Alteplase for Acute Ischemic Stroke in Patients Aged >80 Years: Pooled Analyses of Individual Patient Data

Does Old Age Comprise Distinct Subphases? Evidence from an Analysis of the Relationship between Age and Activities of Daily Living, Comorbidities, and Geriatric Syndromes

BACKGROUND

Older individuals are usually treated as a homogenous group despite evidence that old age consists of distinct subphases. This observational study including 493 older patients aimed to identify differences among age subgroups of older persons. Receiver operating characteristic (ROC) curve analysis was then applied to identify the optimal age cutoff points to distinguish those age groups.

METHODS

Data were collected on the demographics of older patients, their medical and medication histories, dependence on activities of daily living (ADLs), and instrumental activities of daily living (IADLs). Non-parametric tests (Kruskal-Wallis and Mann-Whitney U tests) and ROC curves were used for statistical analysis.

RESULTS

The 65-79 and ≥80 years of age groups showed distinct frailty status, comorbidity, and dependency in ADLs. The median age to remain completely independent in IADLs was 76-79 years, while the median age for being free from geriatric syndromes was slightly higher (77-80 years) and reached 82 years for the absence of delirium, falls, and swallowing problems. In the ROC analysis, the optimal cutoff ages for the presence of frailty, cognitive impairment, and dependency in ADLs were 80-82 years.

CONCLUSION

The 65-79 and ≥80 years of age groups differed significantly in numerous parameters, underscoring the need to address these distinct age groups differently, both for applying medical therapies and interventions, as well as for conducting health research.

Clinical outcome after thrombectomy in patients with MeVO stroke: importance of clinical and technical factors

BACKGROUND AND AIMS

Whereas high-level evidence has been proven for safety and efficacy of endovascular treatment (EVT) in large vessel occlusion (LVO) stroke, the evidence for EVT in medium vessel occlusion (MeVO) in both sexes and different age groupremains to be answered. The aim of this study was to evaluate the importance of clinical and technical parameters, focusing on sex, age and EVT procedural factors, on functional outcome in primary MeVO (pMeVO) strokes.

METHODS

144 patients with pMeVO in the MCA territory from the Oslo Acute Reperfusion Stroke Study (OSCAR) were included. Clinical and radiological data were collected including 90-day mRS follow-up.

RESULTS

Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 123 patients (84%). Good functional outcome (mRS ≤ 2) at 90-day follow-up was achieved in 84 patients (61.8%). Two or more passes with stent retriever was associated with increased risk of SAH, poor mTICI and poor functional outcome. In average, women had 62 min longer ictus to recanalization time compared to men. Age over 80 years was significantly associated with poor outcome and death.

CONCLUSION

In pMeVO patients, TICI score and number of passes with stent retriever were the main technical factors predicting mRS ≤ 2. Good clinical outcome occurred almost twice as often in patients under 80 years of age compared to patients over 80 years. Women with MeVO strokes had significant longer time from ictus to recanalization; however, this did not affect the clinical outcome.

Intravenous Thrombolysis in Patients 90 Years or Older with Moderate to Severe Acute Ischemic Stroke Increases Ambulation at Discharge and Is Safe: A Prospective Cohort Study from a Single Center in Santiago, Chile

INTRODUCTION

The World Health Organization predicts that the global population aged 60 years and older will double by 2050, leading to a significant rise in the public health impact of acute ischemic stroke (AIS). Existing stroke guidelines do not specify an upper age limit for the administration of intravenous thrombolysis (IVT), although some suggest a relative exclusion criterion in patients aged ≥80 in the 3-4.5-h window. Many physicians avoid treating these patients with IVT, argumenting high risk and little benefit. Our aim was to investigate the efficacy and safety of IVT treatment in patients with non-minor AIS aged ≥90, admitted to our institution. The primary efficacy endpoint was the ability to walk at discharge (mRS 0-3), and the primary safety endpoints were death and symptomatic intracranial hemorrhagic transformation (sIHT) at discharge.

METHODS

Patients with AIS aged ≥90 admitted to our center from January 2003 to December 2022 were included. They were selected if had an NIHSS ≥5, were previously ambulatory (prestroke mRS score 3 or less), and arrived within 6 h from symptom onset. Those treated or not with IVT were compared with univariate analysis.

RESULTS

The mean age was 93.2 (2.4) years, and 51 (73.9%) were female. The admission mRS and NIHSS were 1 (IQR 0-2) and 14 (IQR 7-22), respectively. Thrombolyzed patients had a shorter time from symptom onset to door and lower glycemia on admission. IVT was associated with a higher proportion of patients achieving mRS 0-3 at discharge (p = 0.03) and at 90 days (p = 0.04). There were no differences between groups in the risk of death (p = 0.55) or sIHT (p = 0.38).

