Early magnetic resonance imaging findings in patients receiving tissue plasminogen activator predict outcome: Insights into the pathophysiology of acute stroke in the thrombolysis era

We measured ischemic brain changes with diffusion and perfusion MRI in 42 ischemic stroke patients before and 2 hours (range approximately 1.5 to 4.5 hours) after standard intravenous tissue plasminogen activator (tPA) therapy. The median time from stroke onset to tPA was 131 minutes. Clinical and MRI variables (change in perfusion and/or diffusion weighted lesion volume) were compared between those with excellent outcome defined as 3-month modified Rankin score (mRS) of 0 to 1 and those with incomplete recovery (mRS >1). In multivariate logististic regression analysis, the most powerful independent predictor for excellent outcome was improved brain perfusion: hypoperfusion volume on mean transit time (MTT) map decrease >30% from baseline to 2-hour post tPA scan (p=0.009; odds ratio [95% confidence interval], 20.7 [2.1-203.9]). Except for age < 70 years, no other baseline clinical or imaging variable was an independent predictor of outcome. We propose MTT lesion volume decrease more than 30% 2 hours after tPA as an early marker of long-term clinical benefit of thrombolytic therapy.     

Inverse relationship of baseline body temperature and outcome between ischemic stroke patients treated and not treated with thrombolysis: the Bergen stroke study

Naess H, Idicula T, Lagallo N, Brogger J, Waje‐Andreassen U, Thomassen L. Inverse relationship of baseline body temperature and outcome between ischemic stroke patients treated and not treated with thrombolysis: the Bergen stroke study.
Acta Neurol Scand: 2010: 122: 414–417.
© 2010 The Authors Journal compilation © 2010 Blackwell Munksgaard. Background – High body temperature may promote clot lysis whereas low body temperature is neuroprotective in patients with cerebral infarction. We hypothesized that high body temperature is associated with favorable outcome in patients treated with tissue plasminogen activator (tPA) and that low body temperature is associated with favorable outcome in patients not treated with tPA. Methods – Patients (n = 111) who were treated with tPA and patients (n = 139) who were not treated with tPA, but presented within 6 h of stroke onset were included. Patients with no temperature measurements within 6 h of stroke onset were excluded. National Institute of Health Stroke Scale (NIHSS) score was obtained on admission. Modified Rankin score (mRS) was obtained after 1 week. Favorable outcome was defined as mRS 0–2 and unfavorable outcome as mRS 3–6. Results – On logistic regression analysis, high body temperature was independently associated with favorable outcome among patients treated with tPA (OR = 3.7, P = 0.009) and low body temperature was independently associated with favorable prognosis among patients not treated with tPA (OR = 2.0, P = 0.042). Conclusions – Our study suggests that the effect of high body temperature on clot lysis is more important than the neuroprotective effect of low body temperature in the early phase after cerebral infarction treated with tPA.     

Outcome of MRI-based intravenous thrombolysis in carotid-T occlusion

Low recanalization rates and poor clinical outcome have been reported after intravenous thrombolysis (IV-tPA) in carotid-T occlusion (CTO). We studied clinical outcome and imaging findings of MRI-based intravenous thrombolysis in CTO. Data of patients with acute ischemic stroke and CTO treated with IV-tPA within 6?h of symptom onset based on MRI criteria were retrospectively analyzed. Vessel occlusion was defined based on MR angiography. Acute diffusion and perfusion lesion volumes and final infarct volumes after 3-7?days were delineated. The National Institutes of Health Stroke Scale (NIHSS) was used to assess the neurological deficit on admission. Recanalization was evaluated after 24?h. Clinical outcome was assessed using the modified Rankin Scale (mRS) after 90?days. Clinical and imaging data were compared to patients with middle cerebral artery main stem occlusion (MCAO). A total of 20 patients with CTO and 51 patients with MCAO were studied. Onset to treatment time, NIHSS on admission, initial diffusion and perfusion lesion volumes, and recanalization rates after 24?h were similar between groups. Final infarct volume was larger for CTO (82 vs. 30?ml, p?=?0.006). Although overall outcome was not significantly different between groups (p?=?0.251), independent outcome (mRS 0-2) tended to be less frequent in CTO (17 vs. 39?%), while poor outcome (mRS 4-6) appeared more common (72 vs. 43?%). The proportion of patients with good clinical outcome after intravenous thrombolysis in CTO is small. Moreover, final infarct volume is larger and clinical outcome appears to be worse compared to MCAO.     

