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Oh H, Sim SY, Choi JY, Shim YS, Oh SY, Park SK, Kim MJ, Lim YC, Chung J. The effect of hematoma evacuation with decompressive craniectomy on clinical outcomes in patients with parenchymal hematoma type 2 of hemorrhagic transformation after middle cerebral artery infarction. Neurol Res 2022; 44:894-901. [DOI: 10.1080/01616412.2022.2066784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Hyeongcheol Oh
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sook Young Sim
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Republic of Korea
| | - Jin Young Choi
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu-Shik Shim
- Department of Neurosurgery, Inha University College of Medicine and Hospital, Incheon, Republic of Korea
| | - Se-Yang Oh
- Department of Neurosurgery, Inha University College of Medicine and Hospital, Incheon, Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeong Jin Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University College of Medicine and Hospital, Suwon, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Prognosis comparisons in acute ischemic stroke patients with thrombolysis and nonthrombolysis therapy: a retrospective study with larger sample size. Blood Coagul Fibrinolysis 2018; 29:178-183. [PMID: 29232256 DOI: 10.1097/mbc.0000000000000685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: We compared the short-term, middle-term and long-term primary outcomes between thrombolysis and nonthrombolysis therapy in acute ischemic stroke (AIS) patients. Medical records were collected from patients suffered from AIS between 2010 and 2013 and allocated into either the intravenous recombinant tissue plasminogen activator (as rt-PA group) treatment, or non-rt-PA treatment group (as control group). The primary outcomes included a proportion of patients with favorable outcome [as defined with a modified Rankin Scale (mRS) of 0-1], functional independence (mRS of 0-2) or with bad outcome (mRS of 5-6) at 3, 6 and 12 months and the overall mortality. The secondary outcome included the events of intracranial hemorrhage. A total of 357 patients from Xinhua Hospital were selected. At 3-month follow-up, 86 patients in rt-PA vs. 99 in control group had favorable outcome, 105 vs. 122 were independent and 23 vs. 27 had bad outcome. At 6-month follow-up, 101 patients in rt-PA vs. 104 in control group had favorable outcome, 114 vs. 124 were independent and 20 vs. 34 had bad outcome. At 12 months, 104 patients in rt-PA vs. 105 in control group had favorable outcome, 117 vs. 125 were independent and 12 vs. 32 had bad outcome. At the end of 12 months, more deaths occurred in control group (20) than in the rt-PA group (11), but it was not statistically significant. Alteplase treatment in AIS patients showed the superior primary outcomes compared with control group, especially during the middle/long follow-up.
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Ali SF, Siddiqui K, Ay H, Silverman S, Singhal A, Viswanathan A, Rost N, Lev M, Schwamm LH. Baseline Predictors of Poor Outcome in Patients Too Good to Treat With Intravenous Thrombolysis. Stroke 2016; 47:2986-2992. [PMID: 27834750 DOI: 10.1161/strokeaha.116.014871] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have reported poor outcomes in patients too good to treat with intravenous thrombolysis because of mild or rapidly improving symptoms. We sought to determine baseline clinical and imaging predictors of poor outcome in these patients. METHODS Among 3950 consecutive stroke admissions (2009-2015) in our local Get With the Guidelines-Stroke database, 632 patients presented ≤4.5 hours and did not receive tissue-type plasminogen activator, with 380 of 632 (60.1%) being too good to treat. Univariate and multivariable analyses explored the clinical and imaging features associated with poor outcome (defined as not being discharged to home) in these 380 cases. RESULTS Among these 380 cases, only 68% were discharged home; the other 25% to inpatient rehabilitation, 4% to a skilled nursing facility, and 3% expired or were discharged to hospice. Patients with poor outcome were older, were more often Hispanic, had more vascular risk factors, and had higher median National Institutes of Health Stroke Scale. Imaging characteristics associated with poor outcomes included large or multifocal infarction and poor collaterals. In multivariable analysis, only age, initial National Institutes of Health Stroke Scale, and infarct location were independently associated with poor outcome. CONCLUSIONS Approximately one third of patients deemed too good for intravenous tissue-type plasminogen activator are unable to be discharged directly to home. Given the current safety profile of intravenous tissue-type plasminogen activator, our results suggest that the concept of being too good to treat should be re-examined with an emphasis on the features associated with poor outcome identified in our study. If replicated, these findings could be incorporated into tissue-type plasminogen activator decision-making algorithms.
