Restriction of therapy mainly explains lower thrombolysis rates in reduced stroke service levels

Quality Indicators and Clinical Outcomes of Acute Stroke: Results from a Prospective Multicenter Registry in Greece (SUN4P)

AIM

The Stroke Units Necessity for Patients (SUN4P) project aims to provide essential data on stroke healthcare in Greece. Herein, we present results on established quality indicators and outcomes after first-ever stroke occurrences.

METHODS

This prospective multicenter study included consecutive patients admitted to nine hospitals across Greece in 2019-2021. Descriptive statistics were used to present patients' characteristics, key performance measures and stroke outcomes.

RESULTS

Among 892 patients, 755 had ischemic stroke (IS) (mean age 75.6 ± 13.6, 48.7% males) and 137 had hemorrhagic stroke (HS) (mean age 75.8 ± 13.2, 57.7% males). Of those, 15.4% of IS and 8% of HS patients were treated in the acute stroke unit (ASU) and 20.7% and 33.8% were admitted to the intensive care unit (ICU) or high-dependency unit (HDU), respectively. A total of 35 (4.6%) out of 125 eligible patients received intravenous alteplase with a door-to needle time of 60 min (21-90). The time to first scan for IS patients was 60 min (31-105) with 53.2% undergoing a CT scan within 60 min post presentation. Furthermore, 94.4% were discharged on antiplatelets, 69.8% on lipid-lowering therapy and 61.6% on antihypertensives. Oral anticoagulants (OAC) were initiated in 73.2% of the 153 IS patients with atrial fibrillation (AF). Among the 687 IS patients who survived, 85.4% were discharged home, 12% were transferred to rehabilitation centers, 1.2% to nursing homes and 1.3% to another hospital.

CONCLUSIONS

The SUN4P Registry is the first study to provide data from a prospectively collected cohort of consecutive patients from nine representative national hospitals. It represents an important step in the evaluation and improvement of the quality of acute stroke care in Greece.

10-year Temporal Trends of Intravenous Thrombolysis in Acute Ischemic Stroke: Analysis of the China National Stroke Registry I-Ⅲ

OBJECTIVES

To investigate the 10-year trend in healthcare quality of intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator in acute ischemic stroke (AIS) in China.

MATERIALS AND METHODS

We analyzed 42,188 AIS within 7 days of onset from the China National Stroke Registry (CNSR) Ⅰ-Ⅲ. Primary outcomes were temporal changes in the proportion of patients arriving at the hospital within 3.5 hours (and 2 hours) of onset and receiving IVT within 4.5 hours (and 3 hours), stratified by region and hospital tier. Secondary outcomes included temporal changes in door-to-needle time (DNT), DNT ≤60 min and favorable outcome defined as a 90-day modified Rankin Scale (mRS) of 0-1.

RESULTS

Among patients arriving at the hospital within 3.5 hours of onset, 13.5%, 7.1% and 33.4% patients received IVT within 4.5 hours in CNSR Ⅰ, Ⅱ and Ⅲ, respectively, including a higher proportion from eastern China (37.0%) and tertiary hospitals (36.5%). The median DNT was shorter in CNSR Ⅲ (60.0 min) than those in Ⅱ (95.0 min) and I (94.0 min). The proportion of patients with DNT ≤60 min was greater in Ⅲ (53.4%) than those in Ⅱ (26.7%) and Ⅰ (13.4%). The proportion of favorable outcomes was higher in CNSR Ⅲ (72.8%) than those in Ⅱ (49.6%) and Ⅰ (49.4%). Similar trends were observed for patients arriving at the hospital within 2 hours and receiving IVT within 3 hours of onset.

CONCLUSIONS

The healthcare quality of IVT has improved remarkably in the past decade, notably in eastern China and tertiary hospitals.

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.

Reasons and predictors of non-thrombolysis in patients with acute ischemic stroke admitted within 4.5 h

Objectives

Thrombolytic treatment in acute ischemic stroke (AIS) reduces stroke‐related disability. Nearly 40% of all patients with AIS (<4.5 h) receive thrombolysis, but there is a large variation in the use between hospitals. Little is known about reasons and predictors for not giving thrombolytic treatment. Therefore, we aimed to investigate reasons for non‐thrombolysis in patients admitted within 4.5 h.

Methods

All patients with AIS (<4.5 h) admitted to Akershus University Hospital, Norway, between January 2015 and December 2017 were examined. Patient characteristics and reasons for not giving thrombolysis were registered. Descriptive statistics and logistic regression analyses were performed.