Analysis of 16,922 patients with acute ischemic stroke and transient ischemic attack in Japan. A hospital-based prospective registration study

OBJECTIVE: The purpose of the present study was to clarify the present status of stroke medicine in Japan using a hospital-based, prospective registration study of 156 hospitals from all over Japan. METHODS: Consecutive patients with acute ischemic stroke and transient ischemic attack (TIA) who presented to hospital within 7 days of onset from May 1999 to April 2000 were enrolled in this study. A common protocol was applied in every participating hospital. RESULTS: A total of 16,922 patients (TIA, 6.4%) with a mean age of 70.6 +/- 11.5 years (median 71 years, range 18-107 years) were enrolled in the study. Lacunar stroke was the most frequent stroke subtype (38.8%), followed by atherothrombotic (33.3%), cardioembolic (21.8%) and other stroke (6.1%). NIH stroke scale score on admission was 8.0 +/- 7.9 (median 5; 25th to 75th percentile, 2-11). 36.8% arrived at hospital within 3 h of symptom onset, and 49.5% within 6 h. The ambulance was used for 70.2% of patients arriving within 3 h after onset, but in only 29.9% of patients visiting the hospital later than 3 h after onset (p < 0.0001). 60.8% displayed good outcome (modified Rankin Scale score of 0-2 at discharge), while 32.3% displayed poor outcome (score 3-5), and mortality rate was 6.9%. CONCLUSIONS: More than half of the acute stroke patients arrived at hospital later than 6 h after onset. Establishment of ideal emergency systems is needed for better management of stroke and for improvement of patient outcome, in particular, in the future after approval of intravenous recombinant tissue plasminogen activator for acute ischemic stroke by the Japanese government.     

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.     

Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000.

CONTEXT: Intravenous tissue-type plasminogen activator (tPA) therapy using the National Institute of Neurological Disorders and Stroke criteria has been given with variable safety to less than 5% of the patients who have ischemic strokes nationwide. Our center is experienced in treating large numbers of stroke patients with intravenous tPA. OBJECTIVE: To report our total 4-year experience in the treatment of consecutive patients who had an ischemic stroke. DESIGN: Prospective inception cohort registry of all patients seen by our stroke team and an additional retrospective medical record review of all patients treated between January 1, 1996, and June 1, 2000. SETTING: A veteran stroke team composed of fellows and stroke-specialty faculty servicing 1 university and 3 community hospitals in a large urban setting. PATIENTS: Consecutive patients with ischemic stroke treated within the first 3 hours of symptom onset. INTERVENTION: According to the National Institute of Neurological Disorders and Stroke protocol, 0.9 mg/kg of intravenous tissue-type plasminogen activator was administered. MAIN OUTCOME MEASURES: Number and proportion treated, patient demographics, time to treatment, hemorrhage rates, and clinical outcome. RESULTS: A total of 269 patients were treated between January 1, 1996, and June 1, 2000. Their mean age was 68 years (age range, 24-93 years); 48% were women. This represented 9% of all patients admitted with symptoms of cerebral ischemia at our most active hospital (over the final 6 months, 13% of all patients with symptoms of cerebral ischemia and 15% of all acute ischemic stroke patients). Before treatment the mean +/- SD National Institutes of Health Stroke Scale (NIHSS) score was 14.4 +/- 6.1 points (median, 14 points; range, 4-33 points). A tPA bolus was given at 137 minutes (range, 30-180 minutes); 28% of the patients were treated within 2 hours. The mean door-to-needle time was 70 minutes (range, 10-129 minutes). The symptomatic intracerebral hemorrhage rate was 5.6% of those patients with a second set of brain scans (4.5% of all patients), with a declining trend from 1996 to 2000. Protocol violations were found in 13% of all patients; the symptomatic intracerebral hemorrhage rate in these patients was 15%. At 24 hours, the NIHSS score was 10 +/- 8 points (median, 8 points; range, 0-36 points). In-hospital mortality was 15% and the patients' discharge NIHSS scores were 7 +/- 7 points (median, 3 points; range, 0-35 points). CONCLUSIONS: Intravenous tPA therapy can be given to up to 15% of the patients with acute ischemic stroke with a low risk of symptomatic intracerebral hemorrhage. Successful experience with intravenous tPA therapy depends on the experience and organization of the treating team and adherence to published guidelines.     