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Affiliation(s)
- Syed F Ali
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Khawja Siddiqui
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Hakan Ay
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Scott Silverman
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Aneesh Singhal
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Natalia Rost
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Michael Lev
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Lee H Schwamm
- From the Department of Neurology, Massachusetts General Hospital, Boston.
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Mocco J, Fargen KM, Goyal M, Levy EI, Mitchell PJ, Campbell BCV, Majoie CBLM, Dippel DWJ, Khatri P, Hill MD, Saver JL. Neurothrombectomy trial results: stroke systems, not just devices, make the difference. Int J Stroke 2016; 10:990-3. [PMID: 26404879 DOI: 10.1111/ijs.12614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/01/2015] [Indexed: 11/26/2022]
Abstract
The overwhelming benefit demonstrated in the four recent randomized trials comparing intra-arterial therapies to medical management alone will have a transformative effect on the emergent management of strokes throughout the world. New generation neurothrombectomy devices were critical to trial success, but not the sole driver of patient outcomes in these trials. Patients in the positive trials were treated at hospitals with complex, efficient, resource-rich, team-based stroke systems in place. To ensure attainment of trial results in actual practice, patients should receive treatment at facilities certified as having the resources, personnel, organization, and continuous quality improvement processes characteristic of trial centers. It is our hope that, through greater education initiatives, robust resource investment, and developing quality-based certification processes, the results demonstrated by these trials may be extrapolated to greater numbers of centers - in turn allowing greater access for patients to high-quality, advanced stroke care.
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Affiliation(s)
- J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Peter J Mitchell
- Department of Radiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Center at the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Charles B L M Majoie
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, Cincinnati, OH, USA
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Jeffery L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
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Kutluk K, Kaya D, Afsar N, Arsava EM, Ozturk V, Uzuner N, Giray S, Topcuoglu MA, Gungor L, Sirin H, Yaka E, Ozdemir O, Dalkara T. Analyses of the Turkish National Intravenous Thrombolysis Registry. J Stroke Cerebrovasc Dis 2016; 25:1041-1047. [PMID: 26853139 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/30/2015] [Accepted: 01/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The relatively late approval of use of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke in Turkey has resulted in obvious underuse of this treatment. Here we present the analyses of the nationwide registry, which was created to prompt wider use of intravenous thrombolysis, as well as to monitor safe implementation of the treatment in our country. METHODS Patients were registered prospectively in our database between 2006 and 2013. Admission and 24-hour National Institutes of Health Stroke Scale and 3-month modified Rankin Scale scores were recorded. A "high-volume center" was defined as a center treating 10 or more patients with rt-PA per year. RESULTS A total of 1133 patients were enrolled into the registry by 38 centers in 18 cities. A nearly 4-fold increase in the study population and in the number of participating centers was observed over the 6 years of the study. The mean baseline NIHSS score was 14.5 ± 5.7, and the prevalence of symptomatic hemorrhage was 4.9%. Mortality at 3 months decreased from 22% to 11% in the 6 years of enrollment, and 65% of cases were functionally independent. Age older than 70 years, an NIHSS score higher than 14 upon hospital admission, and intracranial hemorrhage were independently associated with mortality, and being treated in a high-volume center was related to good outcome. CONCLUSIONS We observed a decreasing trend in mortality and an acceptable prevalence of symptomatic hemorrhage over 6 years with continuous addition of new centers to the registry. The first results of this prospective study are encouraging and will stimulate our efforts at increasing the use of intravenous thrombolysis in Turkey.
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Affiliation(s)
- Kursad Kutluk
- Department of Neurology, University of Dokuz Eylul, Izmir, Turkey.