CONCLUSION

In this small sample, ambulatory patients aged ≥90 with moderate or severe AIS treated with IVT had increased odds of being able to walk independently at discharge than those not treated, without safety concerns.

Comparison of pharmacokinetic properties of alteplase and tenecteplase. The future of thrombolysis in acute ischemic stroke

INTRODUCTION

The drug most frequently used for thrombolysis in cases of acute ischemic stroke (AIS) is alteplase. However, there is moderate-to-high-quality evidence that tenecteplase has similar or higher efficacy and safety. With improved pharmacokinetic properties over alteplase, tenecteplase could be a significant advantage in treating AIS.

AREAS COVERED

After conducting an extensive search on Scopus and PubMed, this manuscript reviews and compares the pharmacokinetic properties of alteplase and tenecteplase. Additionally, it provides information on pharmacodynamics, clinical efficacy, safety, tolerability, and drug-drug interactions.

EXPERT OPINION

The pharmacokinetic profile of alteplase and tenecteplase is derived from studies in patients with acute myocardial infarction. Thanks to its pharmacokinetic properties, tenecteplase is the drug closest to being the ideal fibrinolytic for AIS. Its longer half-life enables a single-bolus administration, which is particularly useful in emergencies. Tenecteplase has proven to have a good efficacy and safety profile in randomized clinical trials. Although we are awaiting the results of the ongoing phase 3 randomized clinical trials, we believe that tenecteplase has the potential to revolutionize the treatment of AIS through thrombolysis.

Risk Factors Associated With Exclusion of Obese Patients Ischemic Stroke With a History of Smoking From Thrombolysis Therapy

The objective of this study is to determine risk factors that may contribute to exclusion decision from recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) with a combined current or history of smoking and obesity. This study was conducted on data from 5469 patients with AIS collected from a regional stroke registry. Risk factors associated with inclusion or exclusion from rtPA were determined using multivariate logistic regression analysis. The adjusted odds ratios and 95% confidence interval for each risk factor were used to predict the increasing odds of an association of a specific risk factor with exclusion from rtPA. In the adjusted analysis, obese patients with AIS with a history of smoking (current and previous) excluded from rtPA were more likely to present with carotid artery stenosis (OR = 0.069, 95% CI 0.011-0.442), diabetes (OR = 0.604, 95% CI 0.366-0.997), higher total cholesterol (OR = 0.975, 95% CI 0.956-0.995), and history of alcohol use (OR = 0.438, 95% CI 0.232-0.828). Higher NIHSS score (OR = 1.051, 95% CI 1.017-1.086), higher triglycerides (OR = 1.004, 95% CI 1.001-1.006), and higher high-density lipoprotein (OR = 1.028, 95% CI 1.000-1.057) were associated with the inclusion for rtPA. Our findings reveal specific risk factors that contribute to the exclusion of patients with AIS with a combined effect of smoking and obesity from rtPA. These findings suggest the need to develop management strategies to improve the use of rtPA for obese patients with AIS with a history of smoking.

Chinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update

BACKGROUND

China is one of the countries with the highest burden of stroke. Implementing multidimensional management guidelines will help clinicians practise evidence-based care, improve patient outcomes and alleviate societal burdens. This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases.

METHODS

We conducted a comprehensive search on MEDLINE (via PubMed) up to 31 August 2023. The writing team established the recommendations through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association (CSA). The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee.

RESULTS

This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care: emergency assessment and diagnosis of ischaemic cerebrovascular disease, acute-phase reperfusion therapy, evaluation of underlying mechanisms, antithrombotic therapy, prevention and treatment of complications, and risk factor management.

CONCLUSIONS

This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.

Thrombolysis and thrombectomy for stroke in octogenarians and nonagenarians: A regional observational study

INTRODUCTION

Elderly patients are a growing population in stroke units, characterized by higher frailty, but underrepresented in clinical trials about acute care. We investigated efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in elderlies in current practice.

METHODS

We assessed consecutive patients with acute ischemic stroke (AIS) hospitalized in the four stroke units of the French Northern Alps Emergency Network between 2015 and 2020. We compared baseline characteristics, early neurological evolution and outcome of patients aged 80-89 and≥90years old (yo).

