酶静脉溶栓治疗的疗效及安全性。 方法 将我院2015年10月-2017年10月连续收治入院的发病3 h内48例高龄急性轻型缺血性卒中患者 随机分为阿替普酶静脉溶栓组24例和未溶栓组24例。比较两组患者入院时的一般情况,基线美国 国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NHISS）评分,治疗24 h后颅内出 血转化率,治疗后90 d改良Rankin量表（modified Rankin Scale,mRS）评分及90 d病死率。 结果 阿替普酶静脉溶栓组和未溶栓组患者一般临床资料、基线NIHSS评分比较,差异无统计学意 义。阿替普酶静脉溶栓组和未溶栓组治疗24 h后颅内出血转化率分别为4.17%和0（P =1.000）,两组 90 d病死率均为4.17%（P =1.000）,阿替普酶静脉溶栓组及未溶栓组90 d mRS评分为0～2分的比率 分别为83.33%和54.17%（P =0.029）。 结论 早期阿替普酶静脉溶栓治疗高龄急性轻型缺血性卒中不增加急性期颅内出血转化的风险, 可以改善高龄轻型缺血性卒中患者预后,不增加病死率。     

Local mild hypothermia with thrombolysis for acute ischemic stroke within a 6-h window

Objective

To determine the safety and efficacy of combined local mild hypothermia and IV rtPA in treating acute ischemic stroke (AIS) patients with MRI perfusion- and diffusion-weighted imaging (PWI/DWI) mismatch within a 6-h stroke window.

Methods

AIS patients within 6 h of a minimum 20% PWI/DWI MRI mismatch were randomly assigned to 3 groups: local mild hypothermia with IV rtPA (Group A); IV rtPA (Group B); or conventional anti-platelet aggregation (Group C). Mortality and National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) score and Barthel Index (BI) were used in evaluation.

Results

There were significant differences in NIHSS 24 h after treatment among the three groups (P < 0.001). Based on mRS and BI, more patients in Groups A and B showed favorable outcomes than patients in Group C (P = 0.017 and P = 0.009, respectively); however, there were no significant efficacy differences between Groups A and B. The incidence of symptomatic ICH and the mortality rates within 90 days in the 3 groups were similar. In addition, there were no significant differences in NIHSS improvement at 24 h and favorable outcomes 90 days after IV rtPA treatment between patients within 3 h and 3–6 h from symptom onset.

Conclusions

There was no benefit of combined local hypothermia/IV rtPA treatment compared to IV rtPA alone. PWI/DWI mismatching on MRI can be a selection criteria for IV rtPA treatment within a 6-h window.     

Outcomes of intravenous thrombolytic therapy for acute ischemic stroke with an integrated acute stroke referral network: initial experience of a community-based hospital in a developing country

Some of the literature encourages the use of intravenous (IV) thrombolytic therapy for acute ischemic stroke (AIS) in centers with no previous experience with this therapy. The benefits of an acute stroke referral network for IV thrombolytic therapy remain controversial, however. We present outcomes of IV thrombolytic therapy for AIS with an integrated acute stroke referral network at an institution with no previous experience in stroke thrombolysis and compare the results with previously published data. A total of 458 patients with AIS or transient ischemic attack (TIA), referred from a hospital in the acute stroke referral network or walk-ins, admitted to the stroke unit of Thammasat Hospital between October 2007 and January 2009 (16 months) were prospectively assessed. The main outcome measures were IV thrombolytic treatment rate, initial National Institutes of Health Stroke Scale (NIHSS) score, door-to-needle time, onset-to-treatment time (OTT), intracerebral hemorrhage, and morbidity and mortality at 3 months after onset. A total of 100 patients (59 from hospitals in the stroke referral network) received IV recombinant tissue plasminogen activator (rt-PA) therapy (21% of the admissions with AIS and TIA); 41% of the patients referred from a hospital in the network received IV rt-PA. The median NIHSS score before thrombolysis was 15 (range, 3-34). Mean door-to-needle time was 54 minutes (range, 15-125 minutes), and mean OTT was 160 minutes (range, 60-270 minutes). There were 13 asymptomatic intracerebral hemorrhages and 2 symptomatic intracerebral hemorrhages (1 fatal). By 3 months, 42 patients had achieved excellent recovery (modified Rankin Scale score of 0-1), and 14 had died. These outcomes are comparable to data from the National Institute of Neurological Disorders and Stroke and previous studies of IV rt-PA therapy in Thailand. Our findings indicate that integrating an acute stroke referral network into IV thrombolytic therapy for AIS in a community-based setting is safe and feasible and should help increase the rate of thrombolytic therapy. Previously inexperienced community-based centers can reproduce the experience and outcome measures reported by clinical trials and in the landmark literature of IV thrombolytic therapy in patients with stroke.     

