Intravenous tissue plasminogen activator for acute ischemic stroke: feasibility, safety, and efficacy in the first year of clinical practice

Knowledge of stroke and the window period for thrombolytic therapy in ischemic stroke among South Indians: A hospital-based survey with educational intervention

Objectives

The objective of this study was to determine the awareness of stroke in regards to the risk factors, warning symptoms, and knowledge of the therapeutic window period among varied strata of non-medical people attending a tertiary care center.

Materials and Methods

The interventional study involved the collection of data regarding awareness of stroke using a structured questionnaire with a total score of 16. Pre-intervention assessment was followed by intervention in the form of education regarding awareness of stroke administered one-on-one for personalized and effective comprehension by subjects. Then, subjects were asked to recall the information that was delivered to them and were scored accordingly.

Results

Among the 500 subjects included, 51% were female. About 76.8% of participants were young (age <50 years), and 83.4% were literate. Only 25.4% of participants were aware of the brain as the site of stroke. About 32.2% of candidates were aware of a few risk factors for stroke. Among them, the majority of participants were aware of hypertension (24%) as a risk factor. The most known warning symptom was "Numbness" or weakness of arm. The majority of the subjects (97.8%) were unaware of a therapeutic window period for stroke being 4.5 h or below. The mean pre-intervention score was 2.52 ± 1.65 while the mean post-intervention score was 15.10 ± 1.79 (P < 0.0001).

Conclusion

The study showed that even among literate participants, only a meager number of subjects were aware of the golden window period of intravenous thrombolysis. Educational intervention by means of an in-person and one-on-one explanation achieved significant levels of understanding of stroke. The study could be used to formulate large-scale educational programs that focus on spreading awareness of symptoms and risk factors while also instilling the importance of timely medical intervention for efficient thrombolytic therapy.

Oxygen-loaded microbubble-mediated sonoperfusion and oxygenation for neuroprotection after ischemic stroke reperfusion

BACKGROUND

Ischemic stroke-reperfusion (S/R) injury is a crucial issue in the protection of brain function after thrombolysis. The vasodilation induced by ultrasound (US)-stimulated microbubble cavitation has been applied to reduce S/R injury through sonoperfusion. The present study uses oxygen-loaded microbubbles (OMBs) with US stimulation to provide sonoperfusion and local oxygen therapy for the reduction of brain infarct size and neuroprotection after S/R.

METHODS

The murine S/R model was established by photodynamic thrombosis and thrombolysis at the remote branch of the anterior cerebral artery. In vivo blood flow, partial oxygen pressure (pO₂), and brain infarct staining were examined to analyze the validity of the animal model and OMB treatment results. The animal behaviors and measurement of the brain infarct area were used to evaluate long-term recovery of brain function.

RESULTS

The percentage of blood flow was 45 ± 3%, 70 ± 3%, and 86 ± 2% after 60 min stroke, 20 min reperfusion, and 10 min OMB treatment, respectively, demonstrating sonoperfusion, and the corresponding pO₂ level was 60 ± 1%, 76 ± 2%, and 79 ± 4%, showing reoxygenation. After 14 days of treatment, a 87 ± 3% reduction in brain infarction and recovery of limb coordination were observed in S/R mice. The expression of NF-κB, HIF-1α, IL-1β, and MMP-9 was inhibited and that of eNOS, BDNF, Bcl2, and IL-10 was enhanced, indicating activation of anti-inflammatory and anti-apoptosis responses and neuroprotection. Our study demonstrated that OMB treatment combines the beneficial effects of sonoperfusion and local oxygen therapy to reduce brain infarction and activate neuroprotection to prevent S/R injury.

Safety and efficacy of low-dose rt-PA with tirofiban to treat acute non-cardiogenic stroke: a single-center randomized controlled study

BACKGROUND AND PURPOSE

The recanalization rate after intravenous thrombolysis (IVT) is not enough and there is still the possibility of re-occlusion. We aim to investigate the effectiveness and safety of infusing tirofiban after IVT.

METHODS

We performed a prospective controlled study of 60 patients with acute non-cardiogenic ischemic stroke who were hospitalized in Yantai Yuhuangding Hospital from January 2018 to December 2019. The patients were divided into 2 groups: those who received tirofiban for 24 h after IVT (rt-PA + T group) and those who did not receive postprocedural intravenous tirofiban (rt-PA group). The rt-PA + T group received low-dose rt-PA (0.6 mg/kg). The rt-PA group received standard dose rt-PA (0.9 mg/kg). The main outcome measure were safety, included the symptomatic intracranial hemorrhage (sICH), any ICH, severe systemic bleeding, and mortality. The secondary outcome measure is curative efficacy which were evaluated by the 7d-NIHSS score and functional outcomes at 90 days. During hospitalization, the deterioration of neurological function was recorded.

RESULTS

All patients completed the follow-up with complete data, there were 30 patients in each of groups. The general characteristics between the two group patients had no statistically significant differences. Compared with the rt-PA + T group and the rt-PA group, in terms of safety, the rates of the sICH, severe systemic bleeding, and mortality in both groups were 0, and there was no statistically significant difference in the rates of any ICH between the two groups (10.0% vs. 3.3%, P = 0.306). In terms of efficacy, the rate of the early neurological deterioration events (END) was no statistical significance (0 vs. 6.6%, P = 0.246). There was no significant difference in the NIHSS score between the two groups before the IVT, and also at 24 h, however, the 7d-NIHSS score was lower in the rt-PA + T group compared with the rt-PA group (2.33 ± 1.85 vs. 4.80 ± 4.02, P = 0.004). At 90 days, 83.3% of patients in the rt-PA + T group had favorable functional outcomes compared with 60.0% of patients in the rt-PA group (P = 0.045).

CONCLUSIONS

Low-dose rt-PA combined with tirofiban in acute non-cardiogenic ischemic stroke did not increase the risk of ICH, and mortality, and it was associated with neurological improvement.

TRIAL REGISTRATION

The trial has been registered at the ChiCTR and identified as ChiCTR1800014666 (28/01/2018).

A Review of Risk Factors and Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

Acute ischemic strokes (AIS) and hemorrhagic strokes lead to disabling neuropsychiatric and cognitive deficits. A serious and fatal complication of AIS is the occurrence of hemorrhagic transformation (HT). HT is cerebral bleeding that occurs after an ischemic event in the infarcted areas. This review summarises how specific risk factors such as demographic factors like age, gender, and race/ethnicity, comorbidities including essential hypertension, atrial fibrillation, diabetes mellitus, congestive heart failure, and ischemic heart disease along with predictors like higher NIHSS score, larger infarction size, cardioembolic strokes, systolic blood pressure/pulse pressure variability, higher plasma glucose levels, and higher body temperature during ischemic event, lower low-density lipoprotein and total cholesterol, early ischemic changes on imaging modalities, and some rare causes make an individual more susceptible to developing HT. We also discuss few other risk factors such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels in patients postreperfusion using thrombolysis and mechanical thrombectomy. In addition, we discuss the implications of dual antiplatelet therapy and the length of treatment in reference to the incidence of developing HT. Current research into inflammatory mediators and biomarkers such as Cyclooxygenase-2, matrix metalloproteinases, and soluble ST2 and their potential role as treatment options for HT is also briefly discussed. Finally, this review calls for more research into use of dual antiplatelet and the timing of antiplatelet and anticoagulant use in reference to hemorrhagic transformation.

