Factors associated with early improvement after intravenous thrombolytic treatment in acute ischemic stroke

OBJECTIVE

: The aim of this study was to determine the factors associated with early neurological improvement (ENI) in patients who experienced acute ischemic stroke and were treated with intravenous recombinant tissue plasminogen activator (IV rt-PA), and determine the relationship with the outcome at the first control.

METHOD

: This study included 377 patients who were treated with IV rt-PA in Izmir Dokuz Eylül University Hospital between January 2010 and October 2018. ENI was defined as a 4 or more improvement in the National Institutes of Health Stroke Scale (NIHSS) score in the first hour, the twenty-fourth hour and the seventh day when compared to the pretreatment phase. The modified Rankin Scale (mRS) 0-1 score was defined as 'very good outcome'.

RESULTS

: The basal NIHSS (p=0.003, p=0.003, p=0.022) was high in the first hour, twenty-fourth hour, and seventh day ENI groups. Blood urea nitrogen (BUN) level was low in the first- and twenty-fourth-hour ENI groups (p=0.007, p=0.020). Furthermore, admission glucose was low at the twenty-fourth hour and on the seventh day ENI groups (p=0.005, p=0.048). A high infarct volume was observed on magnetic resonance imaging (MRI) at the twenty-fourth hour and on the seventh day non-ENI groups (p= <0.001, p= <0.001).

CONCLUSION

: Management of factors associated with ENI and determination of treatment strategies accordingly are important for obtaining a better clinical outcome. It can help quickly select patients, who, even though they will not respond to rt-PA, may be appropriate candidates for bridging therapy.

Combined Treatment With 2-(2-Benzofu-Ranyl)-2-Imidazoline and Recombinant Tissue Plasminogen Activator Protects Blood-Brain Barrier Integrity in a Rat Model of Embolic Middle Cerebral Artery Occlusion

Recombinant tissue plasminogen activator (rt-PA) is used to treat acute ischemic stroke but is only effective if administered within 4.5 h after stroke onset. Delayed rt-PA treatment causes blood-brain barrier (BBB) disruption and hemorrhagic transformation. The compound 2-(-2-benzofuranyl)-2-imidazoline (2-BFI), a newly discovered antagonist of high-affinity postsynaptic N-methyl-D-aspartate (NMDA) receptors, has been shown to have neuroprotective effects in ischemia. Here, we investigated whether combining 2-BFI and rt-PA can ameliorate BBB disruption and prolong the therapeutic window in a rat model of embolic middle cerebral artery occlusion (eMCAO). Ischemia was induced in male Sprague Dawley rats by eMCAO, after which they were treated with 2-BFI (3 mg/kg) at 0.5 h in combination with rt-PA (10 mg/kg) at 6 or 8 h. Control rats were treated with saline or 2-BFI or rt-PA. Combined therapy with 2-BFI and rt-PA (6 h) reduced the infarct volume, denatured cell index, BBB permeability, and brain edema. This was associated with increased expression of aquaporin 4 (AQP4) and tight junction proteins (occludin and ZO-1) and downregulation of intercellular adhesion molecule 1 (ICAM-1) and matrix metalloproteinases 2 and 9 (MMP2 and MMP9). We conclude that 2-BFI protects the BBB from damage caused by delayed rt-PA treatment in ischemia. 2-BFI may therefore extend the therapeutic window up to 6 h after stroke onset in rats and may be a promising therapeutic strategy for humans. However, mechanisms to explain the effects oberved in the present study are not yet elucidated.

Protective effects of 2-(2-benzonfuranyl)-2-imidazoline combined with tissue plasminogen activator after embolic stroke in rats

Stroke is the third leading cause of death and disability in developing countries. The effective therapy for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (rt-PA) within 4.5 h of stroke onset. An effective post-ischemic neuroprotectant would extend the advantages of rt-PA, and protect against complications of thrombolysis. We previously reported that 2-(2-benzofuranyl)-2-imidazoline (2-BFI), a newly discovered ligand for high-affinity type 2 imidazoline receptor (I2R), provides neuroprotection against ischemic stroke in rats. Here we investigated the protective effects of 2-BFI in combination with delayed intravenous rt-PA after stroke induced by embolic middle cerebral artery occlusion (eMCAO) in rats. Infarct size was determined using 2,3,5-triphenyltrazolium chloride staining, while neurological deficit was assessed based on neurological score. Numbers of apoptotic cells in vivo were estimated using TUNEL stain, and expression of the pro-apoptotic protein BAX and anti-apoptotic protein BCL-2 were quantified by Western blotting. The results showed that 2-BFI (3 mg/kg) administered at 0.5 h after embolic MCAO combined with rt-PA (10 mg/kg) administered at 6 h reduced brain infarct size, mitigated neurological deficit, decreased the number of TUNEL-positive cells, down-regulated BAX expression, and up-regulated BCL-2 expression. These findings suggest that 2-BFI may extend the therapeutic window of rt-PA to 6 h after embolic stroke onset in rats.