Results

Of 535 patients admitted with AIS (<4.5 h), 250 (47%) did not receive thrombolysis and of these only 26% had an absolute contraindication to treatment. Among the 74% with relative contraindications, the most common reasons given were mild and improving symptoms. Previous stroke (OR 3.32, 95%CI 1.99–5.52), arriving between 3 h and 4.5 h after onset (OR 7.76, 95%CI 3.73–16.11) or having mild symptoms (OR 2.33, 95%CI 1.56–3.49) were all significant predictors of not receiving thrombolytic treatment in the multivariable logistic regression model.

Conclusion

A large proportion of patients with AIS do not receive thrombolysis. This study highlights up‐to‐date findings that arriving late in the time window, mild symptoms, and previous stroke are strong predictors of non‐treatment. It is uncertain whether there is an underuse of thrombolysis in AIS. Increasing the utility of thrombolysis in the 4.5 h time window must be weighed against possible harms.

Aspects of ischemic stroke biomechanics derived using ex-vivo and in-vitro methods relating to mechanical thrombectomy

Establishing the underlying biomechanics of acute ischemic stroke (AIS) and its treatment is fundamental to developing more effective clinical treatments for one of society's most impactful diseases. Recent changes in AIS management, driven by clinical evidence of improved treatments, has already led to a rapid rate of innovation, which is likely to be sustained for many years to come. These unprecedented AIS triage and treatment innovations provide a great opportunity to better understand the disease. In this article we provide a perspective on the recreation of AIS in the laboratory to inform contemporary device design and procedural techniques in mechanical thrombectomy. Presentation of these findings, which have been used to solve the applied problem of designing mechanical thrombectomy devices, is intended to help inform the development of basic biomechanics solutions for AIS.

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept

Background:

Computed tomography (CT) scans are the first-line imaging technique in acute stroke patients based on the argument of rapid feasibility. Using magnetic resonance imaging (MRI) as the first-line imaging technique is the exception to the rule, although it provides much more diagnostic information and avoids exposure to radiation. We evaluated whether an MRI-based acute stroke concept is fast, suitable, and useful to improve recanalization rates and patient outcomes.

Methods:

We performed a retrospective observational cohort study comparing patients treated at a comprehensive stroke center (Ulm/Germany) applying an MRI-based acute stroke concept with patients recorded in a large comprehensive stroke registry in Baden-Württemberg (Germany). We analyzed the quality indicators of acute stroke treatment, patient’s outcome, and the rate of transient ischemic attack (TIA) at discharge.

Results:

A total of 2182 patients from Ulm and 82,760 patients from the Baden-Württemberg (BW) stroke registry (including 29,575 patients of comprehensive stroke centers (BWc)) were included. Intravenous thrombolysis rate was higher in Ulm than in BW or the BWc stroke centers (Ulm 27.4% versus BW 20.9% versus BWc 26.1; p < 0.01), while a door-to-needle time <30 min could be achieved more frequently (Ulm 73.6% versus BW 44.1% versus BWc 47.1%; p < 0.01). Thrombectomy rate in patients with a proximal vascular occlusion was higher (Ulm 69.2% versus BW 50.7% versus BWc 59.3; p < 0.01). The number of TIA diagnoses was lower (Ulm 16.2% versus BW 24.6% versus BWc 19.9%; p < 0.01). More patients showed a shift to a favorable outcome (Ulm 21.1% versus BW 16.9% versus BWc 15.3; p < 0.01). Complication rates were similar.

Conclusions:

The MRI-based acute stroke concept is suitable, fast and seems to be beneficial. The time-dependent quality indicators were better both in comparison to all stroke units and to the comprehensive stroke units in the area. Based on the MRI concept, high rates of recanalization procedures and fewer TIA diagnoses could be observed. In addition, there was a clear trend towards an improved clinical outcome. A clinical trial comparing the effects of CT and MRI as the primary imaging technique in otherwise identical stroke unit settings is warranted.

Stroke 20 20: Implementation goals for intravenous thrombolysis

Introduction

Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis.

Material and Method

Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004.

Results

Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients.

Discussion

Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes.

Conclusion

Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.

[Telemedicine in stroke-pertinent to stroke care in Germany]

BACKGROUND AND OBJECTIVE

Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution.

METHODS

The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks.

RESULTS

Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states.