| | - Dilaver Kaya
- Department of Neurology, University of Acibadem, Istanbul, Turkey
| | - Nazire Afsar
- Department of Neurology, University of Bahcesehir, Istanbul, Turkey
| | | | - Vesile Ozturk
- Department of Neurology, University of Dokuz Eylul, Izmir, Turkey
| | - Nevzat Uzuner
- Department of Neurology, University of Osman Gazi, Eskisehir, Turkey
| | - Semih Giray
- Department of Neurology, University of Gaziantep, Gaziantep, Turkey
| | | | - Levent Gungor
- Department of Neurology, University of Ondokuz Mayis, Samsun, Turkey
| | - Hadiye Sirin
- Department of Neurology, University of Ege, Izmir, Turkey
| | - Erdem Yaka
- Department of Neurology, University of Dokuz Eylul, Izmir, Turkey
| | - Ozcan Ozdemir
- Department of Neurology, University of Osman Gazi, Eskisehir, Turkey
| | - Turgay Dalkara
- Department of Neurology, University of Hacettepe, Ankara, Turkey
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Adelman EE, Scott PA, Skolarus LE, Fox AK, Frederiksen SM, Meurer WJ. Protocol Deviations before and after Treatment with Intravenous Tissue Plasminogen Activator in Community Hospitals. J Stroke Cerebrovasc Dis 2015; 25:67-73. [PMID: 26419527 DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 07/24/2015] [Accepted: 08/23/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Protocol deviations before and after tissue plasminogen activator (tPA) treatment for ischemic stroke are common. It is unclear if patient or hospital factors predict protocol deviations. We examined predictors of protocol deviations and the effects of protocol violations on symptomatic intracerebral hemorrhage (sICH). METHODS We used data from the Increasing Stroke Treatment through Interventional Behavior Change Tactics trial, a cluster-randomized, controlled trial evaluating the efficacy of a barrier assessment and educational intervention to increase appropriate tPA use in 24 Michigan community hospitals, to review tPA treatments between 2007 and 2010. Protocol violations were defined as deviations from the standard tPA protocol, both before and after treatment. Multilevel logistic regression models were fitted to determine if patient and hospital variables were associated with pretreatment or post-treatment protocol deviations. RESULTS During the study, 557 patients (mean age 70, 52% male, median National Institutes of Health Stroke Scale score 12) were treated with tPA. Protocol deviations occurred in 233 (42%) patients: 16% had pretreatment deviations, 35% had post-treatment deviations, and 9% had both. The most common protocol deviations included elevated post-treatment blood pressure, antithrombotic agent use within 24 hours of treatment, and elevated pretreatment blood pressure. Protocol deviations were not associated with sICH, stroke severity, or hospital factors. Older age was associated with pretreatment protocol deviations (adjusted odds ratio [OR], .52; 95% confidence interval [CI], .30-.92). Pretreatment deviations were associated with post-treatment deviations (adjusted OR, 3.20; 95% CI, 1.91-5.35). CONCLUSIONS Protocol deviations were not associated with sICH. Aside from age, patient and hospital factors were not associated with protocol deviations.
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Affiliation(s)
- Eric E Adelman
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Phillip A Scott
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lesli E Skolarus
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Allison K Fox
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Shirley M Frederiksen
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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Rhine DJ. Intravenous tPA for acute stroke: Any and all hospitals? Any and all docs? CAN J EMERG MED 2015; 2:189-91. [PMID: 17621395 DOI: 10.1017/s1481803500004899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- D J Rhine
- Department of Emergency Medicine, King Faisal Specialist Hospital Research Center, Riyadh, Saudi Arabia
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8
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Masingue M, Alamowitch S. [An update on limitations of intravenous thrombolysis to treat acute ischemic stroke]. Presse Med 2015; 44:515-25. [PMID: 25697630 DOI: 10.1016/j.lpm.2014.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/06/2014] [Accepted: 07/08/2014] [Indexed: 11/15/2022] Open
Abstract
The benefit of intravenous thrombolysis with rt-pa has been demonstrated in acute ischemic stroke up to 4 h 30 after the first symptoms. The number of patients with stroke treated by rt-pa remains low at less than 5%. In the license of rt-pa in acute ischemic stroke, there are numerous contra-indications explained by the fear of cerebral hemorrhagic complications. These contra-indications are based on the first therapeutic trials published more than 15 years ago, but are not all evidence-based. Large post-marketing registers and new randomized trials have shown a favorable ratio benefit/risk of rt-pa in acute ischemic strokes in some classical contra-indications. Reconsidering some of the official contra-indications would increase the target population with treatable acute ischemic stroke using rt-pa to 20%.
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Affiliation(s)
- Marion Masingue
- Hôpital Saint-Antoine, service de neurologie et d'urgences neuro-vasculaires, 75012 Paris, France
| | - Sonia Alamowitch
- Hôpital Saint-Antoine, service de neurologie et d'urgences neuro-vasculaires, 75012 Paris, France; Université Pierre-et-Marie-Curie, Paris VI, 75005 Paris, France.