The protective effect of 2-(2-benzonfu-ranyl)-2-imidazoline against oxygen-glucose deprivation in cultured rat cortical astrocytes

Astrocytes play a pivotal role in neuronal survival in the setting of post-ischemic brain inflammation, but the astrocyte-derived mediators of ischemic brain injury remain to be defined. 2-(2-Benzofu-ranyl)-2-imidazoline (2-BFI) is a newly discovered ligand for high-affinity imidazoline I2 receptors (I2Rs) mainly located on the mitochondrial outer membrane in astrocytes. We previously reported that in a rat model of cerebral ischemia-reperfusion injury, 2-BFI limits infarct volume, reduces neurological impairment scores, and inhibits neuronal apoptosis in the ischemic penumbra. This study was performed to clarify the underlying mechanism in an astrocyte oxygen-glucose deprivation (OGD) model. The results show that 2-BFI reduces lipid peroxidation and inhibits mitochondria apoptotic pathways.

Efficacy of Citalopram on Acute Ischemic Stroke Outcome: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Ischemic stroke (IS) is one of the main causes of death and disability in the adult population, and recovery from it is a major health concern worldwide. The aim of the present study was to evaluate the effectiveness of citalopram on 3-mounth outcome of nondepressed acute IS patients.

METHODS

In a randomized, placebo-controlled clinical trial, 144 patients with acute IS were studied for 3 months. In one group, the patients received oral citalopram 20 mg (once daily), and in the other group, they received placebo. All patients received standard care, including physiotherapy. Patients with depression were excluded throughout the study. The primary outcome of the study was set to a 50% reduction in the 3-month National Institutes of Health Stroke Scale compared with the baseline scores (Clinical Trial Registration URL: http://www.irct.ir ; Unique identifier: IRCT201203192150N2).

RESULTS

The mean age of patients was 66.4 years. Of 144 eligible patients, 15 patients died (4 in the citalopram and 11 in the placebo group), and 21 patients did not complete the study follow-up period (10 in the citalopram and 11 in the placebo group). The primary outcome of the study was achieved in 57 patients (79%) in the citalopram and 39 patients (54%) in the placebo group ( P < .001), with risk ratio and number needed to treat of 2 (CI = 1.2-3) and 4 (CI = 2.5-8.6), respectively. No major adverse events were found in either group.

CONCLUSIONS

Citalopram is a safe and tolerable medication in patients with acute IS, which could improve the outcome in these patients.

Electroencephalographic markers of robot-aided therapy in stroke patients for the evaluation of upper limb rehabilitation

Stroke is the leading cause of permanent disability in developed countries; its effects may include sensory, motor, and cognitive impairment as well as a reduced ability to perform self-care and participate in social and community activities. A number of studies have shown that the use of robotic systems in upper limb motor rehabilitation programs provides safe and intensive treatment to patients with motor impairments because of a neurological injury. Furthermore, robot-aided therapy was shown to be well accepted and tolerated by all patients; however, it is not known whether a specific robot-aided rehabilitation can induce beneficial cortical plasticity in stroke patients. Here, we present a procedure to study neural underpinning of robot-aided upper limb rehabilitation in stroke patients. Neurophysiological recordings use the following: (a) 10-20 system electroencephalographic (EEG) electrode montage; (b) bipolar vertical and horizontal electrooculographies; and (c) bipolar electromyography from the operating upper limb. Behavior monitoring includes the following: (a) clinical data and (b) kinematic and dynamic of the operant upper limb movements. Experimental conditions include the following: (a) resting state eyes closed and eyes open, and (b) robotic rehabilitation task (maximum 80 s each block to reach 4-min EEG data; interblock pause of 1 min). The data collection is performed before and after a program of 30 daily rehabilitation sessions. EEG markers include the following: (a) EEG power density in the eyes-closed condition; (b) reactivity of EEG power density to eyes opening; and (c) reactivity of EEG power density to robotic rehabilitation task. The above procedure was tested on a subacute patient (29 poststroke days) and on a chronic patient (21 poststroke months). After the rehabilitation program, we observed (a) improved clinical condition; (b) improved performance during the robotic task; (c) reduced delta rhythms (1-4 Hz) and increased alpha rhythms (8-12 Hz) during the resting state eyes-closed condition; (d) increased alpha desynchronization to eyes opening; and (e) decreased alpha desynchronization during the robotic rehabilitation task. We conclude that the present procedure is suitable for evaluation of the neural underpinning of robot-aided upper limb rehabilitation.