CONCLUSION

Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

Clinical Outcomes and Safety of Mechanical Thrombectomy for Acute Ischaemic Stroke in Patients with Pre-Existing Dependency

OBJECTIVES

Pre-stroke dependency (PSD) is associated with poor outcome after stroke. The aim of the study was to evaluate the clinical outcomes and safety of mechanical thrombectomy (MT) in pre-stroke dependent patients compared to pre-stroke independent patients.

MATERIAL AND METHODS

We included consecutive patients with anterior circulation acute ischaemic stroke related to large vessel occlusion (AIS-LVO), treated by MT between January 1^st 2015 and July 1^st 2018 in our single comprehensive stroke center. PSD was defined as a mRS score of 3 to 5 before stroke onset. We studied outcome variables in pre-stroke dependent vs. independent patients, by using logistic regression models. Clinical outcomes included clinical favorable outcome at 3 months (defined as modified Rankin Score 0-2 or equal to pre-stroke mRS score), successful recanalization rates and safety outcomes.

RESULTS

Of 922 patients with anterior circulation AIS-LVO, 155 (16.8%) had PSD. Favorable outcome was less often achieved in patients with PSD (25.8% vs. 44.7%, p <0.001); but the difference did not remain significant in multivariable analysis (adjusted OR, 0.70; 95%CI, 0.44 to 1.12). Mortality at 90-days was significantly higher in patients with PSD (49.0% vs. 18.8%, adjusted OR, 2.63; 95%CI, 1.69 to 4.00). Successful recanalization was strongly associated with favorable outcome (adjusted OR, 8.15; 95%CI 4.97 to 13.34).

CONCLUSIONS

One out of four patients with PSD had a favorable outcome after MT. Despite higher mortality rates compared to pre-stroke independent patients, PSD alone should not be used alone to deny mechanical thrombectomy.

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.

Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke

Background and purpose

Current demographic changes indicate that more people will be care-dependent due to increasing life expectancy. Little is known about impact of preexisting dependency on stroke outcome after endovascular treatment (EVT).

Methods

We compared prospectively collected baseline and outcome data of previously dependent vs. independent stroke patients (prestroke modified Rankin Scale score of 3–5 vs. 0–2) treated with EVT. Outcome measures were favorable 3-month outcome (mRS ≤ 3 for previously dependent and mRS ≤ 2 for independent patients, respectively), death and symptomatic intracranial hemorrhage (sICH).

Results

Among 1247 patients, 84 (6.7%) were dependent before stroke. They were older (81 vs. 72 years of age), more often female (61.9% vs. 46%), had a higher stroke severity at baseline (NIHSS 18 vs. 15 points), more often history of previous stroke (32.9% vs. 9.1%) and more vascular risk factors than independent patients. Favorable outcome and mortality were to the disadvantage of independent patients (26.2% vs. 44.4% and 46.4% vs. 25.5%, respectively), whereas sICH was comparable in both cohorts (4.9% vs. 5%). However, preexisting dependency was not associated with clinical outcome and mortality after adjusting for outcome predictors (OR 1.076, 95% CI 0.612–1.891; p = 0.799 and OR 1.267, 95% CI 0.758–2.119; p = 0.367, respectively).

Conclusion

Our study underscores the need for careful selection of care-dependent stroke patients when considering EVT, given a less favorable outcome observed in this cohort. Nonetheless, EVT should not systematically be withheld in patients with preexisting disability, since prior dependency does not significantly influence outcome.

Outcomes of patients with stroke treated with thrombolysis according to prestroke Rankin Scale scores

BACKGROUND

It is common practice to withhold IV thrombolysis (IVT) for acute ischemic stroke in patients with preexisting disabilities. To test the hypothesis of an association of IVT and good clinical outcome also in patients with preexisting disabilities without an increase in mortality, we analyzed data from 52,741 patients (15,317 treated with IVT) depending on prestroke Rankin Scale (pRS) score.

METHODS

We performed an observational study based on a consecutive stroke registry covering 10.8 million inhabitants. The outcome at discharge of patients with stroke admitted in the time window of potential eligibility for IVT (<4.5 hours after stroke onset) was compared between patients treated and those not treated with thrombolysis, stratified by pRS score. Logistic regression analysis was used to estimate adjusted odds ratios (ORs) along with 95% confidence intervals (CIs) for favorable clinical outcome, defined as returning to the baseline pRS score or a score of 0 or 1 and mortality. Sensitivity analyses for subgroups of mildly and severely affected patients with stroke were performed, and the influence of treatment duration was assessed.