RESULTS

Among 8367 patients, 2744 (32.8%) were 80-89 yo and 541 (6.5%) were≥90 yo. IVT and/or MT were performed in 787 patients≥80 yo (632 patients aged 80-89, 155 patients aged>90). Early neurological improvement was more frequent in patients≥80 yo treated by IVT and/or MT compared to untreated patients (45.6% versus 38.4%, P=0.002). After adjustment, reperfusion treatments improved likelihood of good outcome at discharge (OR=2.0 [1.6-2.7]) and reduced in-hospital mortality (OR=0.5 [0.4-0.7]). Age and initial NIHSS score were independent factors of poor functional outcome at discharge and in-hospital mortality. The rate of successful recanalization was comparable between octogenarians and nonagenarians (87% versus 85.2%, P=0.8). Octogenarians had better functional outcome at discharge compared to nonagenarians [modified Rankin scale (mRS) 0-2: 36% versus 25.7%, P=0.02], whatever IVT or MT strategy. In-hospital mortality was lower for octogenarians compared to nonagenarians (19.5% versus 27.1%, P=0.04).

DISCUSSION

IVT and MT improve early neurological recovery and functional outcome at discharge of both octogenarians and nonagenarians in current practice. Despite a poorer outcome for nonagenarians than octogenarians, these reperfusion treatments should not be withheld on the basis of age only.

Efficacy and safety of intravenous thrombolytic therapy in patients over eighty years

INTRODUCTION

Intravenous thrombolytic therapy (IVTT) is licensed for patients under 80 years in many countries. In this study, we aimed to demonstrate functional results and complication rates of IVTT in patients over eighty years and whether there is a difference in efficacy and safety between low dose and standard dose recombinant tissue plasminogen activator (rTPA).

METHODS

A retrospective observational study of patients over eighty who admitted to Suleyman Demirel University Faculty of Medicine Hospital between August 2016 and April 2021 and to Isparta City Hospital between April 2017 and April 2021 and diagnosed with acute ischemic stroke were conducted. Third month modified rankin scores (mRS) and mortality rates of patients and hemorrhagic transformations were determined.

RESULTS

There were 29 patients in IVTT group and 25 patients in non-IVTT group. By the third month, it was observed that functional independence (mRS 0-2) ratio was increased more in IVTT group, but it wasn't statistically significant (p: 0.087). In mortality and symptomatic intracerebral hemorrhage rates, there wasn't statistically significant difference between IVTT and non-IVTT groups and low dose and standard dose rTPA groups by the third month.

CONCLUSION

The efficacy and complication rates of IVTT in patients over 80 years were found similar to not receive IVTT. These results support the safety of IVTT in patients over 80 years. In low or standard dose rTPA preference, we observed that there was not statistically significance in efficacy and safety. We believe that these results will be supported by studies with larger number of patients.

Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi

Objectives

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT.

Methods

This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT.

Results

Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49).

Conclusion

Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.

Strokes and Predictors of Outcomes

Stroke is a leading cause of long-term disability and fifth leading cause of death. Acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, the 3 subtypes of strokes, have varying treatment modalities. Common themes in management advocate for early interventions to reduce morbidity and mortality but not all perception is supported through randomized controlled trials. Each stroke subtype has varying premorbid-related and ictus-related outcome predictive models that have differing sensitivities and specificities.

Replacing Alteplase with Tenecteplase: Is the Time Ripe?

Thrombolysis for acute ischemic stroke has predominantly been with alteplase for over a quarter of a century. In recent years, with trials showing evidence of higher rates of successful reperfusion, similar safety profile and efficacy of tenecteplase (TNK) as compared to alteplase, TNK has now emerged as another potential choice for thrombolysis in acute ischemic stroke. In this review, we will focus on these recent advances, aiming: (1) to provide a brief overview of thrombolysis in stroke; (2) to provide comparisons between alteplase and TNK for clinical, imaging, and safety outcomes; (3) to focus on key subgroups of interest to understand if there is an advantage of using TNK over alteplase or vice-versa, to review available evidence on role of TNK in intra-arterial thrombolysis, as bridging therapy and in mobile stroke units; and (4) to summarize what to expect in the near future from recently completed trials and propose areas for future research on this evolving topic. We present compelling data from several trials regarding the safety and efficacy of TNK in acute ischemic stroke along with completed yet unpublished trials that will help provide insight into these unanswered questions.

Methodological survey of missing outcome data in an alteplase for ischemic stroke meta-analysis

OBJECTIVE

Recent national guidelines recommend alteplase treatment for ischemic stroke within 4.5 h of symptom-onset based on meta-analyses of randomized controlled clinical trials (RCT). A detailed description of missing outcome data (MOD) due to participant loss to follow-up has never been published. The objective of this study was to perform a methodlogical survey on missing outcome data in an alteplase for ischemic stroke meta-analysis.