缺血性脑卒中急性期降压治疗对预后的影响

目的 探讨降压治疗对急性缺血性脑卒中预后的影响,比较早期降压与晚期降压的差异.方法 纳入2018-10—2020-08包头医学院第一附属医院神经内科急性脑梗死合并血压升高的患者54例,随机分为早期降压组和晚期降压组,记录2组患者14 d、30 d NIHSS评分和30 d、90 d mRS评分,比较2组预后.结果 早期...     

The rtPA increases MMP-9 activity in serum during ischaemic stroke

Background and purposeTo find the relationship between rtPA treatment vs. MMP-9 activity, MMP-3, and TIMP-1 serum levels related to patients’ neurological status during acute ischaemic stroke (IS).Material and methods35 IS patients were enrolled. 14 of them underwent thrombolytic therapy with Actylise (rtPA group). The serum samples were obtained at 3 time-points for rtPA group (time-point 0: 1st–4th hour of stroke; time-point 1 – immediately after rtPA administration; time-point 2 – on day 5–7 from stroke onset). Remaining patients had venous blood collection at two time-points: time-point 1 – 5th–10th hour of stroke and time-point 2 – on day 5–7 of stroke. MMP-9 was analyzed with gelatin zymography, MMP-3 and TIMP-1 serum levels were analyzed with ELISA method. NIHSS improvement ratio (IR) was calculated as a difference between NIHSS score at the admission and discharge of patient.ResultsThe active form of MMP-9 (86 kDa) was not observed in any analyzed samples. Total MMP-9 activity was significantly elevated at time-point 1 in rtPA group in comparison with non-rtPA group. MMP-3 serum level significantly decreased during rtPA administration in comparison with non-rtPA group and it was restored at time-point 2. MMP-3 negatively correlated with IR values (p = 0.06).ConclusionsThrombolysis applied for IS treatment increases MMP-9 activity in serum, however, rtPA does not facilitate the conversion of pro-MMP-9 into the active form. Our results also suggest the involvement of MMP-3 to the biochemical processes occurring during acute phase of IS.     

Factors related to unfavorable outcome in minor ischemic stroke

BackgroundStroke recurrence and disability are important challenges to overcome in patients with minor ischemic stroke. The aim of our study was to determine the factors associated with unfavorable outcomes in patients with minor ischemic stroke.MethodsThis was a prospective cohort study including patients with minor ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 4 who were treated at the Bach Mai Hospital stroke center from June 15, 2021, to September 15, 2022. Unfavorable outcome was defined as mRS 2-6 at 90 days. Multivariable logistic regression analysis was conducted to assess risk factors related to clinical outcomes.ResultsOf 678 patients presenting with minor ischemic stroke, there were 90 (13.3%, 90/678) patients with no intracranial artery imaging. Hence, 588 were patients analyzed, of whom 6.0% received thrombolytic therapy, 8.5% developed NIHSS > 4 in 24 hours, and 30.4% had intracranial stenosis > 50%. Compared with the group of unfavorable outcomes, the favorable outcome group had more NIHSS 0-1 (29.9% vs.8.7%, P<0.001), lower cardioembolic (3.2% vs.7.9%, P=0.021), low IV-tPA ratio (4.8% vs.10.3%, P=0.019), lower NIHSS progression > 4 in the first 24 hours (3.9% vs.25.4%, P<0.001), and lower ICAS rate (28.1% vs.38.9%, P=0.02). Multivariable regression analysis of factors affecting unfavorable outcomes included baseline NIHSS 2-4 (OR, 3.85; 95% CI, 1.97-7.52), NIHSS progression > 4 (OR, 7.57; 95% CI, 3.80-15.10), and ICAS (OR 1.68; 95%CI, 1.07-2.64).ConclusionsIn patients with minor ischemic stroke, unfavorable outcomes were associated with baseline NIHSS 2-4, NIHSS progression > 4 points in 24 hours, and ICAS. These factors may identify a patient population in need of close monitoring and at higher risk of adverse outcomes.     