Acute development of collateral circulation and therapeutic prospects in ischemic stroke

In acute ischemic stroke, collateral circulation plays an important role in maintaining blood flow to the tissue that is at risk of progressing into ischemia, and in increasing the successful recanalization rate without hemorrhagic transformation. We have reported that well-developed collateral circulation is associated with smaller infarct volume and better long-term neurological outcome, and it disappears promptly once the effective recanalization is achieved. Contrary to the belief that collateral vessels develop over time in chronic stenotic condition, there exists a phenomenon that collateral circulation develops immediately in acute stenosis or occlusion of the arteries and it seems to be triggered by fluid shear stress, which occurs between the territories of stenotic/occluded arteries and those fed by surrounding intact arteries. We believe that this acute development of collateral circulation is a target of novel therapeutics in ischemic stroke and refer our recent attempt in enhancing collateral circulation by modulating sphingosine-1-phosphate receptor 1, which is a known shear-stress mechanosensing protein.

Vascular Risk Factors in Patients with Different Subtypes of Ischemic Stroke May Affect Their Outcome after Intravenous tPA

Intravenous (IV) tissue-type plasminogen activator (tPA) is the only approved noninvasive therapy for acute ischemic stroke (AIS). However, after tPA treatment, the outcome of patients with different subtypes of stroke according to their vascular risk factors remains to be elucidated. We aim to explore the relationship between the outcome and different risk factors in patients with different subtype of acute strokes treated with IV tPA. Records of patients in this cohort were reviewed. Data collected and analysed included the demographics, vascular risk factors, baseline National Institutes of Health Stroke Scale (NIHSS) scores, 90-day modified Rankin Scores (mRS), and subtypes of stroke. By using the 90-day mRS, patients were dichotomized into favorable versus unfavorable outcome in each subtype of stroke. We identified the vascular risk factors that are likely associated with the poor outcome in each subtype. Among 570 AIS patients received IV tPA, 217 were in the large artery atherosclerosis (LAA) group, 146 in the small vessel occlusion(SVO) group, and 140 in the cardioaortic embolism(CE) group. Lower NIHSS score on admission was related to favorable outcome in patients in all subtypes. Patients with history of dyslipidemia were likely on statin treatment before their admission and hence less likely to have elevated cholesterol level on admission. Therefore, there was a possible paradoxical effect on the outcome in patients with LAA and SVO subtypes of strokes. SVO patients with history of diabetes had higher risk of unfavorable outcome. SVO patients had favorable outcome if their time from onset to treatment was short. In conclusion, the outcome of patients treated with IV tPA may be related to different vascular risk factors associated with different subtypes of stroke.

Significance of Development and Reversion of Collaterals on MRI in Early Neurologic Improvement and Long-Term Functional Outcome after Intravenous Thrombolysis for Ischemic Stroke

BACKGROUND AND PURPOSE

Predicting response to rtPA is essential in the era of endovascular therapy for stroke. The purpose of this study was to elucidate prognostic factors of early neurologic improvement and long-term outcome with respect to the development and reversion of leptomeningeal collaterals in recanalization therapy after acute ischemic stroke.

MATERIALS AND METHODS

We analyzed consecutive patients with proximal MCA occlusion treated with rtPA from 2007 to 2012 at 2 hospital stroke centers. All patients routinely underwent brain MR imaging before rtPA. To assess the reversion of collateral signs, we included patients who underwent follow-up MR imaging. We assessed the development and reversion of collaterals by using a combination of 2 MR imaging collateral markers, the hyperintense vessel sign and the posterior cerebral artery laterality sign. Early neurologic improvement was defined as a decrease in the NIHSS score of ≥10 or a score of ≤2 at 24 hours of treatment.