MATERIALS AND METHODS

A methodological survey was performed on a chosen meta-analysis of alteplase for ischemic stroke RCTs that most closely aligns with recent national guideline recommendations. Data were collected to assess the number of participants lost to follow-up; differential lost to follow-up between allocation groups; baseline characteristics of those lost to follow-up; and the imputation methods used by individual trials and the chosen meta-analysis. The number of participants lost to follow-up was compared with the fragility index; and repeated for individually positive RCTs in the meta-analysis.

RESULTS

The methodological survey revealed a substantial degree of missing information regarding MOD in the chosen meta-analysis and in individual RCTs. Single imputation was exclusively used in all RCTs and in the meta-analysis. The number of participants lost to follow-up was greater than the fragility index in the chosen meta-analysis and individually positive component RCTs suggesting that MOD may impact the direction of the reported effect or effect size.

CONCLUSION

This methodological survey of an alteplase for ischemic stroke meta-analysis revealed MOD may be an important source of unrecognized bias. This survey highlights the need for sensitivity analyses using more robust methods of imputation.

Factors Associated with Unfavorable Functional Outcomes After Intravenous Thrombolysis in Patients with Acute Ischemic Stroke

Purpose

Intravenous thrombolysis (IVT) has become a standard treatment for eligible ischemic stroke patients. However, functional outcomes after receiving IVT varied widely. Hence the primary goal of this study is to identify characteristics related to poor outcomes.

Patients and Methods

The study enrolled acute ischemic stroke patients aged 18 or older who received IVT within 4.5 hours after onset between January 2018 and December 2020. The data were retrospectively collected from medical records. The patients were classified as having an excellent (0–2) or poor (3–6) outcomes based on the 90-day modified Rankin Scale (mRS). Univariable and multivariable logistic regression analyses were used to evaluate the results. The predictive model was determined and developed the score using regression coefficients. The prediction power was validated using the area under the receiver operating characteristic curve analysis.

Results

The study included 138 eligible participants. Forty-eight patients had unfavorable functional outcomes. With multivariable logistic regression analysis, factors significantly associated with poor outcomes were age (adjusted odds ratio (AOR), 1.03; 95% confidence interval (CI), 0.99–1.07; P = 0.05), diabetes (3.96; 1.61–9.37; P = 0.003), admission National Institute of Health Stroke Scale (NIHSS) (1.08; 1.01–1.15; P = 0.02) and initial Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (0.56; 0.37–0.86; P = 0.009). The predictive model developed from the findings demonstrated good discrimination power (AuROC 0.803, 95% CI 0.728–0.877).

Conclusion

The current study found that older age, diabetes, atrial fibrillation, higher admission NIHSS, and lower ASPECTS on the initial NCCT brain were related to unfavorable functional outcomes following IVT and served as good predictors of patient functional outcomes.

Intravenous thrombolysis for acute ischemic stroke: why not?

PURPOSE OF REVIEW

The aim of this study was to summarize available evidence regarding the safety and efficacy of intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with specific comorbidities and potential contraindications to systemic reperfusion therapy. Recent advances in IVT implementation in wake-up stroke and in extended time window using advanced neuroimaging will also be highlighted.

RECENT FINDINGS

Despite theoretical concerns of a higher bleeding risk with IVT, there are no data showing increased risk of symptomatic intracerebral haemorrhage (sICH) in patients with stroke mimics, including seizures, increasing age and dual antiplatelet pretreatment. In addition, recent randomized evidence allows us to expand the time window of IVT for AIS using advanced neuroimaging both in wake-up stroke patients and in patients presenting within 4.5-9 h from symptom onset fulfilling certain neuroimaging criteria (based on DWI/FLAIR mismatch or perfusion mismatch).

SUMMARY

IVT is a highly effective systemic reperfusion therapy that counts 25 years of everyday clinical experience but still presents several challenges in its application. Appropriate patient selection and adherence to rt-PA protocol is paramount in terms of safety. The effort to simplify the indications, expand the therapeutic time window and eliminate specific initial contraindications is continuously evolving.

Intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage: a meta-analysis

Background:

The history of intracranial hemorrhage (ICrH) is considered a contraindication for intravenous thrombolysis (IVT) among patients with acute ischemic stroke (AIS). Objective: This study aimed at comparing the safety of IVT among patients with and without a history of ICrH.

Methods:

We performed a systematic review of the literature. Data regarding all AIS patients with prior ICrH who received IVT were retrieved. Meta-analysis was performed to compare the rate of symptomatic hemorrhagic transformation (sHT), death within 90 days, and favorable and unfavorable 90-day functional outcomes based on modified Rankin Scale (mRS) among stroke patients with and without prior ICrH.