急性缺血性卒中围静脉溶栓时间窗临床症状波动的静脉溶栓研究

目的 探讨急性缺血性卒中患者围静脉溶栓时间窗临床症状波动的患者进行静脉溶栓治疗的临 床特征及预后分析。 方法 前瞻性纳入绵阳市中心医院2013年10月-2018年6月连续登记的发病4.5 h内进行静脉溶栓的 患者,以实施静脉溶栓时NIHSS评分较入院时NIHSS评分上下波动2分作为临床症状波动判断标准,将 所有纳入患者分为无变化组、波动组。分析比较两组患者的临床特征及24 h出血转化率、出院NIHSS 评分、3个月预后良好（mRS评分≤2分）和全因死亡率,多因素Logistic回归分析围静脉溶栓时间窗发生 临床症状波动的影响因素。 结果 共纳入156例,其中男性110例（70.5%）,年龄范围42～87岁,平均65±13岁,发生围静脉 溶栓时间窗临床症状波动41例（26.3%）。与无变化组患者相比,波动组患者年龄、基线NIHSS评 分、糖尿病比例、高血压比例、随机血糖水平、后循环梗死比例较高,差异均具有统计学意义。两 组患者的24 h出血转化率、出院NI HSS评分、3个月良好预后率、3个月时全因死亡率差异无统计学意 义。Logistic回归分析发现年龄（每增加10岁：OR 1.143,95%CI 1.016～1.836,P =0.040）、基线NIHSS 评分（每增加1分：OR 1.353,95%CI 1.053～1.393,P =0.006）、随机血糖（每增加1 mmol/L：OR 2.120, 95%CI 1.185～2.748,P =0.001）、后循环梗死（OR 2.603,95%CI 1.037～3.950,P =0.042）是围静脉 溶栓时间窗临床症状波动的独立危险因素。 结论 尽管高龄、NIHSS评分高、血糖水平高、后循环梗死患者容易出现围静脉溶栓时间窗临床症 状波动,但对终点事件并无影响。对于出现临床症状波动的患者,溶栓可使患者获益。     

Redefining Early Neurological Improvement After Reperfusion Therapy in Stroke

Background and Purpose: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. We hypothesized that ENI defined as a percentage change in the National Institute of Health Stroke Scale (NIHSS) score (percent change NIHSS score) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS score (delta NIHSS score) at 24 hours. Methods: Retrospective analysis of prospectively collected single-center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. We examined delta NIHSS score and percent change NIHSS score in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1). Results: Among 586 patients who met the inclusion criteria, 194 (33.1%) had a favorable outcome at 3 months. In fully adjusted models, both delta NIHSS score (OR per point decrease 1.27; 95% confidence interval [CI] 1.19-1.36) and percent change NIHSS score (OR per 10 percent decrease 1.17; 95% CI 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS score (.755) was greater than delta NIHSS score (.613) or admission NIHSS (.694). Conclusions: Percentage change in NIHSS score may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.     

Are in-Hospital Delays Important Obstacles in Thrombolytic Therapy Following Acute Ischemic Stroke?

Background and purpose

The advances in the diagnosis and treatment of acute stroke increase the importance of providing these patients with timely medical attention. This study was designed to assess time delays in neurological evaluation and neuroimaging and to determine whether they are important obstacles to performing thrombolytic therapy.

Methods

Data were obtained between May 2004 and September 2006 from 195 consecutive patients who were admitted to Cheju National University Hospital for acute ischemic stroke within 24 hours of the onset of symptoms. We determined the time of the onset of symptoms, arrival time at the emergency department (ED), and times of neurology notification, neurology evaluation, and neuroimaging using interviews and by reviewing the medical record.

Results

Short onset-to-door time, performing computed tomography rather than magnetic resonance imaging, presence of aphasia or motor weakness, and severe initial neurological deficit were significantly associated with reduced in-hospital delays. Seventeen (20%) of the 85 patients who arrived within 3 hours of the onset of symptoms received intravenous thrombolysis. Mild neurological deficit, rapidly improving symptoms, and insufficient time to workup were the main causes of the nonreceipt of thrombolytic therapy in these patients. Only one patient did not receive thrombolytic therapy due to delay in neurology consultation.