Low versus standard dose intravenous alteplase in the treatment of acute ischemic stroke in Egyptian patients

Objectives:

To assess low dose altepase outcome and safety in comparison with a standard-dose regimen for acute ischemic stroke treatment in Egyptian patients.

Materials:

An observational prospective cohort non-randomized single blinded study was carried out during the period from November 2017 to December 2018. Eighty Egyptian acute ischemic stroke patients, all eligible for intravenous alteplase, were subdivided into 2 groups (40 patients in each group). Patients were thrombolysed at a dose of 0.6 mg/kg in the first group and 0.9 mg/kg in the second group. Both groups were compared in regard to safety and outcome. Safety was expressed by the rate of symptomatic intracranial hemorrhage (SICH) and 3 months mortality, while outcome was expressed by favorable outcomes at three months (modified Rankin Scale [mRS] of 0 to 2).

Results:

In the first group, 69.2% (n=27) achieved favorable outcomes at 90 days compared with 64.1% (n=25) in the second group (p=0.631). Ninety-day mortality was 5% (n=2) in the first group versus 2.5% (n=1) in the second group (p=0.556). Symptomatic intracranial hemorrhage was noted in 3 patients in the second group and zero patients in the first group (p=0.077).

Conclusion:

Low-dose alteplase could be a practical alternative for Egyptian populations with acute ischemic stroke especially in 3 to 4.5 hours window.

Outcomes of thrombolytic therapy in acute ischemic stroke: mothership, drip-and-ship, and ship-and-drip paradigms

Background

Chulalongkorn Stroke Center is a comprehensive stroke center (CSC) located in Bangkok, Thailand. Our stroke network consists of different levels of spoke hospitals, ranging from community hospitals where thrombolytic treatment is not available, to those capable of onsite thrombolytic therapy. This study aimed to assess the time to treatment and outcomes among acute ischemic stroke patients who received thrombolytic treatment in the Chulalongkorn Stroke Network by 1.) Direct arrival at the CSC (mothership) 2.) Telestroke-assisted thrombolytic treatment with secondary transfer to the CSC (drip-and-ship) 3.) Referral from community hospital to the CSC for thrombolytic treatment (ship-and-drip).

Methods

Acute ischemic stroke patients who received thrombolytic treatment during January 2016–December 2017 in the Chulalongkorn Stroke Network were studied. Time to treatment and clinical outcomes were compared among treatment groups.

Results

There were 273 patients in the study including 147, 87, and 39 patients in mothership, drip-and-ship, and ship-and-drip paradigms, respectively. The door-to-needle-time (DTN) and onset-to-needle-time (OTN) times were significantly longest in ship-and-drip group (146.5 ± 62/205.03 ± 44.88 mins) compared to mothership (38 ± 23/155.2 ± 60.54 mins) and drip-and-ship (63.0 ± 44/166.09 ± 87 mins), P < 0.05. There was no significant difference regarding functional independence defined by modified Rankin Scale (mRS) ≤ 2 at 3 months (P = 0.12), in-hospital mortality (P = 0.37), mortality at 3 months (P = 0.73), and symptomatic intracerebral hemorrhage (P = 0.24) among groups.

Conclusion

Thrombolytic treatment with drip and ship method under teleconsultation is feasible in Thailand. There was no difference of clinical outcome among the 3 treatment paradigms. However, DTN time and OTN time were longest in the ship-and-drip paradigm.

Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention

BACKGROUND

Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window.

OBJECTIVE

We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times.

METHODS

Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%.

RESULTS

The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY.

CONCLUSION

II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.

Imbalanced Regional Development of Acute Ischemic Stroke Care in Emergency Departments in China

Objective

Most patients of acute ischemic stroke (AIS) receive treatments in the department of emergency in China. We aimed to examine the status of AIS diagnosis and treatment and the impact of green pathway operation in different regions of China.

Methods

In this nationwide survey, information regarding the emergency care of AIS was collected from 451 hospitals in different regions of China, by interviewing 484 physicians from these hospitals. Structured questionnaire was used to explore the status of AIS care and impact of the green pathway.

Results

445 hospitals from 18 provinces, 4 municipalities, and 3 ethnic autonomous regions in China were included in the present study. Overall, the proportion of door-to-needle time (DNT) less than 60 min was 66.08% in the enrolled hospitals (n = 298). Stratified by regions, the results suggested that hospitals located in East regions had shorter DNT time (P=0.036), and more proportion of rtPA (P < 0.001) than those in West regions. Further analysis suggested that hospitals with a green channel were more likely to shorten DNT and improve the proportion of rtPA (P < 0.01).

Conclusion

Considerable regional differences were observed in terms of DNT time and thrombolysis rates in the departments of emergency in China. Further studies are required to confirm the regional differences in AIS care in China.

The Yellow Scale Is Superior to the Gray Scale for Detecting Acute Ischemic Stroke on a Monitor Display in Computed Tomography

RATIONALE AND OBJECTIVES

The purpose of this study was to compare the efficacy of the color scale with regard to focal detection with computed tomography in acute ischemic stroke.

MATERIALS AND METHODS

Computed tomography images of the brain of 19 patients diagnosed with acute stroke, based on magnetic resonance diffusion-weighted images obtained within an onset of 24 hours, and the images of five normal patients were displayed in each color look-up table on a monitor. The detection of acute stroke was compared among 15 radiologists. The images were compared in the gray, green, yellow, red, and blue scales of the look-up tables. The observers recorded acute ischemic stroke as "present" or "absent." They also located the position of the stroke lesion and described the degree of their conviction as to whether a lesion existed. Detection was evaluated by receiver operating characteristic analysis. The area under the receiver operating characteristic curves was compared. In addition, reduced fatigue and the ease in image observation were compared.

RESULTS

Compared to the other scales, the yellow scale had a significantly higher area under the receiver operating characteristic curve, which indicated that this scale allowed better detection of acute ischemic stroke. The gray scale produced the least fatigue in image observation.