Results:

Out of 13,032 reviewed records, 7 studies were included in the systematic review and meta-analysis. Quantitative synthesis of data regarding the rate of sHT (5068 patients) revealed no significant difference between the two groups [odds ratio, OR: 1.55 (0.77, 3.12); p = 0.22]. However, a significantly higher risk of death within 90 days [OR: 3.91 (2.16, 7.08); p < 0.00001] and a significantly higher 90-day poor functional outcomes (mRS, 4–6) [OR: 1.57 (1.07, 2.30); p = 0.02] were observed among patients with prior ICrH. Likewise, the percentage of 90-day good functional outcomes (mRS, 0–1) was lower in the prior ICrH group [OR: 0.54 (0.35, 0.84); p = 0.06]. Subgroup analyses in patients with a history of ICrH (based on both patients’ medical history and imaging confirmation) revealed no significant between-group differences in rates of sHT. Also, sensitivity analysis consisting of only studies using standard-dose IVT showed no difference in sHT rates and 90-day outcomes between the two groups. There was no evidence of heterogeneity (I² >50%) among included studies.

Conclusion:

The results of this study indicated that prior history of ICrH does not increase the risk of sHT post-IVT, but it is associated with a higher risk of death and poor functional outcomes in 90 days.

[Intravenous thrombolytic therapy of ischemic stroke with the drug Revelisa in real clinical practice: results of the IVT-AIS-R study]

OBJECTIVE

Evaluation of the safety and effectiveness of thrombolytic therapy (TLT) with the drug Revelisa (alteplase) in patients with ischemic stroke (AI) in real clinical practice.

MATERIAL AND METHODS

An open prospective multicenter non-interventional register study was conducted, which included 550 patients with AI - 259 (47.1%) women and 291 (52.9%) men; average age 67.7±12.6 years. All included patients underwent TLT with the drug Revelisa within 4.5 hours from the onset of the disease and, according to the protocol of reperfusion therapy of AI, clinical, instrumental and laboratory examinations were performed. Symptomatic hemorrhagic transformation (GT) was determined in accordance with the criteria of the ECASS 3 study.

RESULTS

The majority of patients (95.8%) suffered from hypertension, 69.6% had chronic heart failure, 53.8% had coronary heart disease, 38.7% had various cardiac arrhythmias, 20.7% of patients suffered from type 2 diabetes mellitus. A day after TLT, an improvement of 4 points or more on the NIHSS scale was noted in 45% of patients. The average dynamics index on the NIHSS stroke scale after a day was -3.2±4.7 and -4.4±6.1 per 7 females (p<0.0001). GT of the lesion of the brain developed in 10.9% of cases, symptomatic GT was diagnosed in 12 (2.3%) patients. The hospital mortality rate was 12.7%. The proportion of patients with good functional recovery (0-2 points on the modified Rankin scale (mRS)) at discharge, on days 30 and 90 was 44.7%, 59.2% and 68.5%, respectively.

CONCLUSION

Performing TLT with the drug Revelisa in patients with AI leads to a statistically significant regression of neurological symptoms. A significant proportion of patients achieve a favorable clinical outcome upon discharge from the hospital and in the long term. The obtained data on the efficacy and safety profile correlate with previously published register studies of alteplase in AI.

Thrombolysis for stroke in elderly in the late window period

OBJECTIVES

Safety of intravenous thrombolysis (IVT) within 3-4.5 hours of stroke onset in patients ≥80 years is still disputable. We evaluated the association of symptom onset-to-treatment time (SOTT) with the symptomatic intracranial hemorrhage (sICH), poor outcome, and mortality in patients≥80 years.

MATERIALS AND METHODS

In a retrospective study, patients treated with IVT following stroke were registered. Outcomes were poor outcome (mRS>2), sICH/ECASS-2, and in-hospital mortality. We compared the patients≥80 years who received IVT within 3 hours with those receiving IVT within 3-4.5 hours. We further compared the patients who were <80 years with those ≥80 years and SOTT of 3-4.5 hours.

RESULTS

Of 834 patients, 265 aged over 80. In those above 80 and in multivariable analysis, the associations of SOTT with poor outcome (aOR: 1.401, CI: 0.503-3.903, p=0.519), sICH (aOR=2.50, CI=0.76-8.26, p= 0.132) and mortality (aOR=1.12, CI=0.39-3.25, p= 0.833) were not significant. 106 patients received IVT within 3-4.5 hours. In multivariable analysis, the associations of age (≥80 versus <80) with poor outcome (aOR=1.87, CI=0.65-5.37, p=0.246), sICH (aOR=0.65, CI=0.14-3.11, p=0.590), and mortality (aOR=0.87, 95% CI=0.16-4.57, p=0.867) were not significant in patients with SOTT of 3-4.5 hours.

