Predicting abnormal coagulation in ischemic stroke: reducing delay in rt-PA use

Clinical Features of Craniopharyngioma With Tumoral Hemorrhage: A Retrospective Case-Controlled Study

Background

Craniopharyngioma (CP) with tumoral hemorrhage is a very rare syndrome presenting with various manifestation and unfavorable outcomes. The current retrospective study was performed to summarize the clinical features of CP with tumoral hemorrhage.

Methods

In this study, 185 patients with pathological diagnosis of CP (18 patients with hemorrhage) were enrolled. Clinical characteristics, radiological and surgical treatments, and post-operative complications were analyzed. In addition, the correlations between sexual hormones and tumor volume were explored.

Results

Drowsiness, acute syndrome, and pituitary deficiency were more frequent in patients with hemorrhage patients. Prothrombin time (PT) were higher in patients with hemorrhage. Luteinizing hormone (LH) and testosterone (T) were lower in male patients with hemorrhage. Post-operative electrolyte disturbances, hypothalamic syndrome, and death appeared more frequently in the hemorrhage group. Moreover, prolactin (PRL) and cortisol 8AM were found to be correlated with the volume of the tumor and the hematoma, respectively.

Conclusion

The current study presented the clinical features of CP apoplexy from the aspects of clinical characteristics, radiography, surgical treatment, and post-operative complications. Patients with CP apoplexy could benefit from the proper processing of peritumoral hemorrhage and post-operative monitoring of the electrolyte.

The Routine Follow-up Head CT: Is it Still a Necessary Step in the Thrombolysis Pathway?

Background

The 24-h head computed tomography (CT) scan following intravenous tissue plasminogen activator or mechanical thrombectomy (MT) is currently part of most acute stroke protocols. However, as evidence emerges regarding who is at highest risk for treatment complications, the utility of routine neuroimaging for all patients has become less clear.

Methods

Four hundred seventy-five patients presenting with acute ischemic stroke to Johns Hopkins Bayview Medical Center between 2004 and 2018 and treated with intravenous tissue plasminogen activator and/or MT were evaluated. Neuroimaging performed during the first 48 h of hospitalization was reviewed for edema, hemorrhagic transformation (HT), or other findings altering management. Early imaging (< 24 h), performed for neurologic deterioration, was compared with imaging performed per protocol (24 ± 6 h). Factors predictive of radiographically and clinically significant findings on per-protocol imaging were determined.

Results

One hundred fifty-three patients (32%) underwent early imaging. These patients generally had more severe strokes. HT was found in 15% of cases. For the remaining patients (n = 322), imaging at 24 h impacted acute management for only 24 patients: resulting in emergent hemicraniectomy in 1 (0.3%) and leading to additional imaging to monitor asymptomatic HT or edema in 23 (7.1%). Advanced age, higher stroke severity, MT, and atrial fibrillation were associated with significant findings on the 24-h CT scan. Only 2 of the 24 patients had an initial National Institutes of Health Stroke Scale score of < 7.

Conclusions

The 24-h head CT scan does not change management for most patients, particularly those with low National Institutes of Health Stroke Scale scores who do not undergo MT. Consideration should be given to removing routine follow-up imaging from postthrombolysis protocols in favor of an examination-based approach.

Administration of tissue plasminogen activator without coagulation results in a Chinese population

Routine coagulation test before intravenous tissue plasminogen activator (tPA) use increases the door to needle time (DNT). We sought to evaluate the safety of tPA use without coagulation results and its impact on prognosis. In our stroke registry, tPA was delivered with coagulation results from December 2015 to April 2016 and without coagulation results from May 2016 to December 2016. Differences of demographics, clinical characteristic, and prognosis between these two groups were analyzed. In addition, logistic regression analysis was conducted to identify predictors for DNT of over 60 min. A total of 201 stroke patients were included in the final analysis. Of these, 81 patients received tPA with coagulation results and 120 patients without coagulation results. Only one (0.8%) patient with abnormal coagulation results met the exclusion criteria of tPA use in patients without coagulation results. The difference of DNT between groups with (mean, 61.7 min) and without (mean, 41.9 min) coagulation results was significant (P = 0.00). The group without coagulation results had a higher rate of favorable 90-day outcome (74.2 vs 70.4%) and lower rates of symptomatic intracranial hemorrhage/nonintracranial hemorrhage (4.9 and 22.2% vs 1.7 and 19.2%) than the group with coagulation results did; these differences were not statistically significant. In multivariate analysis, only tPA use with coagulation results was the predictor for DNT of over 60 min (P = 0.0030, OR = 2.44, 95% CI 1.28-4.65). The present study suggests that tPA could be delivered safely without coagulation results in patients without suspected coagulopathy, and avoiding coagulation tests reduces significantly the DNT interval.