RESULTS

Among included patients, IVT rates were 32% for patients with pRS scores of 0 to 1 and 20% for patients with pRS scores of 2 to 5. IVT in patients with pRS scores of 0 to 4 was associated with a higher chance of returning to the baseline pRS score (or a modified Rankin Scale score of 0/1), with ORs ranging between 1.42 (pRS score 2; 95% CI 1.16-1.73) and 1.73 (pRS score 0; 95% CI 1.61-1). The OR observed in patients with a pRS score of 5 was 0.65 (95% CI 0.25-1.70). Observed associations remained consistent in sensitivity analyses. Subgroup analyses revealed no evidence of bias due to potential floor and ceiling effects. No evidence of elevated in-hospital mortality of patients treated with thrombolysis was observed.

CONCLUSIONS

Our study suggests that IVT can be effective even in patients with severe preexisting disabilities, provided that they were not bedridden before stroke onset. Withholding IVT on the sole ground of prestroke disabilities may not be justified.

Validation of the Simplified Stroke-Thrombolytic Predictive Instrument to Predict Functional Outcomes in Chinese Patients

Background and Purpose- The simplified stroke-thrombolytic predictive instrument (s-Stroke-TPI) is useful for predicting the outcomes in thrombolysis-treated patients in Western populations. We aimed to validate its predictive value in Chinese patients. Methods- Data from thrombolysis implementation and monitor of acute ischemic stroke in China were analyzed. Patients with acute ischemic stroke and treated with thrombolysis within 4.5 hours of symptom onset were included. The 3-month functional outcomes were assessed with the modified Rankin Scale (mRS). Model discrimination was quantified by calculating the area under receiver operating characteristic curve. s-Stroke-TPI was compared with dense artery sign, mRS score, age, glucose, onset to treatment time, and National Institutes of Health Stroke Scale or stroke prognostication using age and National Institutes of Health Stroke Scale. Results- A total of 1102 patients who received thrombolysis were enrolled. The area under receiver operating characteristic curve of s-Stroke-TPI for predicting a catastrophic outcome (mRS score, 5-6), a normal/near-normal outcome (mRS score, 0-1), and independent outcome (mRS score, 0-2) at 3 months were 0.80, 0.73, and 0.75, respectively, which were significantly higher than or similar to those of dense artery sign, mRS score, age, glucose, onset to treatment time, and National Institutes of Health Stroke Scale or stroke prognostication using age and National Institutes of Health Stroke Scale. The calibration analysis of the s-Stroke-TPI showed a high correlation between the predicted and observed probabilities of the functional outcomes at 3 months. Conclusions- The s-Stroke-TPI reliably predicted the 3-month functional outcomes, especially catastrophic outcomes, in Chinese stroke patients with thrombolysis. Further validation is needed to confirm outcome predictions in patients both with and without thrombolysis.

Stroke Factors Associated with Thrombolysis Use in Hospitals in Singapore and US: A Cross-Registry Comparative Study

BACKGROUND AND OBJECTIVES

This paper aims to describe and compare the characteristics of 2 stroke populations in Singapore and in St. Louis, USA, and to document thrombolysis rates and contrast factors associated with its uptake in both populations.

METHODS

The stroke populations described were from the Singapore Stroke Registry (SSR) in -Singapore and the Cognitive Rehabilitation Research Group Stroke Registry (CRRGSR) in St. Louis, MO, USA. The registries were compared in terms of demographics and stroke risk factor history. Logistic regression was used to determine factors associated with thrombolysis uptake.

RESULTS

A total of 39,323 and 8,106 episodes were recorded in SSR and CRRGSR, respectively, from 2005 to 2012. Compared to CRRGSR, patients in SSR were older, male, and from the ethnic majority. Thrombolysis rates in SSR and CRRGSR were 2.5 and 8.2%, respectively, for the study period. History of ischemic heart disease or atrial fibrillation was associated with increased uptake in both populations, while history of stroke was associated with lower uptake. For SSR, younger age and males were associated with increased uptake, while having a history of smoking or diabetes was associated with decreased uptake. For CRRGSR, ethnic minority status was associated with decreased uptake.

CONCLUSIONS

The comparison of stroke populations in Singapore and St Louis revealed distinct differences in clinicodemographics of the 2 groups. Thrombolysis uptake was driven by nonethnicity demographics in Singapore. Ethnicity was the only demographic driver of uptake in the CRRGSR population, highlighting the need to target ethnic minorities in increasing access to thrombolysis.