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9
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Haršány M, Kadlecová P, Švigelj V, Kõrv J, Kes VB, Vilionskis A, Krespi Y, Mikulík R. Factors influencing door-to-imaging time: analysis of the safe implementation of treatments in Stroke-EAST registry. J Stroke Cerebrovasc Dis 2014; 23:2122-2129. [PMID: 25106830 DOI: 10.1016/j.jstrokecerebrovasdis.2014.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/20/2014] [Accepted: 03/28/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Brain imaging is logistically the most difficult step before thrombolysis. To improve door-to-needle time (DNT), it is important to understand if (1) longer door-to-imaging time (DIT) results in longer DNT, (2) hospitals have different DIT performances, and (3) patient and hospital characteristics predict DIT. METHODS Prospectively collected data in the Safe Implementation of Treatments in Stroke-EAST (SITS-EAST) registry from Central/Eastern European countries between 2008 and 2011 were analyzed. Hospital characteristics were obtained by questionnaire from each center. Patient- and hospital-level predictors of DIT of 25 minutes or less were identified by the method of generalized estimating equations. RESULTS Altogether 6 of 9 SITS-EAST countries participated with 4212 patients entered into the database of which 3631 (86%) had all required variables. DIT of 25 minutes or less was achieved in 2464 (68%) patients (range, 3%-93%; median, 65%; and interquartile range, 50%-80% between centers). Patients with DIT of 25 minutes or less had shorter DNT (median, 60 minutes) than patients with DIT of more than 25 minutes (median, 86 minutes; P < .001). Four variables independently predicted DIT of 25 minutes or less: longer time from stroke onset to admission (91-180 versus 0-90 minutes; odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.8), transport time of 5 minutes or less (OR, 2.9; 95% CI, 1.7-4.7) between the place of admission and a computed tomography (CT) scanner, no or minimal neurologic deficit before stroke (OR, 1.3; 95% CI, 1.02-1.5), and diabetes mellitus (OR, .8; 95% CI, .7-.97). CONCLUSIONS DIT should be improved in patients arriving early and late. Place of admission should allow transport time to a CT scanner under 5 minutes.
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Affiliation(s)
- Michal Haršány
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic; Department of Neurology, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Pavla Kadlecová
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Viktor Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Centre Ljubljana and Zdravstveni Nasveti, Ljubljana, Slovenia
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Vanja Bašić Kes
- Department of Neurology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Aleksandras Vilionskis
- Department of Neurology and Neurosurgery, Vilnus University and Republican Vilnius University Hospital, Vilnius, Lithuania
| | - Yakup Krespi
- Stroke Rehabilitation and Research Unit, Memorial Healthcare Group Stroke Center, Memorial Şişli Hospital, Istanbul, Turkey
| | - Robert Mikulík
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic; Department of Neurology, St. Anne's University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic.
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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11
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Ning M, Sarracino DA, Buonanno FS, Krastins B, Chou S, McMullin D, Wang X, Lopez M, Lo EH. Proteomic Protease Substrate Profiling of tPA Treatment in Acute Ischemic Stroke Patients: A Step Toward Individualizing Thrombolytic Therapy at the Bedside. Transl Stroke Res 2013; 1:268-75. [PMID: 22140417 DOI: 10.1007/s12975-010-0047-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tissue plasminogen activator (tPA) is the only FDA-approved medical therapy for acute ischemic stroke. But as a serine peptidase, intravenous tPA can affect the expression of other proteases that may be implicated in blood-brain barrier breakdown. Such parallel cascades of cell signaling may be involved in intracranial hemorrhage, the major side effect of tPA. Here, we describe an initial attempt in proteomic substrate profiling, i.e., degradomics in human plasma within the context of acute stroke. Plasma from acute stroke patients were analyzed pre- and post-intravenous tPA using tandem mass spectrometry and protein array profiling to identify substrates and proteases of interest. In non-tPA-treated stroke plasma, degradomic patterns indicated a rapid induction of protease activity within 3 h of stroke onset that mostly stabilized by 24 h. But in tPA-treated patients, pre- and post-tPA samples from the same patient demonstrated distinct degradomic patterns that persisted even up to 3-5 days after stroke onset. Matching control patients without strokes had little change in degradomic profiles over time. Our findings demonstrate that tPA treatment changes the plasma degradomic profiles in acute stroke patients. These composite proteolytic profiles may provide a glimpse of the pleiotropic effects of tPA on cellular signaling cascades at the bedside. This study supports the feasibility of performing pharmaco-proteomics at the bedside, which may ultimately allow us to dissect mechanisms of thrombolysis-related therapeutic efficacy in stroke.