CONCLUSIONS

The detection of acute ischemic stroke is improved by changing the display monitor from the gray scale to the yellow scale. From the perspective of color psychology, yellow is associated with higher arousal, cheerfulness, confidence, creativity, and excitement. Therefore, the yellow scale may be suitable for a medical imaging display.

Effect of Combination Therapy with Neuroprotective and Vasoprotective Agents on Cerebral Ischemia

Because most tested drugs are active against only one of the damaging processes associated with stroke, other mechanisms may cause cellular death. Thus, a combination of protective agents targeting different pathophysiological mechanisms may obtain better effects than a single agent. The major objective of this study was to investigate the effect of combination therapy with vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) after controlled ischemic brain injury in rabbits.Methods:Animals were randomly assigned to one of the following groups: sham group, saline-treated control group or NGF+VEGF-treated group. Animals received an intracerebral microinjection of VEGF and NGF or saline at 5 or 8 hours after ischemia. The two specified time points of administration were greater than or equal to the existing therapeutic time window for monoterapy with VEGF or NGF alone (3 or 5 hours of ischemia). Infarct volume, water content, neurological deficits, neural cell apoptosis and the expression of caspase-3 and Bcl-2 were measured.Results:Compared with saline-treated controls, the combination therapy of VEGF and NGF significantly reduced infarct volume, water content, neural cell apoptosis and the expression of caspase-3, up-regulated the expression of Bcl-2 and improved functional recovery (bothp<0.01) when administered 5 or 8 hours after ischemia. The earlier the administration the better the neuroprotection.Conclusions:These results showed that the combination therapy with VEGF and NGF provided neuroprotective effects. In addition, the time window of combination treatment should be at least 8 hours after ischemia, which was wider than monotherapy.RÉSUMÉ:Les effets d’une polythérapie combinant agents neuro-protecteurs et agents vasoprotecteurs dans les cas d’ischémie cérébrale.Contexte:Étant donné que la plupart des médicaments préalablement testés tendent à n’agir contre seulement un des processus de dommage associés aux AVC, il est possible que d’autres processus entraînent une mort cellulaire. À cet effet, il se pourrait qu’une combinaison d’agents protecteurs ciblant divers mécanismes physiopathologiques permette d’obtenir de meilleurs résultats qu’un simple agent. Après avoir suscité de façon contrôlée des lésions cérébrales ischémiques chez des lapins, l’objectif principal de la présente étude a donc été de se pencher sur l’impact d’une polythérapie combinant la protéine dite « facteur de croissance de l’endothélium vasculaire » (ou « VEGF » en anglais) avec le « facteur de croissance des nerfs » (ou « NGF » en anglais).Méthodes:Les animaux ont été attribués au hasard à l’un des groupes suivants : ceux ayant reçu un traitement fictif ; ceux, du groupe témoin, ayant bénéficié d’un traitement à base de solution saline ; et finalement ceux ayant été traités au moyen des VEGF et NGF. À noter que les lapins ont reçu une micro-injection intracérébrale de VEGF et de NGF ou de solution saline 5 heures ou 8 heures à la suite de leur AVC. Ces deux délais d’administration des VEGF et NGF sont équivalents ou supérieurs aux délais actuels d’administration des VEGF ou NGF à titre de monothérapie (3 heures ou 5 heures à la suite d’un AVC). Tant le volume des infarctus, le contenu en eau, les déficits neurologiques ainsi causés, l’apoptose des neurones que l’expression des protéases caspase 3 et des protéines Bcl-2 ont été mesurés.Résultats:Si on la compare au traitement à base de solution saline administré au groupe témoin, la polythérapie à base de VEGF et de NGF, lorsqu’administrée 5 heures ou 8 heures à la suite de l’AVC, a su réduire de façon notable le volume des infarctus, le contenu en eau, l’apoptose des neurones et l’expression des protéases caspase 3. Elle a également permis de réguler à la hausse l’expression des protéines Bcl-2 en plus d’entraîner une amélioration de la récupération fonctionnelle (p< 0,01 pour ces deux aspects). Ainsi donc, plus tôt l’on opte pour cette polythérapie, meilleure sera la neuroprotection encourue.Conclusions:Ces résultats démontrent que la polythérapie à base de VEGF et de NGF procure des effets neuroprotecteurs. Quant au délai d’administration de ce traitement combinatoire, il devrait être d’au moins 8 heures à la suite d’un AVC, ce qui est plus élevé que la monothérapie.

Prospective assessment of patients with stroke in Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia

Introduction

The burden of stroke is increasing in many low- and middle-income countries. In Ethiopia, stroke has become a major cause of morbidity, long-term disability, and mortality. Time from stroke onset to hospital presentation is a critical factor in acute stroke care. This study aimed to describe risk factors for stroke and clinical presentation of patients presenting to the emergency centre with stroke.

Methods

We conducted a cross sectional study conducted from August 2015 to January 2016 in an urban tertiary care centre in Addis Ababa, Ethiopia. Descriptive statistics and multivariable logistic regression models were used to evaluate associations between stroke types and stroke risk factors, and delayed presentation and clinical indicators. P-values less than .05 were considered statistically significant.

Results

A total of 104 patients were included. The mean age was 53 years, and 56% were male. Only 30% of patients arrived using an ambulance service. The most common presenting symptoms were altered mental status (48%), hemiparesis (47%), facial palsy (45%), hemiplegia (29%), and aphasia (25%). Hypertension was the most common risk factor (49%), followed by cardiovascular disease (20.2%) and diabetes mellitus (11%). The majority of strokes were haemorrhagic in aetiology (56%). The median arrival time to the emergency centre was 24 h after symptoms onset; only 15% presented within three hours. Patients with hypertension, or presented with loss of consciousness were significantly more likely to have haemorrhagic stroke (p < .001 and p = .01 respectively). The only risk factor robustly associated with ischaemic stroke was cardiac illness (odds ratio 3.99, p = .01).

Discussion

Our study identified hypertension to be the most common risk factor for stroke. The predominant aetiology type in this cohort is haemorrhagic stroke. Lastly, the median arrival time to an emergency centre was 24 h after symptom onset.

Acute Ischaemic Stroke: Management, Recent Advances and Controversies

Acute ischaemic stroke is a major cause of death and disability. It may become an enormous burden to the patients themselves, their families as well as the health care systems. Patients at risk of airway, breathing and circulatory compromise should receive prompt resuscitation. Vital parameters and neurological status should be closely monitored. Attentions to blood pressure, temperature and sugar profile are important. The significance of early and correct diagnosis and subsequent treatment cannot be over-emphasised. There have been tremendous recent advances in different treatment modalities in acute stroke management. Various recanalisation modalities include intravenous and/or intra-arterial thrombolysis, acute defibrinogenation, anti-platelet treatment and anticoagulation. Carotid endarterectomy and endovascular strategies are recommended in selected patients. Advanced neuro-imaging techniques and neuroprotectants are being evaluated. Multidisciplinary stroke teams have been shown to improve patient survival and functional outcome. Pre-defined algorithms and protocols should be in place to expedite smooth and effective delivery of stroke service. Future directions should be aimed at exploring safer recanalisation modalities and extending the limit of the current 3-hour treatment window for thrombolysis.