The Cologne stroke experience: safety and outcome in 450 patients treated with intravenous thrombolysis

BACKGROUND: Predictors of outcome and safety in intravenous thrombolysis within 3 h in clinical routine is a matter of ongoing debate. Available reports contain small patient numbers or summarize heterogeneous multicenter data. METHODS: Four hundred and fifty patients received intravenous thrombolysis within 3 h after stroke. Pretreatment NIHSS score and detailed medical history were analyzed. Noncontrast CT was performed before thrombolysis, 24-36 h later and in case of clinical deterioration. Symptomatic intracranial hemorrhage (SICH; any bleeding with an NIHSS increase of > or =4 points) and clinical outcome (modified Rankin Scale, mRS) after 3 months were recorded. Logistic regression identified parameters predictive of independence (mRS 0-2) and SICH. RESULTS: Median onset to admission, door to needle and onset to treatment time was 75, 50 and 135 min, respectively. Direct presentation by emergency service (64%) was the fastest way of referral. Median pretreatment NIHSS was 11 points. Independence (mRS 0-2) was reached by 53%. Mortality was 11% (7% intracerebral, 4% extracerebral complications). Logistic regression identified low NIHSS, low age and absent diabetes as predictors of independence. Overall hemorrhagic complications and SICH were found in 18 and 4% of the patients, respectively. Extracerebral bleeding complications and allergic reactions were found in 3 and 1%, respectively. CONCLUSION: This largest single center report presents a sample in the range of the 3 h rt-PA cohort of all randomized controlled trials. Outcome was comparable to randomized studies with a higher rate of independence and a lower rate of mortality and SICH.     

The sNIHSS-4 predicts outcome in right and left anterior circulation strokes

Background and purpose

Stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS) is a strong predictor of functional outcome.A short version, the sNIHSS-5, scoring only strength in right and left leg, gaze, visual fields and language, was developed for use in the prehospital setting. Because scoring both legs in anterior circulation strokes is not contributive, we assessed the value of a 4-item score (the sNIHSS-4), omitting the item ‘strength in the unaffected leg’, in predicting stroke outcome.

Methods

The study population consisted of anterior circulation ischemic stroke patients who participated in the LUB-INT-9 trial. We included all patients in whom the following data were available: NIHSS within 6 h after stroke onset and daily between days 2 and 5, and the 12-week modified Rankin Scale (mRS) score. Poor outcome was defined as a mRS score > 3.

Results

There was an excellent correlation between the NIHSS and sNIHSS-4 at all time points for both left and right-sided strokes. Scores at day 2 were a good predictor of poor outcome. Cutoff scores for NIHSS and sNIHSS-4 at day 2 were 15 and 5 in left hemispheric strokes, and 12 and 4 in right hemispheric strokes.

Conclusion

The sNIHSS-4 is as good as the NIHSS at predicting stroke outcome in both right and left anterior circulation strokes.     

Predictors of good prognosis in total anterior circulation infarction within 6 h after onset under conventional therapy