CONCLUSION

IVT within 3-4.5 hours in patients ≥80 years is not associated with increased sICH, poor outcome, and mortality compared to the early time window, and also compared to the younger patients in 3-4.5 hours window period. The decision of IVT administration in this age group should not be made solely on the basis of stroke onset timing.

Clinical Outcomes after Intravenous Alteplase in Elderly Patients with Acute Ischaemic Stroke: A Retrospective Analysis of Patients Treated at a Tertiary Neurology Centre in England from 2013 to 2018

Intravenous thrombolysis with alteplase within 4.5 hours from symptom onset is a well-established treatment of acute ischaemic stroke (AIS). The aim was to compare alteplase for AIS between patients aged >80 and ≤80 years in our registry data, from 2013 to 2018. Mechanical thrombectomy cases were excluded. We assessed clinical outcomes over the six-year period and between patients aged over 80 and ≤80 years, using measures including the discharge modified Rankin Scale (mRS), 24-hour National Institutes of Health Stroke Scale (NIHSS) improvement, and symptomatic intracerebral haemorrhage (sICH) rate. Of a total of 805 AIS patients who received intravenous alteplase, 278 (34.5%) were over 80 years old, and 527 (65%) were younger. 616 (76.5%) received thrombolysis ≤ 3 hours after symptom onset and 189 (23.5%) within 3-4.5 hours. Median baseline mRS and NIHSS of the elderly cohort were 1 (IQR 0-5) and 13 (IQR 2-37), respectively, compared to the younger cohort 0 (IQR 0-5) and 9 (IQR 0-29). The sICH rate was 7.2% in the elderly and 4.6% in those ≤80 years, p = 0.05. NIHSS improved within 24 hours in 34% of the elderly cohort compared to 35% in the younger cohort. At hospital discharge, the mortality rate was 9% in the elderly cohort compared to the 6% in the younger cohort, p = 0.154. 25% of patients aged >80 years had mRS ≤ 2 compared to 47% in the younger patients (p < 0.0001). In conclusion, thrombolysis in elderly patients results in clinical improvement comparable to younger patients.

A risk score for prediction of symptomatic intracerebral haemorrhage following thrombolysis

BACKGROUND AND PURPOSE

Intravenous recombinant tissue plasminogen activator (rt-PA) remains the only FDA approved pharmacological therapy for acute ischemic stroke (AIS), but this treatment is associated with symptomatic intracerebral haemorrhage (SICH). The aim of this study was to derive and validate an accurate measure of SICH risk in ischemic stroke patients treated with rt-PA using data readily available from patient clinical records.

METHODS

Demographics, physiological parameters, and clinical data were obtained from 1,270 ischemic stroke patients treated with thrombolysis at 20 hospitals. This included age, sex, weight, blood pressure, glucose levels, smoking preferences, and presence of previous clinical conditions. Using a bivariate analysis on a training dataset of 890 patients, SICH cases were compared against SICH-free patients and key risk factors associated with SICH were identified. Continuous variables were stratified using k-means clustering, and odds ratios computed for each of the categorical risk factors employed in the risk score. The SICH risk score, which was assessed using an independent validation dataset comprising 380 patients, was defined between 0 and 53, and stratified into 4 categories: very low risk (0-6), low risk (7-12), moderate risk (13-19), and high risk (>20).

RESULTS

Older age (age > 75 years), higher blood pressure, higher severity of stroke, pre-treatment antithrombotic and history of hypertension and hyperlipidaemia, were shown to be significant risk factors for SICH following rt-PA treatment (p < 0.05). A number of interaction effects with age produced greater overall SICH risk than that of individual variables alone, including age*weight, age*NIHSS, age*diastolic blood pressure, and age*hypertension. The SICH prediction tool demonstrated a C-statistic of 0.75 for continuous risk scoring (0-53) and 0.71 for stratified risk levels.

CONCLUSION

A novel, computationally efficient risk score utilising data readily available from patient clinical records was shown to predict SICH risk following thrombolysis treatment with high accuracy. This tool may be useful for pre-screening patients for SICH risk to reduce the morbidity and mortality associated with thrombolysis treatment.

Experiences With Intravenous Thrombolysis in Acute Ischemic Stroke by Elderly Patients-A "Real World Scenario"

Objectives: This retrospective single-center study aimed to investigate the risk factors, outcomes and complication rates in patients older vs. younger than 80 years treated with intravenous alteplase.

Methods: Data of 1,253 thrombolysed patients were analyzed between January 1, 2004 and August 31, 2016. Vascular risk factors, stroke severity based on the NIHSS score, functional outcome using modified Rankin Scale (mRS), mortality and symptomatic intracerebral hemorrhage (SICH) were compared between two subgroups (<80 and ≥80 years).