RESULTS

Early neurologic improvement was observed in 22 of 48 eligible patients. The development of collaterals at arrival (15/22 versus 9/26, P = .042) was significantly associated with early neurologic improvement. Multivariate analysis adjusting for other variables showed that the development of collaterals at arrival (OR, 4.82; 95% CI, 1.34-19.98; P = .015) was independently associated with early neurologic improvement. Reversion of collaterals was significantly associated with successful recanalization (P < .001), and multivariate analysis showed that the reversion of collaterals was an independent prognostic factor of long-term functional outcome (OR, 5.07; 95% CI, 1.38-22.09; P = .013).

CONCLUSIONS

Our results indicate that the development of leptomeningeal collaterals plays a crucial role in achieving early neurologic improvement, and reversion of collaterals predicts a favorable outcome via arterial recanalization after rtPA treatment for acute stroke.

Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – A Randomized Monocentric Trial

Background

The optimal peri-interventional management of sedation and airway for endovascular stroke treatment (EST) appears to be a crucial factor for treatment success. According to retrospective studies, the widely favored general anesthesia with intubation seems to be associated with poor functional outcome compared to a slightly sedated non-intubated condition (conscious sedation).

Method

SIESTA is a monocentric, prospective, randomized parallel-group, open-label treatment trial with blinded endpoint evaluation (PROBE design). The study compares the non-intubated with the intubated state in patients receiving endovascular treatment of acute ischemic anterior circulation stroke. The primary endpoint is early neurological improvement as by National Institutes of Health Stroke Scale (NIHSS) after 24 h (difference between NIHSS on admission and NIHSS after 24 h). Secondary endpoints include: functional outcome after three-months as by modified Rankin Scale (mRS), mortality, parameters of ventilation and critical care, feasibility, and safety, i.e. complications related to endovascular stroke treatment.

Conclusion

The aims of this study are to prospectively clarify whether the non-intubated state of conscious sedation is feasible, safe, and superior with regard to early neurological improvement compared to the intubated state of general anesthesia in patients receiving acute endovascular stroke treatment.

Safety and outcome of thrombolysis in mild stroke: a meta-analysis

Background

Whether patients presenting with mild stroke should or should not be treated with intravenous rtPA is still controversial. This systematic review aims to assess the safety and outcome of thrombolysis in these patients.

Material/Methods

We systematically searched PubMed and Cochrane Central Register of Controlled Trials for studies evaluating intravenous rtPA in patients with mild or rapidly improving symptoms except case reports. Excellent outcome (author reported, mainly mRS 0-1), symptomatic intracranial hemorrhage (sICH) and mortality were analyzed.

Results

Fourteen studies were included (n=1906 patients). Of these, 4 studies were comparative (2 randomized and 2 non-randomized). The remaining were single-arm studies. On the basis of 4 comparative studies with a total of 1006 patients, the meta-analysis did not identify a significant difference in the odds of excellent outcome (OR=0.86; 95% CI: 0.64–1.15; I²=0) between IV rtPA-treated minor stroke and those without rtPA treatment. Eleven studies involving 1083 patients showed the pooled rate of excellent outcome was 76.1% (95% CI: 69.8–81.5%, I²=42.5). Seven studies involving 378 patients showed the mortality rate was 4.5% (95% CI: 2.6–7.5%, I²=1.4). Twelve studies involving 831 patients showed the pooled rate of sICH was 2.4% (95% CI: 1.5–3.8, I²=0).

Conclusions

Although efficacy is not clearly established, this study reveals the adverse event rates related to thrombolysis are low in mild stroke. Intravenous rtPA should be considered in these patients until more RCT evidence is available.

Early and continuous neurologic improvements after intravenous thrombolysis are strong predictors of favorable long-term outcomes in acute ischemic stroke

BACKGROUND

Intravenously administered tissue plasminogen activator (IV tPA) remains the only approved therapeutic agent for arterial recanalization in acute ischemic stroke (AIS). Considerable proportion of AIS patients demonstrate changes in their neurologic status within the first 24 hours of intravenous thrombolysis with IV tPA. However, there are little available data on the course of clinical recovery in subacute 2- to 24-hour window and its impact. We evaluated whether neurologic improvement at 2 and 24 hours after IV tPA bolus can predict functional outcomes in AIS patients at 3 months.

METHODS

Data for consecutive AIS patients treated with IV tPA within 4.5 hours of symptom onset during 2007-2011 were prospectively entered in our thrombolyzed registry. National Institutes of Health Stroke Scale (NIHSS) scores were recorded before IV tPA bolus, at 2 and 24 hours. Early neurologic improvement (ENI) at 2 hours was defined as a reduction in NIHSS score by 10 or more points from baseline or an absolute score of 4 or less points at 2 hours. Continuous neurologic improvement (CNI) was defined as a reduction of NIHSS score by 8 or more points between 2 and 24 hours or an absolute score of 4 or less points at 24 hours. Favorable functional outcomes at 3 months were determined by modified Rankin Scale (mRS) score of 0-1.