Efficacy and Safety of Intravenous Thrombolysis in Patients with Acute Ischemic Stroke and Pre⁻Existing Disability

Little is known about intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with pre-existing disability. Disabled patients are often excluded from IVT treatment. Previous studies investigated the role of pre-existing disability on outcomes in AIS patients after IVT. However, no studies have been conducted to date to determine whether IVT may improve clinical outcomes in AIS patients with pre-existing disability. The aim of our study was to evaluate efficacy and safety of IVT in patients with pre-existing moderate and moderately severe disability (pre-stroke modified Rankin Scale score = 3 or 4) affected by AIS. This study was based on a retrospective analysis of a prospectively collected database of consecutive patients admitted to the Udine University Hospital with AIS from January 2015 to May 2018. The efficacy endpoints were the rate of favorable outcome and rate of major neurological improvement. The safety endpoints were the rate of mortality at three months, presence of intracranial hemorrhage (ICH), and presence of symptomatic intracranial hemorrhage (sICH). The study population included 110 AIS patients with pre-existing moderate and moderately severe disability, 36 of which received (IVT+) and 74 did not receive IVT (IVT−). AIS disabled patients treated with IVT had higher rates of favorable outcome (66.7% vs. 36.5%, p = 0.003) and major neurological improvement (39.4% vs. 17.4%, p = 0.01) compared to non-treated ones. Two in three disabled patients returned to their pre-stroke functional status when treated with IVT. Prevalence of three-month mortality, ICH, and sICH did not differ in the two groups. Disabled patients affected by AIS significantly improved after IVT. Moderate and moderately severe disability alone should not be considered, per se, as a contraindication to IVT treatment.

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.

Endovascular stroke treatment does not preclude high thrombolysis rates

BACKGROUND AND PURPOSE

In 1995 intravenous recombinant tissue plasminogen activator (IVRTPA) was the first reperfusion therapy to be approved in patients with acute ischaemic stroke (AIS). The significance and impact of IVRTPA in times of modern endovascular stroke treatment (EST) were analysed in a German academic stroke centre.

METHODS

A retrospective observational cohort analysis of 1034 patients with suspected AIS presenting at the emergency department in 2014 was performed. Patients were evaluated for baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcome, symptomatic intracranial haemorrhage (sICH) and mortality. Data acquisition was part of an investigator-initiated, prospective and blinded end-point registry.

RESULTS

In 718 (69%) patients the diagnosis of symptomatic AIS was confirmed. 419 (58%) patients presented within 4.5 h of symptom onset and of those 260 (62%) received reperfusion therapy (IVRTPA alone, n = 183; combination or bridging therapy, n = 60; EST alone, n = 17). Subtracting cases with absolute contraindications for IVRTPA resulted in an effective thrombolysis rate of 82%. sICH occurred in two patients treated with IVRTPA alone (1.1%). The median door-to-needle interval was 30 min. Fifty (17%) non-EST eligible AIS patients presenting within 4.5 h without absolute contraindications did not receive IVRTPA mainly due to mild or regressive symptoms. Most of these untreated IVRTPA eligible patients (82%) were discharged with a good clinical outcome (modified Rankin Scale ≤ 2).

CONCLUSIONS

Intravenous recombinant tissue plasminogen activator remains the most frequently applied reperfusion therapy in AIS patients presenting within 4.5 h of onset in a tertiary stroke centre. An effective thrombolysis rate of over 80% can be achieved without increased rates of sICH.

Cohort profile: Thrombolysis in Ischemic Stroke Patients (TRISP): a multicentre research collaboration

PURPOSE

The ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration aims to address clinically relevant questions about safety and outcomes of intravenous thrombolysis (IVT) and endovascular thrombectomy. The findings can provide observational information on treatment of patients derived from everyday clinical practice.

PARTICIPANTS

TRISP is an open, investigator-driven collaborative research initiative of European stroke centres with expertise in treatment with revascularisation therapies and maintenance of hospital-based registries. All participating centres made a commitment to prospectively collect data on consecutive patients with stroke treated with IVT using standardised definitions of variables and outcomes, to assure accuracy and completeness of the data and to adapt their local databases to answer novel research questions.

FINDINGS TO DATE

Currently, TRISP comprises 18 centres and registers >10 000 IVT-treated patients. Prior TRISP projects provided evidence on the safety and functional outcome in relevant subgroups of patients who were excluded, under-represented or not specifically addressed in randomised controlled trials (ie, pre-existing disability, cervical artery dissections, stroke mimics, prior statin use), demonstrated deficits in organisation of acute stroke care (ie, IVT during non-working hours, effects of onset-to-door time on onset-to-needle time), evaluated the association between laboratory findings on outcome after IVT and served to develop risk estimation tools for prediction of haemorrhagic complications and functional outcome after IVT.