OBJECTIVE: We investigated the predictors of good prognosis in total anterior circulation infarction (TACI), under conventional therapy. METHODS: We enrolled 166 patients with first-ever ischemic stroke within 6 h after onset with symptoms of TACI. Sixty-three patients (38.0%) with good outcome [G group, the modified Rankin Disability Scale (mRS) after 3 months < or =3] and 103 patients (62.0%) with bad outcome (B group, mRS >3) were compared. RESULTS: On univariate analysis, G group patients were significantly younger, had lower score in the National Institutes of Health Stroke Scale (NIHSS) of total and consciousness sub-score, had lower rate of clinical deterioration. On cranial CT at entry, three early CT signs [hyperdense middle cerebral artery (MCA) sign, hypodensity of >1/3 MCA and brain swelling] were significantly more frequent in the B group. On the second CT at 24-48 h, infarct area as assessed by the Alberta Stroke Programme Early CT Score (ASPECTS) was significantly smaller in the G group. Multivariate analysis with logistic regression revealed age <7 0 years, NIHSS < or =15, no clinical deterioration, and only no brain swelling in early CT signs, and ASPECTS > or =7 as independent predictors of good prognosis. CONCLUSIONS: Some clinical variables are useful in predicting outcome in TACI within the early period after stroke onset.     

Perfusion Computed Tomography-Guided Intravenous Thrombolysis for Acute Ischemic Stroke beyond 4.5 Hours: A Case-Control Study

Background: Extending the therapeutic window of intravenous thrombolysis for acute ischemic stroke beyond the established 4.5-hour limit is of critical importance in order to increase the proportion of thrombolysed stroke patients. In this setting, the capacity of MRI to select acute stroke patients for reperfusion therapies in delayed time windows has been and is being tested in clinical trials. However, whether the more available and cost-effective perfusion computed tomography (PCT) may be useful to select candidates for delayed intravenous thrombolysis remains largely unexplored. We aimed to evaluate the safety and efficacy of PCT-guided intravenous thrombolysis beyond 4.5 h after stroke onset. Methods: We prospectively studied all consecutive acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA) in our stroke unit between January 2008 and December 2010. Patients treated within 0- 4.5 h were treated according to non-contrast CT (NCCT) criteria. Beyond 4.5 h, patients received intravenous tPA according to PCT criteria, i.e. an infarct core on cerebral blood volume (CBV) maps not exceeding one third of the middle cerebral artery (MCA) territory and tissue at risk as defined by mean transit time-CBV mismatch greater than 20%. Predetermined primary endpoints were symptomatic hemorrhagic transformation and favorable long-term outcome, while early neurological improvement and MCA recanalization were considered secondary endpoints. Statistical analysis included bivariate comparisons between the two groups for each endpoint and logistic regression models when significance was found in bivariate analyses. This study was approved by our local ethics committee. Results: A total of 245 patients received intravenous thrombolysis. After the groups were matched by baseline National Institutes of Health Stroke Scale score, 172 patients treated at <4.5 h and 43 patients treated at >4.5 h were finally included. Early and late groups were comparable regarding baseline variables; only cardioembolic etiology was more frequent in the >4.5 h group. Rates of symptomatic hemorrhagic transformation (2.9% in the <4.5 h group vs. 2.3% in the >4.5 h group; p = 1.0) and good long-term outcome (64.5 vs. 60.5%, respectively; p = 0.620) were similar between the groups. However, delayed intravenous thrombolysis was independently associated with a worse early clinical course [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.04-4.1; p = 0.038] and lower 2-hour MCA recanalization rates (OR 0.4, 95% CI 0.17-0.92; p = 0.03). Conclusion: Primary safety and efficacy endpoints were comparable between the early and delayed thrombolysis groups. The results of our exploratory study may justify a randomized clinical trial to test the safety and efficacy of PCT-guided intravenous thrombolysis in acute ischemic stroke patients presenting beyond 4.5 h from symptom onset.     