Results: 1,125 patients were included, 199 (17.6%) among them were aged over 80 years, majority (63.3%) were female (p < 0.00001). Mean age was 68.2 ± 12.4 years, i.e., 64.7 ± 10.8 years and 84.3 ± 3.4 years in the younger and the older groups, respectively (p < 0.001). Atrial fibrillation and pre-stroke anticoagulation among patients over 80 years was more likely (p < 0.0005 and p = 0.02, respectively). NIHSS scores on admission and at 24 h were higher in elderly patients (p < 0.0001). ASPECT score at 24 h was less favorable in elderly patients (p = 0.007) and was associated with worse outcome. At 3 months, 59.8% of the patients from the older group had an unfavorable outcome (p < 0.0001), however 34.7% had independent outcome. The one-year- survival was significantly worse in the older group (p < 0.0001). The incidence of SICH was lower among older patients. In a logistic regression model, atrial fibrillation, heart failure, diabetes mellitus and smoking were proven as a significant independent risk factors for worse outcome.

Conclusion: Although, the outcomes were less favorable in patients over 80 years of age, our results support the feasibility of using intravenous thrombolysis among patients over 80 years of age.

Age-Specific and Sex-Specific Trends in Life-Sustaining Care After Acute Stroke

Background

Temporal trends in life‐sustaining care after acute stroke are not well characterized. We sought to determine contemporary trends by age and sex in the use of life‐sustaining care after acute ischemic stroke and intracerebral hemorrhage in a large, population‐based cohort.

Methods and Results

We used linked administrative data to identify all hospitalizations for acute ischemic stroke or intracerebral hemorrhage in the province of Ontario, Canada, from 2003 to 2017. We calculated yearly proportions of intensive care unit admission, mechanical ventilation, percutaneous feeding tube placement, craniotomy/craniectomy, and tracheostomy. We used logistic regression models to evaluate the association of age and sex with life‐sustaining care and determined whether trends persisted after adjustment for baseline factors and estimated stroke severity. There were 137 358 people with acute ischemic stroke or intracerebral hemorrhage hospitalized during the study period. Between 2003 and 2017, there was an increase in the proportion receiving care in the intensive care unit (12.4% to 17.7%) and mechanical ventilation (4.4% to 6.6%). There was a small increase in craniotomy/craniectomy, a decrease in percutaneous feeding tube use, and no change in tracheostomy. Trends were generally consistent across stroke types and persisted after adjustment for comorbid conditions, stroke‐center type, and estimated stroke severity. After adjustment, women and those aged ≥80 years had lower odds of all life‐sustaining care, although the disparities in intensive care unit admission narrowed over time.

Conclusions

Use of life‐sustaining care after acute stroke increased between 2003 and 2017. Women and those at older ages had lower odds of intensive care, although the differences narrowed over time. Further research is needed to determine the reasons for these findings.

Reperfusion therapy for acute ischemic stroke in older people: An observational real-life study

BACKGROUND

While randomized clinical trials have shown the benefit of thrombolysis and endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS), we aimed to describe in a real-life study the differences between older (>80 years old) and younger patients treated for AIS.

METHODS

Thousand patients treated with thrombolysis and/or EVT were consecutively included in a prospective monocentric database (admitted from December 2015 to May 2019 in our comprehensive stroke center). Demographic data with detailed history, baseline physical examinations and treatments, laboratory and imaging data, prestroke functional status, and outcome 3 months after stroke were analyzed.

RESULTS

Older patients (n = 357) had more baseline comorbidities and lower levels of prestroke independence (modified Rankin scale ≤2; 67.2% vs. 96.1%) and more severe strokes (median National Institute of Health Stroke Score [NIHSS] 15 vs. 12; p < 0.001) than younger patients (n = 643). There was no difference in the reperfusion treatments used or treatment timelines. In older patients, good functional status at 3 months was less common (29.7% vs. 61.3%) and mortality was higher (37.1% vs. 11.4%) than in younger patients. Younger age was independently associated with better prognosis (odds ratio [OR] 0.37, 95% confidence interval [CI]: 0.20-0.67; p = 0.001) and lower mortality (OR 4.38, 95% CI: 2.11-9.09; p < 0.001). Among older adults, features associated with good outcome at 3 months were age (OR 0.89, 95% CI: 0.81-0.97; p = 0.01), initial NIHSS (OR 0.89, 95% CI: 0.83-0.94; p < 0.0001), and absence of severe leukoaraiosis, anticoagulant treatment, and symptomatic intracerebral hemorrhage following reperfusion therapy (respectively, OR 0.42, 95% CI: 0.19-0.93; p = 0.03; OR = 0.07, 95% CI: 0.01-0.70; p = 0.02; and OR = 0.07, 95% CI: 0.01-0.61; p = 0.02).