Care and Charges for Acute Cerebral Infarction Inpatients in China: A Hospital Based Study in Soochow

Objective

The objective of the present study is to evaluate the current status of care and charges of acute ischaemic stroke in a university teaching hospital in China, and to identify the main determinants of such charges.

Methods

Acute ischaemic stroke patients from July 2009 to June 2010 were considered. We examined demographic data, clinical data, hospital care and outcomes at discharge and hospital charges retrospectively. The influence of medical factors on total charges was analyzed.

Results

The mean initial National Institutes of Health Stroke Scale score of all acute ischaemic stroke patients was 7.2 points. Thirteen percents were total anterior circulation syndrome, 20% were partial anterior circulation syndrome, 7% were posterior circulation syndrome and 60% were lacunar syndrome. The mean hospital length of stay (LOS) was 8.5 days. All patients underwent neuroimaging studies, 2% of whom received thrombolysis, 93% received traditional Chinese medicine injection, 83% received antiplatelet and 6% received anticoagulation therapy, only 29% received in-hospital rehabilitation. The mean hospital charges per patient was ¥9230.2 (US$1357.3), of which 56.2% was attributed to the charges for medications, 13.4% for imaging studies, 12.1% for laboratory examinations. Total hospital charges were correlated strongly with LOS, admission to care unit, and computed tomography angiography or digital subtraction angiography of the brain.

Conclusions

Total hospital charges correlates significantly with hospital LOS, admission to care unit, investigation with computed tomography angiography or digital subtraction angiography of the brain, while clinical syndromes do not influence total charges independently. The cost of drug is the largest portion of the mean hospital charge. A treatment protocol in acute ischaemic stroke might optimise cost. (Hong Kong j.emerg.med. 2011;18:383-390)

Mechanical behavior of rf-treated thrombus in mechanical thrombectomy

Intra-arterial mechanical thrombectomy (IAMT) treatments for ischemic stroke have higher recanalization rate, longer treatment time window and lower risk of symptomatic intracerebral hemorrhage (sICH). However, distal embolization may occur because of loose fragments produced during maceration and engagement. The naturally coagulated thrombus is fragile and has poor binding with thrombectomy device. Improvement of thrombus-device binding can reduce fragments breaking loose during wire pull and enhance protein crosslinking in the thrombus that can increase fragmentation resistance. The effects of in-situ applied radio frequency (rf) treatment on thrombus-wire binding and interfacial fracture have been examined in this study using wire pull tests that are mechanically analogous to the embolus retrieval method in thrombectomy. Wire inserted into a thrombus was pull tested after rf-treatment. Pull test results showed that rf-treatment improves binding and reduces thrombus slippage from over 90% to less than 10%. Fracture pull test results also showed that fracture energy density of thrombus-device interface increased 40X after rf-treatment. The dramatic increase in resistance against fracture suggests that the use of in-situ rf-treatment is a promising treatment addition to reduce distal embolization and improve clinical outcomes in mechanical thrombectomy.

Improved thrombolytic effect with focused ultrasound and neuroprotective agent against acute carotid artery thrombosis in rat

Combination therapy with focused ultrasound (FUS) and a neuroprotective agent, BNG-1, was examined in an acute carotid thrombotic occlusion model using LED irradiation in rat to improve the thrombolytic effect of rt-PA. Seven treatment groups included (A) intravenous bolus injection of 0.45 mg/kg rt-PA, (B) intravenous bolus injection of 0.9 mg/kg, (C) sonothrombolysis with FUS alone, (D) oral administration of 2 g/kg BNG-1 for 7 days alone, (E) A + D, (F) A + C, and (G) A + C + D. Four comparison groups were made including (H) 0.45 mg/kg rt-PA 20% bolus +80% IV fusion + FUS, (I) 0.9 mg/kg rt-PA with 10% bolus + 90% intravenous fusion, (J) B + C, (K) B + D. At 7 days after carotid occlusion, small-animal carotid ultrasound and 7 T MR angiography showed the recanalization rate of ≤50% stenosis was 50% in group B and 83% in group I, but 0% in groups A and C and 17% in group D. Combination therapy improved recanalization rate to 50–63% in groups E and F, to 67–83% in groups J and K, and to 100% in groups G and H. Our study demonstrated combination therapy with different remedies can be a feasible strategy to improve the thrombolytic effect of rt-PA.

Induction of Ischemic Stroke and Ischemia-reperfusion in Mice Using the Middle Artery Occlusion Technique and Visualization of Infarct Area

Cerebrovascular disease is highly prevalent in the global population and encompasses several types of conditions, including stroke. To study the impact of stroke on tissue injury and to evaluate the effectiveness of therapeutic interventions, several experimental models in a variety of species were developed. They include complete global cerebral ischemia, incomplete global ischemia, focal cerebral ischemia, and multifocal cerebral ischemia. The model described in this protocol is based on the middle cerebral artery occlusion (MCAO) and is related to the focal ischemia category. This technique produces consistent focal ischemia in a strictly defined region of the hemisphere and is less invasive than other methods. The procedure described is performed on mice, given the availability of several genetic variants and the high number of tests standardized for mice to aid in the behavioral and neurodeficit evaluation.

Factors delaying management of acute stroke: An Indian scenario

Background and Purpose:

The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India.

Methods:

All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05).

Results:

The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most.

Conclusions:

Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to “stroke” and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.

Intravenous recombinant tissue plasminogen activator for acute ischemic stroke: a feasibility and safety study

Background

In developing countries, intravenous thrombolysis (IVT) is available at a limited number of centers. This study aimed to assess the feasibility and safety of IVT at Tabriz Imam Reza Hospital.

Methods

In a prospective study, over a 55-month period, any patient at the hospital for whom stroke code had been activated was enrolled in the study. Data on demographic characteristics, stroke risk factors, admission blood pressure, blood tests, findings of brain computed tomography (CT) scans, time of symtom onset, time of arrival to the emergency department, time of stroke code activation, time of CT scan examination, and the time of recombinant tissue plasminogen activator administration were recorded. National Institutes of Health Stroke Scale assessments were performed before IVT bolus, at 36 hours, at either 7 days or discharge (which ever one was earlier), and at 3-month follow-up. Brain CT scans were done for all patients before and 24 hours after the treatment.