FUTURE PLANS

Further TRISP projects to increase knowledge of the effect and safety of revascularisation therapies in acute stroke are ongoing. TRISP welcomes participation and project proposals of further centres fulfilling the outlined requirements. In the future, TRISP will be extended to include patients undergoing endovascular thrombectomy.

Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency

Background and Purpose—

Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily –independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency.

Methods—

This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression.

Results—

Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69–159; STEMO) and 135 (interquartile range, 98–184; CC; P <0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%; P =0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive ( P =0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02–3.87; P =0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95–3.16; P =0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%; P =0.167).

Conclusions—

The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02358772.

Effects of alteplase for acute stroke according to criteria defining the European Union and United States marketing authorizations: Individual-patient-data meta-analysis of randomized trials

Background

The recommended maximum age and time window for intravenous alteplase treatment of acute ischemic stroke differs between the Europe Union and United States.

Aims

We compared the effects of alteplase in cohorts defined by the current Europe Union or United States marketing approval labels, and by hypothetical revisions of the labels that would remove the Europe Union upper age limit or extend the United States treatment time window to 4.5 h.

Methods

We assessed outcomes in an individual-patient-data meta-analysis of eight randomized trials of intravenous alteplase (0.9 mg/kg) versus control for acute ischemic stroke. Outcomes included: excellent outcome (modified Rankin score 0–1) at 3–6 months, the distribution of modified Rankin score, symptomatic intracerebral hemorrhage, and 90-day mortality.

Results

Alteplase increased the odds of modified Rankin score 0–1 among 2449/6136 (40%) patients who met the current European Union label and 3491 (57%) patients who met the age-revised label (odds ratio 1.42, 95% CI 1.21−1.68 and 1.43, 1.23−1.65, respectively), but not in those outside the age-revised label (1.06, 0.90−1.26). By 90 days, there was no increased mortality in the current and age-revised cohorts (hazard ratios 0.98, 95% CI 0.76−1.25 and 1.01, 0.86–1.19, respectively) but mortality remained higher outside the age-revised label (1.19, 0.99–1.42). Similarly, alteplase increased the odds of modified Rankin score 0-1 among 1174/6136 (19%) patients who met the current US approval and 3326 (54%) who met a 4.5-h revised approval (odds ratio 1.55, 1.19−2.01 and 1.37, 1.17−1.59, respectively), but not for those outside the 4.5-h revised approval (1.14, 0.97−1.34). By 90 days, no increased mortality remained for the current and 4.5-h revised label cohorts (hazard ratios 0.99, 0.77−1.26 and 1.02, 0.87–1.20, respectively) but mortality remained higher outside the 4.5-h revised approval (1.17, 0.98–1.41).

Conclusions

An age-revised European Union label or 4.5-h-revised United States label would each increase the number of patients deriving net benefit from alteplase by 90 days after acute ischemic stroke, without excess mortality.

Thrombolysis management in thrombectomy patients: Real-life data from German stroke centres

Introduction

In randomised clinical trials (RCTs), endovascular thrombectomy (ET) was combined with intravenous thrombolysis (IVT) in the vast majority of patients. We aimed to analyse how German stroke centres manage IVT in patients receiving ET in daily routine.

Patients and Methods

We performed an online survey among neurologists and neurointerventionalists that included all German University hospitals and a selection of German community hospitals known to perform ET. The survey consisted of 20 questions and was open for reply from 20 December 2016 to 9 January 2017.

Findings

Overall, there were 110 replies, 76% (84/110) from neurologists and 20% (22/110) from neurointerventionalists. The majority of participants (75/99, 76%) reported to continue IVT after start of ET. Nine participants (9%) reported to stop IVT as a standard of care before ET and another 15 (15%) reported to stop IVT on a case-by-case basis. Thrombolysis is given intra-arterially in individual cases in 39% (37/99) and as a standard of care in 3% (3/99). Intra-arterial Heparin is given additionally as a standard procedure in 25% (24/96) and in individual cases in 11% (11/96). IVT is omitted even without contraindications before ET in 5% (5/95) as standard procedure and in 14% (13/95) in individual cases.

Discussion

We observed a wide heterogeneity with respect to the management of IVT in the context of ET. Evidence from RCTs is not implemented in a large number of cases.

Conclusion

These findings emphasise a requirement for further education and implementation of standards for the management of intravenous thrombolysis in endovascular treated stroke patients.