In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia

BACKGROUND

Stroke can occur in patients on warfarin despite anticoagulation. Patients with a low international normalized ratio (INR) should theoretically be at greater risk for ischemia than those who are therapeutic. Therefore, INR may be able to indicate whether new neurological deficits are more likely strokes or stroke mimics in patients on warfarin. This study evaluates the association and predictive value of INR in determining the likelihood of ischemia.

METHODS

Patients were identified using the acute stroke registry at a Primary Stroke Center from January 2013 through December 2014. All adult patients undergoing evaluation for acute stroke with prior documented use of warfarin and an INR level at presentation were included. Data were collected regarding patient demographics, medical comorbidities, stroke severity, reason for anticoagulation, and laboratory studies including INR. Student t tests and χ2 analysis were used to evaluate factors associated with increased likelihood of ischemia (stroke or transient ischemic attack) versus mimic. Significant results were entered into a multivariable regression analysis. Sensitivity and specificity analyses were conducted to determine the predictive value of INR for ischemic risk.

RESULTS

116 patients were included; 46 were diagnosed with ischemia, 70 were diagnosed as mimics. 75% of patients were on warfarin for atrial fibrillation versus 25% for venous thrombosis. A statistically significant difference in mean INR for patients with ischemia (n = 46) versus mimics (n = 70) was observed (1.7 vs. 2.8; p < 0.001). In multivariable analysis, both sub-therapeutic INR (p < 0.001) and atrial fibrillation (p = 0.014) were predictors of ischemia. In patients with an INR ≥2, the predictive value of having a non-ischemic etiology was 79%. No patient with an INR of ≥3.6 was found to have ischemia.

CONCLUSIONS

Sub-therapeutic INR and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients' risk for acute ischemic stroke and guide further neurologic imaging and workup.

Intravenous Tissue Plasminogen Activator Can Be Safely Given without Complete Blood Count Results Back

Introduction

It is well known that the efficacy of intravenous (IV) tissue plasminogen activator (tPA) is time-dependent when used to treat patients with acute ischemic strokes.

Aim

Our study examines the safety issue of giving IV tPA without complete blood count (CBC) resulted.

Materials and Methods

This is a retrospective observational study by examining the database from Huashan Hospital in China and OSF/INI Comprehensive Stroke Center in United States. Patient data collected included demographics, occurrence of symptomatic intracranial hemorrhage, door to needle intervals, National Institute of Health Stroke Scale scores on admission, CBC results on admission and follow-up modified Rankin Scale scores. Linear regression and multivariable logistic regression analysis were used to identify factors that would have an impact on door-to-needle intervals.

Results

Our study included120 patients from Huashan Hospital and 123 patients from INI. Among them, 36 in Huashan Hospital and 51in INI received IV tPA prior to their CBC resulted. Normal platelet count was found in 98.8% patients after tPA was given. One patient had thrombocytopenia but no hemorrhagic event. A significantly shorter door to needle interval (DTN) was found in the group without CBC resulted. There was also a difference in treatment interval between the two hospitals. Door to needle intervals had a strong correlation to onset to treatment intervals and NIHSS scores on admission.

Conclusion

In patients presented with acute ischemic stroke, the risk of developing hemorrhagic event is low if IV tPA is given before CBC has resulted. The door to needle intervals can be significantly reduced.

Thrombolysis for acute stroke in hemodialysis: international survey of expert opinion

BACKGROUND AND OBJECTIVES

Although data are absent, it has been stated that thrombolysis is probably not safe in the treatment of acute stroke in patients undergoing hemodialysis. The objective of this study was for stroke experts to define the range of management concerning thrombolytic treatment of acute stroke in hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Sixty-five stroke experts in thrombolytic therapy of acute ischemic stroke were queried regarding their personal experience in the use of thrombolysis in hemodialysis patients. Hypothetical case scenarios were presented.

RESULTS

Of the 65 stroke experts who were queried, 40 (62%) responded. One-third of the responders had previously treated hemodialysis patients with recombinant tissue-type plasminogen activator (rt-PA). Most favored use of intravenous rt-PA for hemodialysis patients with acute ischemic stroke. When presented with a case of a patient who had recently undergone dialysis with a mildly prolonged activated partial thromboplastin time (aPTT), 50% favored immediate intravenous thrombolysis. Seventy-eight percent of the experts would have considered an intra-arterial approach and would have preferred mechanical clot retrieval to thrombolysis.