Results

Stroke code was activated for 407 patients and IVT was done in 168 patients. The rate of functional independence (modified Rankin Scale [mRS] 0–1) at 3 months was 39.2% (62/158). The mortality rate at day 7 was 6% (10/168). Hemorrhagic transformation was noted in 16 patients (9.5%). Symptomatic intracranial hemorrhage occurred in 5 (3%), all of which were fatal. One case of severe urinary bleeding and one other fatal case of severe angioedema were observed.

Conclusion

During the first 4–5 years of administration of IVT in the hospital, it was found to be feasible and safe, but to increase the efficacy, poststroke care should be more organized and a stroke center should be established.

Changes in the prevalence of hospitalization and comorbidity in US adults with stroke: A three decade cross-sectional and birth cohort analysis

BACKGROUND AND PURPOSE

Little attention was paid to the transition of care for stroke that may partially explain the long-term trend of stroke rates. We aimed to test the trend of hospitalization attributable to stroke in US adults.

METHODS

Data from National Hospital Discharge Surveys 1980-2010 in patients aged ≥18 (n = 6,527,304) were analyzed to examine the trend of patients with first-list diagnoses of stroke. Stroke comorbidities were classified in stroke patients with second- to seven-listed diagnoses of coronary heart disease, hypertension, diabetes, arrhythmias, or hyperlipidemia. Stroke trends by survey years and birth cohorts were analyzed using univariate, multivariate, and birth cohorts methods.

RESULTS

Of the total study sample, the prevalence of hospitalization due to stroke was 22.99%, 30.00%, and 27.03% in years of 1980-1989, 1990-1999, and 2000-2010 in males, and 17.30%, 22.04%, and 19.34% in females, respectively. Overall, hospitalization rates in stroke patients significantly increased among adults aged <65, and decreased in adults aged ≥65. There was an increase in stroke hospitalization rate in the old adults aged ≥65 in recent birth cohorts. Significant increased trends of comorbid hypertension, diabetes, arrhythmias, and hyperlipidemia were observed from 1980 to 2010.

CONCLUSION

A significant increase in stroke hospitalization rate was observed in adults aged <65 in the past three decades, and in old adults in recent years. Increases in stroke comorbidity rates were observed in all age groups. Findings from the study highlight that both public health and clinical practices face a serious challenge in controlling this unwelcome increased stroke trend.

Neurothrombectomy trial results: stroke systems, not just devices, make the difference

The overwhelming benefit demonstrated in the four recent randomized trials comparing intra-arterial therapies to medical management alone will have a transformative effect on the emergent management of strokes throughout the world. New generation neurothrombectomy devices were critical to trial success, but not the sole driver of patient outcomes in these trials. Patients in the positive trials were treated at hospitals with complex, efficient, resource-rich, team-based stroke systems in place. To ensure attainment of trial results in actual practice, patients should receive treatment at facilities certified as having the resources, personnel, organization, and continuous quality improvement processes characteristic of trial centers. It is our hope that, through greater education initiatives, robust resource investment, and developing quality-based certification processes, the results demonstrated by these trials may be extrapolated to greater numbers of centers - in turn allowing greater access for patients to high-quality, advanced stroke care.

Therapeutic benefits of combined treatment with tissue plasminogen activator and 2-(4-methoxyphenyl)ethyl-2-acetamido-2-deoxy-β-d-pyranoside in an animal model of ischemic stroke

Tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke, but tPA therapy is limited by a short therapeutic window and some adverse side effects. 2-(4-Methoxyphenyl)ethyl-2-acetamido-2-deoxy-β-d-pyranoside, a salidroside analog (code-named SalA-4g), has shown potent neuroprotective effects. In this study, a rat model of embolic middle cerebral artery occlusion (MCAO) was used to mimic ischemic stroke. The embolic MCAO rats were intravenously (iv) injected with tPA alone, SalA-4g alone, or a combination of tPA and SalA-4g. Compared to treatment with tPA alone at 4h post MCAO, combined treatment with tPA at 4h post MCAO and SalA-4g starting at 4h post MCAO and continuing for 3days at an interval of 24h significantly reduced neurological deficits and infarct volume, and significantly inhibited the intracerebral bleeding, edema formation, neuronal loss, and cellular apoptosis in the ischemic brain. Our results suggested that additive neuroprotective actions of SalA-4g contributed to widening the therapeutic window of tPA therapy and ameliorating its side effects in treating MCAO rats. The therapeutic benefits of combined treatment with tPA and SalA-4g for ischemic stroke might be associated with its effects on cerebral glucose metabolism.

Optimization modeling to maximize population access to comprehensive stroke centers

OBJECTIVE

The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs.

METHODS

Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers.

RESULTS

In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04).

CONCLUSION

Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes.

tPA use for Stroke in the Registry of the Canadian Stroke Network

Background:

Thrombolytic therapy with recombinant tissue plasminogen activator (tPA) has been shown to be cost-effective and safe. Thrombolysis for stroke with tPA is now a standard of care in North America. However, it is only used on a small percentage of patients.

Methods:

The Registry of the Canadian Stroke Network was a consent-based stroke registry from 21 hospital sites across Canada. Using the thrombolysis data in phase 1 and 2 of the Registry, we sought to describe the use of stroke thrombolysis and its outcomes.

Results:

A total of 4107 patients were diagnosed with ischemic stroke in phase 1 and 2 of the Registry, of which 8.9% were treated with tPA. In consented tPA patients, the method of tPA administration was 85.8% IV only, 9.0% IA only, and 5.2% IV/IA combined. Patients had a median onset-to-treatment time of 167 minutes [IQR 140-188]. One quarter (25.5%) of eligible candidates (time from onset <150 minutes) were treated with tPA. Protocol violations occurred in 27.7% (67/242) of patients with 14.9% (10/67) mortality. Overall, in-hospital mortality was 11.6%. Lower Canadian Neurological Scale score and higher glucose level were predictive of mortality The symptomatic intracerebral hemorrhage (ICH) rate (phase 2 only) was 4.3%. The mean Stroke Impact Scale-16 score at six months was 73.2, approximately equivalent to a modified Rankin scale score of 2.

Conclusions:

At selected hospitals in Canada, thrombolysis use is higher than previously reported rates. Thrombolysis continues to be safe and effective in Canada.

Disparities in accessibility of certified primary stroke centers

BACKGROUND AND PURPOSE

We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors.

METHODS

Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity.

RESULTS

Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources.

CONCLUSIONS

There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.

Starting early: integration of self-management support into an acute stroke service

Self-management support following stroke is rare, despite emerging evidence for impact on patient outcomes. The promotion of a common approach to self-management support across a stroke pathway requires collaboration between professionals. To date, the feasibility of self-management support in acute stroke settings has not been evaluated.

The Bridges stroke self-management package (SMP) is based on self-efficacy principles. It is delivered by professionals and supported by a patient-held workbook. The aim of this project was to introduce the Bridges stroke SMP to the multidisciplinary staff of a London hyperacute and acute stroke unit.