Off-label intravenous thrombolysis in acute stroke

Background and purpose:  Therapy for stroke with intravenous tissue plasminogen activator (IV‐tPA) is hampered by tight licensing restrictions; some of them have been discussed in recent literature. We assessed the safety and effectiveness of off‐label IV‐tPA in the clinical settings. Methods:  Retrospective analysis of all the patients treated with IV‐tPA at our Stroke Unit. Patients were divided into two groups by licence criteria [on‐label group (OnLG), off‐label group (OffLG)]. Primary outcome measures were symptomatic intracranial haemorrhages (sICH), major systemic haemorrhages, modified Rankin scale (mRS) and mortality rate at 3 months. Results:  Five hundred and five patients were registered, 269 (53.2%) were assigned to OnLG and 236 (46.9%) to OffLG. Inclusion criteria for the OffLG were aged >80 years (129 patients), time from onset of symptoms to treatment over 3 h (111), prior oral anticoagulant treatment with International Normalised Ratio ≤ 1.7 (41), combination of previous stroke and diabetes mellitus (14), surgery or severe trauma within 3 months of stroke (13), National Institutes of Health Stroke Scale score over 25 (11), intracranial tumours (5), systemic diseases with risk of bleeding (7) and seizure at the onset of stroke (2). No significant differences were identified between both groups regarding the proportion of sICH (OnLG 2.2% vs. OffLG 1.6%, P = 0.78) or the 3‐month mortality rate (11.1% vs. 19%: odds ratio (OR), 1.49; 95% CI, 0.86–2.55; P = 0.14). Multivariate analysis showed no significant differences in functional independence at 3 months between both groups (mRS <3 64.3% vs. 50.4%: OR mRS >2 1.7; 95% CI, 0.96–2.5; P = 0.07). Conclusion:  Intravenous thrombolysis may be safe and efficacious beyond its current label restrictions.     

Impact of CHADS2 Score on Neurological Severity and Long-Term Outcome in Atrial Fibrillation-Related Ischemic Stroke

Background and Purpose

The CHADS₂ (an acronym for congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack or thromboembolism) score is a widely used system for estimating the risk of stroke in patients with atrial fibrillation. However, how the CHADS₂ score is related to stroke severity and outcome in patients with strokes due to atrial fibrillation has not yet been elucidated.

Methods

We enrolled patients with atrial fibrillation who visited our stroke center within 7 days after the onset of acute ischemic stroke between October 2002 and September 2008. CHADS₂ scores were categorized into three groups: 0 points, low risk; 1 or 2 points, intermediate risk; and 3-6 points, high risk. Poor neurological state was defined as follows: a National Institutes of Health Stroke Scale (NIHSS) score of ≥2, and a modified Rankin Scale (mRS) score of ≥3 at discharge. Mortality information was ascertained as at December 2008.

Results

A cohort of 298 patients with atrial-fibrillation-related stroke was included in this study. A high-risk CHADS₂ score at admission was a powerful predictor of poor neurological outcome [for NIHSS: odds ratio (OR), 4.17; 95% confidence interval (CI), 1.76-9.87; for mRS: OR, 2.97; 95% CI, 1.23-7.16] after controlling for all possible confounders. In addition, a high-risk CHADS₂ score was an independent predictor of all causes of death during the follow-up [hazard ratio (HR), 3.01; 95% CI, 1.18-7.65] and vascular death (HR, 12.25; 95% CI, 1.50-99.90).

Conclusions

Although the CHADS₂ score was originally designed to distinguish patients with a future risk of stroke, our study shows that it may also be used to predict poor neurological outcome after atrial-fibrillation-related stroke.     

Intravenous tissue plasminogen activator (t-PA) for acute ischemic stroke in a local university hospital]

Thrombolytic therapy for ischemic stroke has not been approved in Japan yet. However, we have used intravenous t-PA for acute ischemic stroke patients. We reviewed the clinical data on patients who were treated with intravenous t-PA and entered in the stroke registry of our hospital between April 1999 and March 2004. Of 408 acute ischemic stroke patients, 20 patients (mean age 73.6 +/- 10.9, male 15, female 5) were given intravenous t-PA (alteplase in 18 patients and monteplase in two patients). The baseline NIH Stroke Scale (NIHSS) and Japan Stroke Scale (JSS) scores were 17.5 (median) and 13.3 +/- 7.6 (mean), respectively. The NIHSS and JSS at discharge were 12.5 and 12.1 +/- 11.8, respectively. Symptomatic intracerebral hemorrhage occurred in one patient. The rate of favorable outcome (mRS 0-3) at 90 days was 40%. The rate of favorable outcome at 90 days in our study was lower than that in reported randomized trials of intravenous t-PA, such as the NINDS study or the ATIANTIS trial, perhaps because age and baseline severity were higher in our patients than in the subjects in these trials. Another reason may be the dose of t-PA. As we concerned about the occurrence of symptomatic intracranial hemorrhage and there are no data on appropriate dose of t-PA for Japanese patients, the dose of t-PA that we used was 0.4 mg/kg in most patients. Although five patients died in our study, the cause of death in four patients was not hemorrhagic transformation but deteriorating ischemic infraction. The dose of t-PA that we used may have been safe but a little low for thrombolysis.     