Conclusions

Whilst in-hospital delays were not major obstacles to performing thrombolytic therapy in this study, there is still a high probability of missing patients with mild-to-moderate stroke symptoms. More effective in-hospital organization is required for the prompt evaluation and treatment of patients with acute ischemic stroke.     

高血糖对急性缺血性卒中早期预后影响的初步研究

目的 探讨高血糖对急性缺血性卒中早期预后的影响。方法 采用前瞻性研究设计,连续纳入发病72h内入院的急性缺血性卒中患者143例。急诊入院时检测入院随机静脉血清血糖,高血糖定义为入院随机静脉血清血糖≥7.2mmol/L。入院时评定美国国立卫生研究院卒中量表（NIH Stroke Scale,NIHSS）评分,根据病史及辅助检查确定缺血性卒中类型（TOAST分型）。发病30d时进行改良Rankin’s评分（mRS）,作为评估早期预后的指标。结果 （1）本研究入选的143例急性缺血性卒中患者中,85例（59.4%）出现高血糖,单因素分析显示,年龄、糖尿病史、NIHSS评分是急性缺血性卒中合并高血糖的危险因素（P＜0.05）,logistic回归分析显示,糖尿病史、NIHSS评分是急性缺血性卒中合并高血糖的独立危险因素（P＜0.05）。（2）单因素分析显示,年龄、感染、高血糖、NIHSS评分和TOAST分型对mRS评分的影响有统计学差异（P＜0.05）,logistic回归分析显示,高血糖、NIHSS评分是预后不良的独立危险因素（P＜0.05）。结论 高血糖在急性缺血性卒中患者中的发生率较高,其出现与卒中的严重程度密切相关,可以作为反映急性缺血性卒中发病时病情较重的指标之一,高血糖是急性缺血性卒中早期预后不良的独立危险因素。     

Changes in coagulation and fibrinolysis markers in acute ischemic stroke treated with recombinant tissue plasminogen activator.

BACKGROUND AND PURPOSE: Shifts of the balance between coagulation and fibrinolysis play a crucial role in pathogenesis and treatment of cerebral ischemia. In this study, we characterized the kinetics of hemostatic abnormalities induced by acute ischemic stroke and its thrombolytic (recombinant tissue plasminogen activator [rtPA]) or anticoagulant (heparin) treatment. METHODS: Systemic generation of molecular markers of hemostasis (fibrin monomer, D-dimer, thrombin-antithrombin complex, and fibrinopeptide 1.2) was monitored in acute ischemic stroke, and the effects of thrombolytic and anticoagulant treatments were analyzed. RESULTS: Thrombolysis with rtPA induced a massive response of markers of coagulation activation and fibrin formation that peaked after 1 to 3 hours and persisted for up to 72 hours. In contrast, only minor hemostatic changes were induced by acute ischemic stroke itself. Administration of heparin did not significantly affect these hemostatic abnormalities. CONCLUSIONS: This first characterization of the coagulation activation induced by rtPA treatment for acute ischemic stroke and the failure to abolish such hemostatic abnormalities by heparin may be of value for further refinement of the currently discussed thrombolytic therapy and the controversial adjunctive anticoagulant prophylaxis in stroke patients.     

Derivation of a Prediction Rule for Unfavorable Outcome after Ischemic Stroke in the Chinese Population

Background

Efficient assessment of patients after ischemic stroke has important reference value for doctors to choose appropriate treatment for patients. Our study aimed to develop a new prognostic model for predicting outcomes 3 months after ischemic stroke among Chinese Population.