The ‘Plan Do Study Act’ (PDSA) cycle guided iterative stages of project development, with normalisation process theory helping to embed the intervention into existing ways of working. Questionnaires explored attitudes, beliefs and experiences of the staff who were integrating self-management support into ways of working in the acute stroke setting.

Self-management support training was delivered to a total of 46 multidisciplinary stroke staff. Of the staff who attended the follow-up training, 66% had implemented Bridges self-management support with patients since initial training, and 100% felt their practice had changed. Questionnaire findings demonstrated that staff attitudes and beliefs had changed following training, particularly regarding ownership and type of rehabilitation goals set, and prioritisation of self-management support within acute stroke care.

Staff initiated an audit of washing and dressing practices pre- and post-training. This was designed to evaluate the number of occasions when techniques were used by staff to facilitate patients’ independence and self-management. They found that the number of occasions featuring optimum practice went from 54% at baseline to 63% at three months post-training.

This project demonstrated the feasibility of integrating self-management support into an acute stroke setting. Further work is required to evaluate sustainability of the Bridges stroke SMP, to understand the barriers and opportunities involved in engaging all professional groups in integrated self-management support in acute stroke settings, and to assess patient reported outcomes.

Thyroid hemorrhage causing airway obstruction after intravenous thrombolysis for acute ischemic stroke

BACKGROUND

There are several life-threatening complications associated with intravenous thrombolysis after acute ischemic stroke such as symptomatic intracerebral hemorrhage, orolingual angioedema, or less frequent, bleedings of the mucosa or ecchymosis. Aside from these known critical incidents, rare and unfamiliar complications may be even more challenging, as they are unexpected and may mimic events that appear more frequently. We report a rare and unusual acute complication of intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) (0.9 mg/kg) administered for acute ischemic stroke.

METHODS

Medical records, radiologic imaging, and pathologic specimens were reviewed.

RESULTS

A 86-year-old woman developed acute respiratory failure 20 h after thrombolysis with suspected angioedema triggered by intravenous rt-PA. The inspiratory stridor and dyspnea were unresponsive to bronchodilators, corticosteroids, and inhaled adrenaline. After endotracheal intubation, laryngoscopy showed no significant supraglottic narrowing. Thyroidal sonography and cervical computed tomography revealed a thyroidal mass causing a tracheal and vascular compression compatible with thyroidal hemorrhage. Sonography showed a nodular goiter of the right thyroid gland. A total thyroidectomy was performed and histologic analysis confirmed a hemorrhage of the right thyroidal lobe.

CONCLUSIONS

Acute airway obstruction with respiratory failure due to thyroidal hemorrhage after intravenous thrombolysis is an important life-threatening complication, mimicking an anaphylactic reaction or a more frequent orolingual angioedema.

A comparison of rt-PA thrombolysis guidelines between China and the USA: are changes needed?

BACKGROUND AND PURPOSE

Thrombolytic treatment criteria vary significantly between China and the USA. We reviewed current intravenous (IV) thrombolytic therapy practices in China and the USA to determine the most appropriate.

METHODS

We conducted a systematic review of studies that used IV recombinant tissue plasminogen activator (rt-PA) therapy in China and the USA published between January 1950 and April 2012.

RESULTS

Literature search identified 17 American and 9 Chinese studies with a total of 2545 subjects. We found a significantly lower mortality rate in the US data compared with China (8% versus 13%; Chi-square  =  24.412, P < 0.001). Our meta-regression analysis uncovered significant factors influencing mortality including male sex, hypertension, high cholesterol, smoking, and onset to treatment time (all P < 0.05). There were significantly more favorable outcomes in China than in the USA (61% versus 49%, Chi-square  =  19.159, P < 0.001). No prior history of stroke and shorter onset to IV time were also significantly associated with a favorable outcome (P < 0.05).

CONCLUSIONS

Onset to IV time is critical for reducing mortality and improving favorable outcomes. We suggest Chinese acute ischemic stroke treatment guidelines be revised to include an increase in the age limit of 80 years, removing contraindications such as a history of previous sever heart, liver, and kidney dysfunction, and placing more emphasis on physician expertise.

Direct access to a hospital offering intravenous thrombolysis therapy improves functional outcome of acute ischemic stroke patients

Referral from other hospitals is one of the primary causes of delayed thrombolysis therapy after acute ischemic stroke (AIS). We aimed to evaluate whether direct access to a hospital offering intravenous thrombolysis therapy was associated with good functional outcome in AIS patients treated with thrombolysis. We enrolled patients who received intravenous thrombolysis within 3 hours of symptom onset at our stroke center. We divided these patients into two groups: those with a direct admission to our stroke center and those with indirect admission by referral from other community hospitals. We investigated onset-to-door time and onset-to-recombinant tissue plasminogen activator (rtPA) time according to admission mode. We then assessed the association between a direct admission and favorable outcome at 90 days. A total of 232 patients (mean age of 66.6 years, median National Institutes of Health Stroke Scale score of 10) were included. A total of 48.7% of AIS patients treated with intravenous thrombolytic therapy were transferred from other hospitals. Patients who were directly admitted to our stroke center had a shorter onset-to-door time (61 versus 120 minutes, p<0.001) and onset-to-rtPA time (103 versus 155 minutes, p<0.001) than those referred from other hospitals. Direct admission was associated with a good outcome with an odds ratio of 2.03 (95% confidence interval 1.051-3.917, p=0.035), after adjusting for baseline variables. Thrombolysis after direct admission to a hospital offering intravenous thrombolysis therapy could shorten onset-to-rtPA time and improve stroke outcome in patients with AIS.

Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke

In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%-15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion.

Organizing regional networks to increase acute stroke intervention

OBJECTIVES

Acute ischemic stroke is the second leading cause of death worldwide and the leading cause of adult disability in the United States (US). Thrombolytic therapy was proved effective, and approved for use, in the US by the Food and Drug Administration in 1996, yet 8 years later just 3-4% of stroke victims in the US are treated with tissue plasminogen activator. In order to understand how this figure can be substantially improved, it is important to evaluate the available therapies and systems of care, delineate the critical steps and the existing barriers in the process for successful intervention, and thoroughly understand the key components in the highly successful interventional stroke programs, especially regionalization of care.

METHODS

A review of the available literature was carried out and interventional stroke data from the Mid America Brain and Stroke Institute at Saint Luke's Hospital (SLH) in Kansas City, Missouri, was analysed.