Management of Stroke in Patients with Left Ventricular Assist Devices

IntroductionThe number of patients with left ventricular assist devices (LVAD) is rapidly growing in industrialized countries. While cerebrovascular events comprise a significant complication, data on stroke etiology, clinical management and functional outcome are scarce.MethodsConsecutive LVAD patients with ischemic or hemorrhagic stroke receiving treatment at an university stroke center between 2010 and 2018 were included into an institutional registry. Clinical characteristics, causes, management and functional outcome of stroke occurring within this cohort are reported. Acceptable functional outcome was defined as mRS 0-3.ResultsN = 30 acute strokes occurred in 20 patients (77% ischemic, 23% hemorrhagic, mean age 57 ± 13 years, 10% female, 8 patients (40%) had more than one event). 87% of all events happened with non-pulsatile devices, on average 9 (IQR 3-22) months after the implantation. All patients used oral anticoagulation with a Vitamin-K antagonist in combination with anti-platelets. The international normalized ratio (INR)-values were outside the therapeutic range in 39% of ischemic strokes and in 57% of hemorrhagic strokes. Ischemic strokes were predominantly of cardioembolic origin (92%) and of mild to moderate clinical severity (median NIHSS 6 (IQR 4-10). None qualified to receive intravenous thrombolysis or intra-arterial endovascular therapy. 61% of IS-patients showed an acceptable functional outcome after three months. 4/7 patients with hemorrhagic stroke received immediate reversal of anticoagulation without any thrombotic complications.ConclusionThe majority of LVAD patients with ischemic stroke had an acceptable functional outcome after three months. Future clinical research is warranted to improve therapeutic strategies for acute care and stroke prevention.     

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。     

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

BACKGROUND: The administration of tissue plasminogen activator (t-PA) has been proven effective for ischemic stroke within 3 h after onset. A pooled-analysis of six trials showed that intravenous t-PA still improves outcome when given between 3 to 4.5 h after stroke onset. On the basis of this pooled analysis, t-PA was also routinely offered to our patients between 3-4.5 h. We report the safety and clinical features of this group together with the features of the group given t-PA within 3 h. METHODS: Prospectively patient characteristics, stroke severity, stroke subtype, incidence of symptomatic intracerebral hemorrhage (SICH), in-hospital mortality, and 3-months modified Rankin Scale scores (mRS) were registered. Data was analyzed separately for patients treated within 3 h (early group) and those treated between 3-4.5 h (late group). RESULTS: Among 176 patients who underwent intravenous thrombolysis, 101 were treated in the early group and 75 in the late group. Six (5.9%; 95% CI 2.8%-12.3%) patients in the early group and 4 (5.3%; 95% CI 2.2%-12.9%) in the late group developed SICH (p=1.0). In the early group 13 (12.9%; 95% CI 7.7%-20.8%) patients died within 7 days after admission, compared to 5 (6.7%; 95% CI 3.0%-14.7%) in the late group (p=0.179). In the early group 44 (43.6%; 95% CI 43.3%-53.3%) were independent (mRS< or =2) at three months, compared to 36 (48.0%; 95% CI 37.0%-59.1%) in the late group (p=0.559). CONCLUSION: Our data show no trend of decreased safety of thrombolysis beyond 3 h. Due to a small sample size a harmful effect cannot be excluded but seems unlikely.     

Emergency Carotid Artery Stent Insertion for Acute ICA Occlusion

Objective

An effective intervention has not yet been established for patients with acute occlusion of the internal carotid artery (ICA). The aim of our study was to investigate the feasibility, safety, and efficacy of emergent stent placement of carotid artery to improve neurologic symptoms and clinical outcome.

