Intravenous thrombolysis for acute ischemic stroke in Greece: the Safe Implementation of Thrombolysis in Stroke registry 15-year experience

Background:

Intravenous thrombolysis (IVT) remains the only approved systemic reperfusion treatment for acute ischemic stroke (AIS), however there are scarce data regarding outcomes and complications of IVT in Greece. We evaluated safety and efficacy outcomes of IVT for AIS in Greece using the Safe Implementation of Thrombolysis in Stroke: International Stroke Thrombolysis Register (SITS-ISTR) dataset.

Methods:

All AIS patients treated with IVT in Greece between December 2002 and July 2017 and recorded in the SITS-ISTR were evaluated. Demographics, risk factors, baseline stroke severity [defined using National Institutes of Health Stroke Scale (NIHSS)], and onset-to-treatment time (OTT) were recorded. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 3-month mortality rates. The efficacy outcomes evaluated a reduction in baseline NIHSS score at 2 and 24 h following IVT onset, 3-month favorable functional outcome [FFO; modified Rankin scale (mRS) scores of 0–1] and 3-month functional independence (FI; mRS-scores of 0–2). The safety and efficacy outcomes were assessed comparatively with previously published data from SITS national and international registries.

Results:

A total of 523 AIS patients were treated with IVT in 12 Greek centers participating in the SITS-ISTR during the study period (mean age 62.4 ± 12.7; 34.6% women; median baseline NIHSS score: 11 points; median OTT: 150 min). The rates of sICH were 1.4%, 2.3%, and 3.8% according to the SIST-MOST, ECASS II, and NINDS criteria respectively. The median reduction in NIHSS score at 2 and 24 h was 3 [interquartile range (IQR): 1–5] and 5 (IQR: 2–8) points respectively. The 3-month FI, FFO and mortality were 66.5%, 55.6% and 7.9%. All safety and efficacy outcomes were comparable with available data from SITS-ISTR in other European countries.

Conclusions:

Our study underscores the safety and efficacy of IVT for AIS in Greece. Additional action is necessary in order to increase the availability of IVT in the Greek population and to include more centers in the SITS-ISTR.

Acute ischemic stroke: comparison of low-dose and standard-dose regimes of tissue plasminogen activator

Intravenous tissue plasminogen activator (IV-TPA), administered within 4.5 h of symptom onset, is the only therapeutic agent approved for achieving arterial recanalization in acute ischemic stroke. Current major guidelines recommend the use of a standard dose (0.9 mg/kg bodyweight; maximum 90 mg) of IV-TPA. However, comparable efficacy of IV-TPA was demonstrated in the observational studies from Japan when a lower dose (0.6 mg/kg bodyweight; maximum 60 mg) was used and later approved by the regulatory authorities. Although limited in numbers, considerable variations in the dose of IV-TPA are noted in recent publications from Asia, with variable results and optimal dose of TPA in Asia remains controversial. The authors present a systemic review of the existing literature and compare the efficacy and safety of standard-versus the low-dose IV-TPA therapy in acute ischemic stroke.

Differences in process management and in-hospital delays in treatment with iv thrombolysis

OBJECTIVES

Rapid initiation of intravenous thrombolysis improves patient's outcome in acute stroke. We analyzed inter-center variability and factors that influence the door-to-needle time with a special focus on process measurements in all Austrian stroke units.

METHODS

Case level data of patients receiving intravenous thrombolysis in the Austrian Stroke Unit Registry were enriched with information of a structured questionnaire on center specific process measures of all Austrian stroke units. Influence of case and center specific variables was determined by LASSO procedure.

RESULTS

Center specific median door-to-needle time ranged between 30 and 78 minutes. Between April 2004 and November 2012, 6246 of 57991 patients treated in Austrian stroke units with acute ischemic stroke received intravenous thrombolysis. An onset-to-door time >120 minutes, patients with total anterior circulation stroke, recent year of admission, patient transportation with ambulance crew and emergency physician, the use of point of care tests reduced the door-to-needle time, whereas onset-to-door ≤ 60 minutes, unknown onset-to-door, patients with an NIHSS ≤ 4 or posterior circulation stroke, initial admission to a general emergency department, a distant radiology department, primary imaging modality other than plain CT and waiting for the lab results were associated with an increase in door-to-needle time. Case level and center specific factors could explain the inter center variability of door-to-needle times in 31 of 34 stroke units in Austria.

CONCLUSIONS

In light of our results it seems crucial that every single stroke center documents and critically reviews possibilities of optimizing practice strategies in acute stroke care.

Imaging and treatment of patients with acute stroke: an evidence-based review

Evidence-based medicine has emerged as a valuable tool to guide clinical decision-making, by summarizing the best possible evidence for both diagnostic and treatment strategies. Imaging plays a critical role in the evaluation and treatment of patients with acute ischemic stroke, especially those who are being considered for thrombolytic or endovascular therapy. Time from stroke-symptom onset to treatment is a strong predictor of long-term functional outcome after stroke. Therefore, imaging and treatment decisions must occur rapidly in this setting, while minimizing unnecessary delays in treatment. The aim of this review was to summarize the best available evidence for the diagnostic and therapeutic management of patients with acute ischemic stroke.

Intravenous thrombolysis in acute ischemic stroke after POLKARD: one center analysis of program impact on clinical practice

PURPOSE

Intravenous thrombolysis in the acute ischemic stroke was initiated in Poland within the National Cardiovascular Disease Prevention and Treatment Program POLKARD in the years 2003-2008. Since 2009 the procedure has been reimbursed by the National Health Fund (Narodowy Fundusz Zdrowia - NFZ). The purpose of the presented study was to assess whether the change of financing institution was associated with the change in proportion of patients treated and with any of the clinical parameters or stroke outcomes.

PATIENTS AND METHODS

We reviewed the data of the 90 consecutive patients with acute ischemic stroke treated with intravenous thrombolysis within 3-hours from symptoms onset. The differences between the POLKARD period and the year 2009, regarding clinical parameters, time delays, death rates and functional outcomes on day 90 after the stroke were analyzed. The association of outcome measures with baseline characteristics of the patients was analyzed with binary logistic regression.

RESULTS

In 2009 there was a significant increase in the proportion of patients treated (7.6%, 95%CI 5.3-10.7%, vs. 4.3%, 95%CI 3.3-5.5% respectively, p=0.013). There were no differences in age, baseline neurological presentation, prevalence of stoke risk factors, treatment time delays or hemorrhagic complications. Higher, but not significantly, 90-day mortality was observed (32.1%, 95%CI 13.3-54.1% vs. 16.1%, 95%CI 6.4-29.7% respectively, p=0.101). Baseline neurological deficits and in-hospital treatment time delays were significant predictors of disability and death.

CONCLUSIONS

After the Polish Ministry of Health program POLKARD termination and elimination of the reimbursement limits, higher proportion of ischemic stroke patients could be treated with the intravenous thrombolysis.