RESULTS

There are several treatment strategies available for acute stroke intervention and more are likely to be developed. There is increasing interest in organizing and standardizing care for stroke. The steps in the process for successful intervention are understood and progress is being made in several areas of the country, but challenges remain in public education, directing emergency transport to 'stroke ready' hospitals and linking stroke experts to primary care providers. The Kansas City regional network linking primary care hospitals to the stroke team at SLH has been highly successful in substantially increasing the number of patients receiving acute stroke intervention.

DISCUSSION

The stage is set for many more stroke victims to receive acute interventional therapy. However, these patients must present to hospitals equipped and staffed to render this therapy. Most stroke victims will go or be taken to the closest medical facility. Organizing regional networks linking primary care hospitals and physicians to comprehensive stroke centers staffed, and capable of providing the entire spectrum of acute stroke intervention will be essential in substantially increasing the number of stroke victims who actually receive acute interventional therapy. This article summarizes the evolving solutions to this challenge with specific data from the successful regional network developed around the Mid America Brain and Stroke Institute at Saint Luke's Hospital in Kansas City, Missouri, USA.

Pre- and in-hospital intersection of stroke care

Acute ischemic stroke is a time-critical emergency for which thrombolytic therapy is the only medical treatment. Many patients who would benefit from this treatment are deprived of it due to delays. Failure to call for help rapidly is the main obstacle, but even when the call is made in time, the prehospital evaluation, transportation, and emergency department (ED) diagnostics often take too long to treat the patient with thrombolysis. Interventions to reduce pre- and in-hospital delays have been described; although no single intervention is likely to make a major difference, a whole set of interventions needs to be implemented. The intersection of the pre- and in-hospital care is of special importance. With successful protocols and good communication between the emergency medical service and ED, delays can be significantly reduced. On the basis of our experience, 94% of patients can be treated within 60 min of arrival, based largely on using the prehospital time effectively.

Two different cases of postoperative symptomatic common carotid artery involvment in type A aortic dissection

Postoperative common carotid artery occlusion after reconstruction for type A aortic dissection can lead to major neurological morbidity. Surgical strategy to re-establish the cerebral perfusion depends on the time of onset of neurological deficits in this otherwise life-threatening disease. We present two cases with neurological deficits after replacement of the ascending aorta for a type A dissection treated with two different surgical strategies. In both cases, prompt surgical interventions improved neurological outcome.

Optimizing the management of acute ischaemic stroke: a review of the utilization of intravenous recombinant tissue plasminogen activator (tPA)

WHAT IS KNOWN AND OBJECTIVE

Thrombolysis using intravenous tissue plasminogen activator (tPA) is the only available evidence-based treatment for acute ischaemic stroke; however, its current utilization is very low. Therefore, the aim of this article is to review the literature regarding the use of intravenous tPA for the treatment of acute ischaemic stroke. The review will also compare utilization rates of thrombolysis in different centres across the world and identify key reasons for the underutilization of thrombolysis in stroke.

METHODS

MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA) and Google Scholar were searched for relevant original articles, review papers and other publications over the publication period 1995-2012.

RESULTS AND DISCUSSION

The National Institute of Neurological Disorders and Stroke (NINDS) (1995, N = 624 patients) and ECASS III (2008, N = 821 patients) are two pivotal randomized controlled trials providing evidence for the use of intravenous tPA within 3 h or 3-4.5 h from stroke onset, respectively. Both trials have shown that tPA administration decreases disability at 90 days from stroke. Furthermore, a recent pooled analysis of randomized controlled trials (2010, N = 3670 patients) supports these results, highlighting that early stroke treatment is associated with better outcomes, especially when treatment is started within 90 min of stroke onset (but suggesting that the benefit could be afforded within a 4.5-h time window). Three major observational trials, STARS (2000, N = 389 patients), CASES (2005, N = 1135 patients) and SITS-MOST (2007, N = 6483 patients), have reported acceptable safety and efficacy in clinical practice. However, only a small proportion of acute ischaemic stroke patients receive tPA in clinical practice, because of the limited availability of tPA-utilizing sites and suboptimal use of tPA in sites where it is available.

WHAT IS NEW AND CONCLUSION

tPA reduces disability in stroke patients. Moreover, acceptable safety has been demonstrated in routine clinical practice. However, tPA is significantly underutilized, and specific efforts are needed to encourage appropriate implementation of the stroke treatment guidelines to optimize the use of this important therapy.

Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

OBJECTIVES

This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA).

METHODS

We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence.

RESULTS

In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B).

CONCLUSIONS

These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.

Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

BACKGROUND AND PURPOSE

We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification.

METHODS

A retrospective cohort study of 30,461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages.

RESULTS

There were 15,687 precertification ED visits and 11,040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival.

CONCLUSIONS

Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.

Intravenous Recombinant Tissue Plasminogen Activator Administered after 3 H following Onset of Ischaemic Stroke: A Metaanalysis

Objective

To assess the efficacy of intravenous recombinant tissue plasminogen activator administered after 3 h following onset of ischaemic stroke.

Background

Some recent data indicate that treatment with intravenous recombinant tissue plasminogen activator may be beneficial even when administered to ischaemic stroke patients beyond 3 h from symptom onset.

Methods

We searched the medical literature using the MEDLINE, BIOSIS, and Cochrane databases for pertinent publications from 1966 to 2008 using the keywords ‘alteplase’, ‘tissue plasminogen activator’, and ‘stroke’. Among the retrieved publications, we selected randomised controlled trials that administered recombinant tissue plasminogen activator during 3–6 h after symptom onset in patients with acute ischaemic stroke. We evaluated the effect of intravenous recombinant tissue plasminogen activator (compared with placebo) on the rate of good functional outcome (determined by modified Rankin Scale of 0–1) and mortality at three-months. A subset analysis was performed according to time of administration of intravenous recombinant tissue plasminogen activator (3–4·5 and 4·5–6 h). Odds ratios of individual trials were pooled using a random effects model.

Results

We analysed four randomised trials totaling 2104 patients (1053 control and 1051 recombinant tissue plasminogen activator-treated patients). Patients that received intravenous recombinant tissue plasminogen activator at 3–6 h following onset of symptoms had a significantly higher rate of favourable neurological outcome over the patients that received placebo (odds ratio 1·24, 95% confidence intervals 1·04–1·47, P=0·02). Treatment within the 3–4·5 time window was significantly associated with higher rate of favourable neurological outcome (OR 1·27, 95% confidence interval 1·01–1·60), but not for the 4·5–6 time window (OR 1·10, 95% confidence interval 0·75–1·51). There was no difference in mortality between patients that received intravenous recombinant tissue plasminogen activator than the patients that received pharmacologic placebo (OR 1·14, 95% confidence interval 0·76–1·70).

Conclusions

Treatment with intravenous recombinant tissue plasminogen activator from 3–4·5 h following symptom onset is associated with an increased rate of favourable outcome at 90-days in this analysis. Treatment with intravenous recombinant tissue plasminogen activator beyond 4·5 h did not show a benefit; however, improved patient selection is needed for future studies.