CONCLUSION

Although reperfusion therapy was less successful in older patients, these patients may benefit from acute recanalization despite their age. With an increasing older adult population, high-quality prospective studies are still required to better predict functional outcome and clarify the criteria that would allow better selection of appropriate treatment.

Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.

Health-Related Quality of Life Among Patients With Acute Ischemic Stroke and Large Vessel Occlusion in the ESCAPE Trial

[Figure: see text].

Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence

Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.

Age differences in utilization and outcomes of tissue-plasminogen activator and mechanical thrombectomy in acute ischemic stroke

BACKGROUND AND PURPOSE

U.S. demographics is shifting towards older population. Older stroke patients likely receive less tissue-plasminogen activator (t-PA) and mechanical thrombectomy (MT) compared to younger patients. The objective of this study is to evaluate extent of difference in utilization of t-PA and MT and outcomes of stroke between three age groups -18-45 (young adults), 46-80 (middle/old), and > 80 (oldest old) years.

METHODS

It is a retrospective cross-sectional observational study. Primary outcomes were rates of stroke intervention and effect of age on stroke intervention. Secondary outcomes were in-hospital mortality, discharge to home, and prolonged length of stay. Multivariate survey-logistic regression was performed to evaluate outcomes.

RESULTS

Among 487,105 patients in the study 4.8% were young adults, 66.6% middle/old, and 28.6% oldest old. Compared to young adults, middle/old received 19% (OR = 0.81; 95%CI = 0.72-0.91) less t-PA alone; and 33% (OR = 0.67; 95%CI = 0.53-0.83) less MT alone; oldest old received 25% less t-PA alone (OR = 0.75; 95%CI = 0.66-0.86) and 51% (OR = 0.49; 95%CI = 0.38-0.63) less MT alone. Compared to young adults, in-hospital mortality was three-fold higher among middle/old (OR = 3.5; 95%CI = 1.3-9.6), and seven-fold higher among oldest old (OR = 7.5; 95%CI = 2.8-20.5) for t-PA alone; discharge to home reduced by 40% in middle/old (OR = 0.6; 95%CI = 0.4-0.7) and by 80% in oldest old (OR = 0.2; 95%CI = 0.1-0.2) for t-PA alone and similarly for MT alone.

CONCLUSIONS

Oldest old receive one-fourth less t-PA and half less MT compared to young adults. Oldest old patients who received t-PA alone or MT alone had remarkably worse outcomes for in-hospital mortality and discharge to home than young adults did.

Early prediction of the 3-month outcome for individual acute ischemic stroke patients who received intravenous thrombolysis using the N2H3 nomogram model

Background:

The aim of this study was to establish a nomogram model for individualized early prediction of the 3-month prognosis in patients with acute ischemic stroke (AIS) who were treated with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis.

Methods:

A total of 691 patients were included in this study; 564 patients were included in the training cohort, while 127 patients were included in the test cohort. The main outcome measure was a 3-month unfavorable outcome (modified Rankin Scale 3–6). To construct the nomogram model, stepwise logistic regression analysis was applied to select the significant predictors of the outcome. The discriminative performance of the model was assessed by calculating the area under the receiver operating characteristic curve (AUC-ROC). A decision curve analysis was used to evaluate prognostic value of the model.

Results:

The initial National Institutes of Health Stroke Scale [NIHSS, odds ratio (OR), 1.35; 95% confidence interval (CI), 1.28–1.44; p < 0.001], delta NIHSS (changes in the NIHSS score from baseline to 24 h, OR, 0.75; 95% CI, 0.70–0.79; p < 0.001), hypertension (OR, 2.07; 95% CI, 1.32–3.31; p = 0.002), hyperhomocysteinemia (Hhcy, OR, 2.18; 95% CI, 1.20–4.11; p = 0.013), and the ratio of high-density lipoprotein cholesterol (HDL-C) to low-density lipoprotein cholesterol (LDL-C) (HDL-C/LDL-C, OR, 3.29; 95% CI, 1.00–10.89; p = 0.049) (N2H3) were found to be independent predictors of a 3-month unfavorable outcome from multivariate logistic regression analysis and were incorporated in the N2H3 nomogram model. The AUC-ROC of the training cohort was 0.872 (95% CI, 0.841–0.902), and the AUC-ROC of the test cohort was 0.900 (95% CI, 0.848–0.953).

Conclusion:

The study presented the N2H3 nomogram model, with initial NIHSS score, delta NIHSS, hypertension, Hhcy, and HDL-C/LDL-C as predictors. It therefore provides an individualized early prediction of the 3-month unfavorable outcome in AIS patients treated with intravenous rt-PA thrombolysis.