RESULTS

Of 2460 AIS patients admitted during the study period, 263 (10.7%) received IV tPA within the time window; median age was 64 years (range 19-92), with 63.9% being men, a median NIHSS score of 17 points (range 5-35), and a median onset-to-treatment time of 145 minutes (range 57-270). Overall, 130 (49.4%) thrombolyzed patients achieved an mRS score of 0-1 at 3 months. The female gender, age, and baseline NIHSS score were found to be significantly associated with CNI on univariate analysis. On multivariate analysis, NIHSS score at onset and female gender (odds ratio [OR]: 2.218, 95% confidence interval [CI]: 1.140-4.285; P=.024) were found to be independent predictors of CNI. Factors associated with favorable outcomes at 3 months on univariate analysis were younger age, female gender, hypertension, NIHSS score at onset, recanalization on transcranial Doppler (TCD) monitoring or repeat computed tomography (CT) angiography, ENI at 2 hours, and CNI. On multivariate analysis, NIHSS score at onset (OR per 1-point increase: .835, 95% CI: .751-.929, P<.001), 2-hour TCD recanalization (OR: 3.048, 95% CI: 1.537-6.046; P=.001), 24-hour CT angiographic recanalization (OR: 4.329, 95% CI: 2.382-9.974; P=.001), ENI at 2 hours (OR: 2.536, 95% CI: 1.321-5.102; P=.004), and CNI (OR: 7.253, 95% CI: 3.682-15.115; P<.001) were independent predictors of favorable outcomes at 3 months.

CONCLUSIONS

Women are twice as likely to have CNI from the 2- to 24-hour period after IV tPA. ENI and CNI within the first 24 hours are strong predictors of favorable functional outcomes in thrombolyzed AIS patients.

Clinical outcomes after intravenous fibrinolysis in cryptogenic strokes with or without patent foramen ovale

BACKGROUND

Pivotal clinical trials suggest that intravenous (IV) recombinant tissue plasminogen activator (rt-PA) benefits stroke patients regardless of the underlying etiology. Paradoxical strokes, presumed to be caused by fibrin-rich clots originating in the venous circulation, may respond better to fibrinolysis than other ischemic stroke subtypes. In this study, we compared the response with IV rt-PA in paradoxical stroke patients and other stroke subtypes.

METHODS

In total, 486 patients treated with IV rt-PA at a single institution were retrospectively reviewed. Adjudication of stroke mechanism was based on chart review. Five major stroke mechanisms--cardioembolic, artery-to-artery emboli, lacunar, cryptogenic, and paradoxical--were identified by final diagnosis from chart reviews. Mimics, undefined etiology, and defined etiology not falling into the major mechanisms were excluded. Analysis of variance and general linear model were used to assess the differences between groups.

RESULTS

A total of 323 patients were analyzed. We found significant differences in clinical outcome between stroke mechanisms, including discharge National Institutes of Health Stroke Scale (NIHSS) (P=.007), discharge Rankin (P=.011), discharge disposition (P=.000), and infarct volume (P=.007). Post hoc analysis showed that cardioembolic patients had the worst outcomes (discharge NIHSS score 11.12±12.26), whereas paradoxical strokes had the best outcomes (discharge NIHSS score 3.67±4.90), but these did not approach statistical significance. However, regression analysis showed that 4 variables--congestive heart failure, admission NIHSS, age, and mean infarct volume--rather than stroke mechanism were the true predictors of poor outcome.

CONCLUSIONS

Paradoxical strokes had better outcomes after IV fibrinolysis than other ischemic stroke subtypes, but this difference is attributable to younger age and milder stroke severity on presentation.

Impact of CHADS(2) 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.

NIHSS scores in ischemic small vessel disease: a study in CADASIL

BACKGROUND

The National Institutes of Health Stroke Scale (NIHSS) is widely used to measure neurological deficits, evaluate the effectiveness of treatment and predict outcome in acute ischemic stroke. It has also been used to measure the residual neurological deficit at the chronic stage after ischemic events. However, the value of NIHSS in ischemic cerebral small vessel disease has not been specifically evaluated. The purpose of this study was to investigate the link between the NIHSS score and clinical severity in a large population of subjects with CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy), a unique model to investigate the pathophysiology and natural history of ischemic small vessel disease.