Stroke fast track reduces time delay to neuroimaging and increases use of thrombolysis in an academic medical center in Thailand

Delays between hospital arrival and neuroimaging prevented patients from receiving thrombolysis. We report impact of Stroke Fast Track (SFT) on time to imaging, and rates of recombinant tissue plasminogen activator (rt-PA) in eligible patients. Characteristics, time intervals, and rates of rt-PA were evaluated in 464 patients with suspected acute stroke within 7 days (2005-2006). Complete time intervals were available on 380. Median times between emergency room arrival, brain computerized tomography (CT), and CT results were 25 and 45 minutes, respectively, for patients arriving <3 hours from onset, 40, and 65 minutes for those arriving >3 hours, and 35 and 60 minutes for all patients, which is significantly shorter than 2.5 hours to CT in 2004, prior to SFT (P < .0001). Although not different in time to first physician, patients arriving >3 hours had longer times to CT and CT results (P < .001). Overall, 5.5% of ischemic stroke patients received intravenous rt-PA, including 27.1% of those arriving within 3 hours, which represented 100% of all eligible patients, compared with 0% in 2004. SFT reduced time delay in neuroimaging and increased use of rt-PA in Thailand. Continuous quality improvement is needed to achieve best results in each setting, and to insure optimal care for acute stroke patients.

Prehospital notification from the emergency medical service reduces the transfer and intra-hospital processing times for acute stroke patients

Background and Purpose

There is little information available about the effects of Emergency Medical Service (EMS) hospital notification on transfer and intrahospital processing times in cases of acute ischemic stroke.

Methods

This study retrospectively investigated the real transfer and imaging processing times for cases of suspected acute stroke (AS) with EMS notification of a requirement for intravenous (IV) tissue-type plasminogen activator (t-PA) and for cases without notification. Also we compared the intra-hospital processing times for receiving t-PA between patients with and without EMS prehospital notification.

Results

Between December 2008 and August 2009, the EMS transported 102 patients with suspected AS to our stroke center. During the same period, 33 patients received IV t-PA without prehospital notification from the EMS. The mean real transfer time after the EMS call was 56.0±32.0 min. Patients with a transfer distance of more than 40 km could not be transported to our center within 60 min. Among the 102 patients, 55 were transferred via the EMS to our emergency room for IV t-PA. The positive predictive value for stroke (90.9% vs. 68.1%, p=0.005) was much higher and the real transfer time was much faster in patients with an EMS t-PA call (47.7±23.1 min, p=0.004) than in those without one (56.3±32.4 min). The door-to-imaging time (17.8±11.0 min vs. 26.9±11.5 min, p=0.01) and door-to-needle time (29.7±9.6 min vs. 42.1±18.1 min, p=0.01) were significantly shorter in the 18 patients for whom there was prehospital notification and who ultimately received t-PA than in those for whom there was no prehospital notification.

Conclusions

Our results indicate that prehospital notification could enable the rapid dispatch of AS patients needing IV t-PA to a stroke centre. In addition, it could reduce intrahospital delays, particularly, imaging processing times.

Attitudes and beliefs of Michigan emergency physicians toward tissue plasminogen activator use in stroke: baseline survey results from the INcreasing Stroke Treatment through INteractive behavioral Change Tactic (INSTINCT) trial hospitals

BACKGROUND AND PURPOSE

The objective of this study was to determine the baseline proportion of emergency physicians with favorable attitudes and beliefs toward intravenous tissue plasminogen activator (tPA) use in a cohort of randomly selected Michigan hospitals.

METHODS

Two hundred seventy-eight emergency physicians from 24 hospitals were surveyed. A confidential, self-administered, pilot-tested survey assessing demographics, practice environment, attitudes, and beliefs regarding tPA use in stroke was used. Main outcome measures assessed belief in a legal standard of care, likelihood of use in an ideal setting, comfort in use without a specialist consultation, and belief that science on tPA use is convincing. ORs with robust 95% CIs (adjusted for clustering) were calculated to quantify the association between responses and physician- and hospital-level characteristics.

RESULTS

One hundred ninety-nine surveys completed (gross response rate 71.6%). Ninety-nine percent (95% CI: 97.8 to 100) indicated use of tPA in eligible patients represented either acceptable or ideal patient care. Twenty-seven percent (95% CI: 21.7 to 32.3) indicated use of tPA represented a legal standard of care. Eighty-three percent (95% CI: 78.5 to 87.5) indicated they were "likely" or "very likely" to use tPA given an ideal setting. When asked about using tPA without a consultation, 65% (95% CI: 59.3 to 70.7) indicated they were uncomfortable. Forty-nine percent (95% CI: 43.0 to 55.0) indicated the science regarding use of tPA in stroke is convincing with 30% remaining neutral. Characteristics associated with favorable attitudes included non-emergency medicine board certification; older age, and a smaller hospital practice environment.

CONCLUSIONS

In this cohort, emergency physician attitudes and beliefs toward intravenous tPA use in stroke are considerably more favorable than previously reported.

Factors associated with prehospital delay for acute stroke in Ulsan, Korea

BACKGROUND

Early hospital presentation is critical in the treatment of acute ischemic stroke with thrombolysis.

OBJECTIVES

The aim of this study was to investigate the factors associated with prehospital delay in acute ischemic stroke.

METHODS

Data were retrospectively collected over a 1-year period from 247 acute ischemic stroke patients who presented to the emergency department (ED) within 7 days after symptom onset. To investigate the factors associated with prehospital delay, sociodemographic data, initial symptoms, risk factor, National Institutes of Stroke Scale in the ED, and use of emergency medical services (EMS) were evaluated. Univariate and multivariate analysis were used to evaluate delay factors.

RESULTS

Of 247 patients (mean age 64.4 ± 12.6 years, 149 male patients), the non-delay group (≤ 2 h after symptom onset) included 45 patients (mean age 60.0 ± 13.1 years, 31 male patients) and the delay group (> 2 h after symptom onset) included 202 patients (mean age 65.4 ± 12.3 years, 118 male patients). Advanced age (odds ratio [OR] 1.056, 95% confidence interval [CI] 1.024-1.089), no consciousness disturbance at symptom onset (OR 2.938, 95% CI 1.066-8.104), presentation to ED by self (OR 3.826, 95% CI 1.580-9.624), referral from other hospital (OR 16.787, 95% CI 5.445-51.750), and worsened symptoms at the ED compared to symptom onset (OR 7.708, 95% CI 1.557-38.151) were associated with a prehospital delay.

CONCLUSION

Elderly patients with progressive symptom worsening had delayed arrival, but those who used EMS or had disturbed consciousness at symptom onset had early arrival.