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Affiliation(s)
- Mingming Ning
- Department of Neurology, Clinical Proteomics Research Center and Neuroprotection Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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12
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Ning M, Gonzalez RG. Case records of the Massachusetts General Hospital. Case 34-2013. A 69-year-old man with dizziness and vomiting. N Engl J Med 2013; 369:1736-48. [PMID: 24171520 DOI: 10.1056/nejmcpc1302431] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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13
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Asaithambi G, Chaudhry SA, Hassan AE, Rodriguez GJ, Suri MFK, Qureshi AI. Adherence to Guidelines by Emergency Medical Services During Transport of Stroke Patients Receiving Intravenous Thrombolytic Infusion. J Stroke Cerebrovasc Dis 2013; 22:e42-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 02/19/2012] [Accepted: 03/27/2012] [Indexed: 12/01/2022] Open
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14
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Rymer MM, Thrutchley DE. Organizing regional networks to increase acute stroke intervention. Neurol Res 2013; 27 Suppl 1:S9-16. [PMID: 16197819 DOI: 10.1179/016164105x25315] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Acute ischemic stroke is the second leading cause of death worldwide and the leading cause of adult disability in the United States (US). Thrombolytic therapy was proved effective, and approved for use, in the US by the Food and Drug Administration in 1996, yet 8 years later just 3-4% of stroke victims in the US are treated with tissue plasminogen activator. In order to understand how this figure can be substantially improved, it is important to evaluate the available therapies and systems of care, delineate the critical steps and the existing barriers in the process for successful intervention, and thoroughly understand the key components in the highly successful interventional stroke programs, especially regionalization of care. METHODS A review of the available literature was carried out and interventional stroke data from the Mid America Brain and Stroke Institute at Saint Luke's Hospital (SLH) in Kansas City, Missouri, was analysed. RESULTS There are several treatment strategies available for acute stroke intervention and more are likely to be developed. There is increasing interest in organizing and standardizing care for stroke. The steps in the process for successful intervention are understood and progress is being made in several areas of the country, but challenges remain in public education, directing emergency transport to 'stroke ready' hospitals and linking stroke experts to primary care providers. The Kansas City regional network linking primary care hospitals to the stroke team at SLH has been highly successful in substantially increasing the number of patients receiving acute stroke intervention. DISCUSSION The stage is set for many more stroke victims to receive acute interventional therapy. However, these patients must present to hospitals equipped and staffed to render this therapy. Most stroke victims will go or be taken to the closest medical facility. Organizing regional networks linking primary care hospitals and physicians to comprehensive stroke centers staffed, and capable of providing the entire spectrum of acute stroke intervention will be essential in substantially increasing the number of stroke victims who actually receive acute interventional therapy. This article summarizes the evolving solutions to this challenge with specific data from the successful regional network developed around the Mid America Brain and Stroke Institute at Saint Luke's Hospital in Kansas City, Missouri, USA.
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Affiliation(s)
- Marilyn M Rymer
- Mid America Brain and Stroke Institute, Saint Luke's Hospital, 4401 Wornall Road, Kansas City, MO 64111, USA.