Methods

Of 84 consecutive patients with severe ICA stenosis who were admitted to our institution from March 2006 to May 2009, 10 patients with acute ICA occlusion (11.9%) underwent emergency carotid artery stent placement. We reviewed their records for neurologic outcome using the National Institutes of Health Stroke Scale (NIHSS) score, before and at 7 days after stent placement; clinical outcome using the modified Rankin Scale score (mRS) and Glasgow Outcome Scale (GOS); frequency of procedure-related complications; and recurrence rate of ipsilateral ischemic stroke within 90 days.

Results

Carotid lesions were dilated completely in all patients. Median NIHSS scores before emergency stent placement and at 7 days were 16.6 and 6, respectively, showing significant improvement. Eight patients (80%) had favorable outcomes (mRS score 0-2 and GOS 4-5). Complications occurred in two patients (20%): stent insertion failed in one and an intracerebral hemorrhage occurred in the other. Ipsilateral ischemic stroke did not recur within 3 months.

Conclusion

Emergency carotid artery stent placement can improve the 7-day neurologic outcome and the 90-day clinical outcome in selected patients with acute cerebral infarction.     

The yield of expanding the therapeutic time window for tPA

OBJECTIVES: Intravenous thrombolysis with recombinant tissue plasminogen activator (tPA) for acute ischemic stroke has been proved to be effective when given within 3 h of onset of stroke symptoms. Partly due to this time limit, less than 10% of stroke patients are treated with tPA. This study assessed the potential for increased tPA utilization with a theoretical time limit of 6 h. MATERIALS AND METHODS: A total of 117 patients admitted with a diagnosis of acute cerebrovascular disease were prospectively registered over a 3-month period, with emphasis on timing and criteria for tPA treatment. RESULTS: Eighty-eight of 117 patients (75%) had an acute ischemic stroke. Of these, 23% arrived within 3 h, 8% within 3-6 h, and 69% later than 6 h after symptom onset. Of the seven patients in the 3-6 h group, only one had time delay as the only contraindication to tPA. CONCLUSIONS: This study suggests that reducing patient delay, rather than increasing the time limit for thrombolytic treatment, may increase the frequency of tPA utilization. Changing time limits for thrombolysis may reduce time delay from stroke onset to arrival in hospital due to more rapid handling of patients by the emergency medical services.     

代谢综合征对急性脑梗死早期预后的影响

目的 探讨急性脑梗死早期预后的影响因素，分析代谢综合征（metabolic syndrome，MS）是否为急性脑梗死早期预后的独立影响因素。方法 采用前瞻性研究设计，纳入连续性急性脑梗死163例，发病1个月时进行改良Rankin量表（mRS）评分作为结局变量，0=mRS 0～2，1=mRS 3～5；急诊入院时进行美国国立卫生研究院卒中量表(NIHSS)评分、格拉斯哥昏迷量表（GCS）评分；依据病史及辅助检查确定TOAST分型。以性别、年龄、吸烟、饮酒、NIHSS评分、GCS评分、TOAST分型、合并症[感染、心肌梗死（MI）、心衰（HF）]、是否合并MS为自变量作单因素分析。多因素分析采用两分类logistic回归，自变量为多分类时采用变量哑化技术。结果 单因素分析结果发现，性别（P <0.05）、吸烟史（P＜0.05）、NIHSS评分（P <0.01）、GCS评分（P <0.01）、TOAST分型（P <0.01）、感染（P <0.01）、HF（P <0.05）、MS（P <0.01）对早期预后（mRS评分）的影响有统计学差异。多因素分析结果发现，MS（OR 3.869，95%CI 1.542～9.711，P <0.01）、NIHSS评分（OR 19.699，95%CI 2.107～184.134，P <0.01）、TOAST分型（OR 0.188，95%CI 0.067～0.525，P <0.01）、感染（OR 2.950，95%CI 1.202～7.238，P＜0.05）对mRS有统计学差异。结论 MS、NIHSS评分、TOAST分型、感染是预后差的独立危险因素。这对急性脑梗死的预后评价、对MS高危人群实施干预提供了可靠的依据。     

The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models

Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7–30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0–11.5 %, and 3.4–31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.