CONCLUSIONS

Despite the acknowledged absence of data and prevalent concerns about bleeding risk, most surveyed experts favored its use. One-third reported treating hemodialysis patients with this therapy. Although these results do not substitute for data, they usefully define the range of current practice of stroke experts.

Unsuspected coagulopathy rarely prevents IV thrombolysis in acute ischemic stroke

BACKGROUND

American Heart Association/American Stroke Association guidelines recommend initiating treatment with IV tissue plasminogen activator (tPA) in acute ischemic stroke patients without suspected coagulopathy prior to availability of clotting results; however, little or no data support this practice. We sought to identify how often blood clotting abnormalities were responsible for withholding IV tPA at our institution.

METHODS

We conducted a retrospective review of our prospectively acquired Get With the Guidelines Stroke database from January 2003 to April 2008. All patients underwent clinical evaluation by a neurologist, diagnostic neuroimaging, and laboratory testing on admission. We classified patients with absolute contraindications to IV tPA as ineligible, and those with warnings/relative contraindications or potentially treatable factors as potentially eligible.

RESULTS

Of 2,335 considered for analysis, 470 (20.1%) patients presented to our emergency department (ED) within 3 hours. Among these, 147 (31.3%) received IV tPA in our ED, 102 (21.7%) had an absolute contraindication, and 221 (47%) had a reason to consider withholding tPA. Only 30/470 (6.4%) of potential thrombolysis patients were discovered to have international normalized ratio > or =1.7 or platelets < or =100,000/microL, and of these, 28 were suspected a priori due to known coagulopathy from medication or illness. Only 2/470 (0.4%) patients had an unsuspected coagulopathy that ultimately prevented thrombolysis.

CONCLUSIONS

Based on the experience of a large thrombolysis referral center, stroke patients without suspected clotting abnormality can safely begin thrombolytic therapy before clotting results are available. These data support the current practice guidelines, and may reassure clinicians that the benefits of early administration greatly outweigh the risks due to an unsuspected bleeding diathesis.

Transient ischemic attack: diagnostic evaluation

A transient ischemic attack portends significant risk of a stroke. Consequently, the diagnostic evaluation in the emergency department is focused on identifying high-risk causes so that preventive strategies can be implemented. The evaluation consists of a facilitated evaluation of the patient's metabolic, cardiac, and neurovascular systems. At a minimum, the following tests are recommended: fingerstick glucose level, electrolyte levels, CBC count, urinalysis, and coagulation studies; noncontrast computed tomography (CT) of the head; electrocardiography; and continuous telemetry monitoring. Vascular imaging studies, such as carotid ultrasonography, CT angiography, or magnetic resonance angiography, should be performed on an urgent basis and prioritized according to the patient's risk stratification for disease. Consideration should be given for echocardiography if no large vessel abnormality is identified.

Therapeutic Hypothermia after Cardiac Arrest: Performance Characteristics and Safety of Surface Cooling with or without Endovascular Cooling

INTRODUCTION

Various methods are available to induce and maintain therapeutic hypothermia after cardiac arrest, but little data is available comparing device-mediated cooling to simple surface methods in this setting.

METHODS

To assess the performance characteristics of simple surface cooling with or without an endovascular cooling catheter system, we retrospectively reviewed all cases of hypothermia for comatose survivors of cardiac arrest treated at a single academically affiliated urban hospital. Forty two comatose survivors of cardiac arrest were treated over a 3.5-year period. Hypothermia was induced and maintained by simple surface methods (ice packs, cooling blankets) with or without placement of an endovascular cooling catheter system with automated temperature feedback regulation.

RESULTS

Overall, the rate of active cooling was not different between patients treated with endovascular catheter-assisted hypothermia and patients treated with surface cooling alone. However, use of a larger (14 F) catheter was associated with faster cooling rates. Maintenance of goal temperature (33 degrees C) was far better controlled with the use of a cooling catheter. Use of surface cooling alone was associated with significant temperature overshoot. Patients treated with surface cooling alone spent more time bradycardic.

CONCLUSION

Use of an endovascular cooling catheter as part of a treatment protocol for hypothermia after cardiac arrest provides better control during maintenance of hypothermia, preventing temperature overshoot. Active cooling rates may be enhanced by the use of a larger cooling catheter.