METHODS

Demographic and clinical data of 220 patients with one or more lacunar infarcts confirmed by MRI examination and enrolled from a prospective cohort study were analyzed. Detailed neurological examinations, including evaluation of the NIHSS and modified Rankin Scale score (mRS) for evaluating the clinical severity, were performed in all subjects. The sensitivity, specificity, positive and negative predictive values of various NIHSS thresholds to capture the absence of significant disability (mRS <3) were calculated. General linear models, controlling for age, educational level and different clinical manifestations frequently observed in CADASIL, were used to evaluate the relationships between NIHSS and clinical severity.

RESULTS

In the whole cohort, 45 (20.5%) subjects presented with mRS ≥3, but only 16 (7.3%) had NIHSS >5. All but 1 subject with NIHSS >5 showed mRS ≥3. NIHSS ≤5 had an 85.3% positive predictive value for no or slight disability with only 33.3% specificity. The NIHSS, MMSE score and presence or absence of gait disturbances were found to be strongly and independently correlated with disability (all p < 0.001). Altogether, they accounted for 73% of the variance of mRS in contrast with the NIHSS alone accounting for only 50% of this variance. Among patients with NIHSS ≤5, subjects with mRS ≥3 showed a lower MMSE score than those with mRS <3 (p < 0.001). All patients with NIHSS ≤5 but with mRS ≥3 presented either with gait disturbances or MMSE score <25.

CONCLUSIONS

The present results suggest that the NIHSS cannot reflect the extent of neurological deficit and clinical severity in subjects with lacunar infarctions in the context of a chronic and diffuse small vessel disease. A specific and global neurological scale, including the assessment of cognitive and gait performances, should be developed for ischemic cerebral microangiopathy.

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.

Outcome after systemic thrombolysis is predicted by age and stroke severity: an open label experience with recombinant tissue plasminogen activator and tirofiban

Stroke patients can recover upon intravenous thrombolysis but remain impaired in lacking recanalization. We sought to investigate the clinical effect of systemic thrombolysis with an intravenous bolus of 20 mg recombinant tissue plasminogen activator (rtPA) and an infusion of body-weight adjusted tirofiban for 48 hours in acute stroke. This prospective, open label study, included 192 patients (68±13 years, 50% males) treated between 1 January 2005 and 31 December 2007. The neurological deficit was assessed with the National Institutes of Health stroke scale (NIHSS). Follow-up was performed using a telephone interview of modified Rankin Scale (mRS) and Barthel index. The site of cerebral artery occlusion was determined by computed tomography or magnetic resonance angiography. Data were analyzed by descriptive statistics and multiple regression analyses. Eighty-one percent of the patients had an infarct in the middle cerebral artery (MCA) territory and were severely affected with a median NIHSS of 10. During treatment on the Stroke Unit the patients improved (P<0.0001) except for patients who deceased due to malignant infarction (n=10) or cerebral haemorrhage (n=6); 18 percent deceased within 100 days which was predicted by older age (76 + 10 years, P<0.05) and more severe affection on admission (P<0.0001). Also, these patients more frequently had atrial fibrillation (P<0.03) than the surviving patients. The surviving patients had more frequently distal MCA occlusions and improved further (P<0.0001). At follow-up 48% of the patients had a mRS of 0 and 1. Similarly to intravenous thrombolysis with body-weight adjusted rtPA, poor prognosis was predicted by higher age, more severe neurological deficit at stroke admission, and a proximal MCA occlusion. Half of the surviving patients improved to no or minimal impairment.

Functional exercise and physical fitness post stroke: the importance of exercise maintenance for motor control and physical fitness after stroke

It is argued that all stroke patients, indifferent of disability, have the same possibility to improve with training. The aim of the study was to follow and register functional improvements in two groups with different functional capacities at baseline for a period of 36 months. Stroke patients were recruited and divided into groups related to their functional status at baseline. During the acute rehabilitation, both groups received functional task-oriented training, followed by regular self- or therapeutic driven training the first year after stroke and varied exercise patterns the following 24 months. The participants were tested on admission, and at three, six, twelve, and thirty-six months after the onset of stroke. Both groups improved functional activity up to six months which then stabilized up to twelve months to decline somewhat at thirty-six months after stroke. Change scores indicate a greater potential for rehabilitation in the MAS ≤35 in relation to group MAS >35 although the functional capacity was higher in the latter. This indicates the importance of maintaining exercise and training for all persons after stroke.