Factors affecting the outcome of delayed intravenous thrombolysis (> 4.5 hours)

IntroductionEvidence of the intravenous tissue plasminogen activator (tPA) efficacy beyond the 4.5 hours window is emerging. We aim to study the factors affecting the outcome of delayed thrombolysis in patients of clear onset acute ischemic stroke (AIS).MethodsData of patients with AIS who received intravenous thrombolytic after 4.5 hours were reviewed including: demographics, risk factors, clinical, laboratory, investigational and radiological data, evidence of mismatch, treatment type and onset, National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, 7 days after thrombolysis and before discharge, and 3 months follow-up modified Rankin Scale (mRS).ResultsWe report 136 patients treated by intravenous tPA between 4.53 and 19.75 hours with average duration of 5.7 h. The ASPECT score of our patients was ≥ 7. Sixty-four cases showed intracranial arterial occlusion. Perfusion mismatch was detected in 117 (84.6%) patients, while clinical imaging mismatch was detected in 19 (15.4%). Early neurological improvement after 24 hours occurred in 114 (83.8%) patients. At 90 days, 91 patients (67%) achieved good outcome (mRS 0–2), while 45 (33%) had bad outcome (mRS 3–6). Age, endovascular treatment, NIHSS, AF, and HT were significantly higher in the bad outcome group. Age (P = 0.001, OR: 1.099, 95% CI: 1.042–1.160) and baseline NIHSS were predictive of the poor outcome (P = 0.002, OR: 1.151, 95% CI: 1.055–1.256). The best cutoff value of age was 72.5 with AUC of 0.76, sensitivity 73.3% and specificity 60.4%. While for NIHSS at admission, the cutoff value of 7 showed the best results with AUC of 0.73, sensitivity 71.1% and specificity 63.7%. Combination of age and admission NIHSS raised the sensitivity and specificity to 84.4% and 63.7%, respectively.ConclusionIncreased age and admission NIHSS may adversely affect the outcome of delayed thrombolysis and narrow the eligibility criteria. Age and baseline NIHSS based stratification of the patients may provide further evidence as regards the efficacy of the delayed thrombolysis.     

The rtPA (alteplase) 0- to 6-hour acute stroke trial, part A (A0276g) : results of a double-blind, placebo-controlled, multicenter study. Thromblytic therapy in acute ischemic stroke study investigators

BACKGROUND AND PURPOSE: The Thrombolytic Therapy in Acute Ischemic Stroke Study, which started in August of 1991, was designed to assess the efficacy and safety of intravenous rtPA (alteplase) in patients with acute (0 to 6 hours) ischemic stroke. In October 1993 enrollment was halted because of Safety Committee (DMSB) concerns. In December 1993 the time window was changed to 0 to 5 hours, and it was decided to restart enrollment as a separate study (part B). We report here the results of the original study (part A), focusing on evaluating the safety and efficacy of rtPA given between 0 and 6 hours after stroke onset. METHODS: This investigation was a phase II, placebo-controlled, double-blind, randomized study utilizing 0.9 mg/kg IV rtPA or placebo over 1 hour, which was conducted at university and community sites in North America. Except for time to treatment, enrollment criteria were very similar to those of the NINDS rtPA stroke study. Primary efficacy end points were the number of patients with a decrease of 4 or more points on the National Institutes of Health Stroke Scale (NIHSS) at 24 hours and day 30, along with infarct volume at day 30. Secondary end points included mortality and functional recoveries on the Barthel Index and Modified Rankin scale at days 30 and 90. RESULTS: A total of 142 patients were enrolled at 42 sites in North America, including 22 <3 hours (15%) and 46 between 5 and 6 hours (32%). The groups were well matched on baseline characteristics, including NIHSS (mean of 13 for both). For the primary end points, a higher percentage of rtPA patients had a 4-point improvement at 24 hours (placebo 21%, rtPA 40%; P=0.02); however, this early effect was reversed by 30 days, with more placebo patients having a 4-point improvement (75%) than patients treated with rtPA (60%, P=0.05). Treatment with rtPA significantly increased the rate of symptomatic intracerebral hemorrhage within 10 days (11% versus 0%, P<0.01) and mortality at 90 days (23% versus 7%, P<0.01). CONCLUSIONS: This study found no significant rtPA benefit on any of the planned efficacy end points at 30 and 90 days in patients treated between 0 and 6 hours after stroke onset. These negative results apply to patients treated after 3 hours, because only 15% of the patients were enrolled before 3 hours. The risk of symptomatic intracerebral hemorrhage was increased with rtPA treatment, particularly in patients treated between 5 and 6 hours after onset. These results do not support the use of intravenous rtPA for stroke treatment >3 hours after onset.     

Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients

ObjectiveTo determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients.Materials and methodsThis prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days.ResultsAmong 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05).ConclusionsIn ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.