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15
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Ning MM, Lopez M, Sarracino D, Cao J, Karchin M, McMullin D, Wang X, Buonanno FS, Lo EH. Pharmaco-proteomics opportunities for individualizing neurovascular treatment. Neurol Res 2013; 35:448-56. [PMID: 23711324 PMCID: PMC4153693 DOI: 10.1179/1743132813y.0000000213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Neurovascular disease often involves multi-organ system injury. For example, patent foramen ovale (PFO) related ischemic strokes involve not just the brain, but also the heart, the lung, and the peripheral vascular circulation. For higher-risk but high-reward systemic therapy (e.g., thrombolytics, therapeutic hypothermia (TH), PFO closure) to be implemented safely, very careful patient selection and close monitoring of disease progression and therapeutic efficacy are imperative. For example, more than a decade after the approval of therapeutic hypothermic and intravenous thrombolysis treatments, they both remain extremely under-utilized, in part due to lack of clinical tools for patient selection or to follow therapeutic efficacy. Therefore, in understanding the complexity of the global effects of clinical neurovascular diseases and their therapies, a systemic approach may offer a unique perspective and provide tools with clinical utility. Clinical proteomic approaches may be promising to monitor systemic changes in complex multi-organ diseases - especially where the disease process can be 'sampled' in clinically accessible fluids such as blood, urine, and CSF. Here, we describe a 'pharmaco-proteomic' approach to three major challenges in translational neurovascular research directly at bedside - in order to better stratify risk, widen therapeutic windows, and explore novel targets to be validated at the bench - (i) thrombolytic treatment for ischemic stroke, (ii) therapeutic hypothermia for post-cardiac arrest syndrome, and (iii) treatment for PFO related paradoxical embolic stroke. In the future, this clinical proteomics approach may help to improve patient selection, ensure more precise clinical phenotyping for clinical trials, and individualize patient treatment.
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Affiliation(s)
- MM Ning
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - M Lopez
- Thermo-Fisher BRIMS, Cambridge, MA
| | | | - J Cao
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
| | - M Karchin
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
| | - D McMullin
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
| | - X Wang
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - FS Buonanno
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - EH Lo
- Clinical Proteomics Research Center, Department of Neurology, Massachusetts General Hospital and Harvard Medical School; Boston, MA
- Neuroprotection Research Laboratory, Department of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3186] [Impact Index Per Article: 289.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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Meunier JM, Chang WTW, Bluett B, Wenker E, Lindsell CJ, Shaw GJ. Temperature affects thrombolytic efficacy using rt-PA and eptifibatide, an in vitro study. Ther Hypothermia Temp Manag 2012; 2:112-8. [PMID: 23667777 PMCID: PMC3621317 DOI: 10.1089/ther.2012.0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The potential for hypothermia as a neuroprotectant during stroke has led to its increase in clinical use. At the same time, combination pharmaceutical therapies for ischemic stroke using recombinant tissue plasminogen activator (rt-PA), and GP IIb-IIIa inhibitors, such as Eptifibatide (Epf ), are under study. However, there is little data on how the reactions triggered by these agents are impacted by temperature. Here, clot lysis during exposure to the combination of rt-PA and Epf is measured in an in vitro human clot model at hypothermic temperatures. The hypothesis is that lytic efficacy of rt-PA and Epf decreases with decreasing temperature. Whole blood clots from 31 volunteers were exposed to rt-PA (0.5 μg/mL) and Epf (0.63 μg/mL) in human fresh-frozen plasma (rt-PA+Epf ), rt-PA alone in plasma (rt-PA Alone), or to plasma alone (Control), at temperatures from 30°C to 37°C, for 30 minutes. Clot lysis was measured using a microscopic imaging technique; the mean fractional clot loss (FCL) at 30 minutes was used to determine lytic efficacy. Temperature had a significant impact on FCL in clots exposed to rt-PA+Epf, with the FCL being lower at 30°C to 36°C than at 37°C. The FCL remained significantly higher for rt-PA+Epf–treated clots than Controls regardless of temperature, with the exception of measurements made at 30°C when no significant differences in the FCL were observed between groups. The use of hypothermia as a neuroprotectant may negatively impact the therapeutic benefit of thrombolytic agents.
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Affiliation(s)
- Jason M. Meunier
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Wan-Tsu W. Chang
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brent Bluett
- The University of Texas Southwestern at Austin, Austin, Texas
| | - Evan Wenker
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - George J. Shaw
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
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Martínez Fernández E, Sanz Fernández G, Blanco Ollero A. Fiabilidad del diagnóstico de ictus en urgencias. Neurologia 2012; 27:284-9. [DOI: 10.1016/j.nrl.2011.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 11/24/2011] [Accepted: 12/03/2011] [Indexed: 11/29/2022] Open
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Martínez Fernández E, Sanz Fernández G, Blanco Ollero A. Reliability of stroke diagnosis in emergency departments. NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2011.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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20
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Kelly AG, Hellkamp AS, Olson D, Smith EE, Schwamm LH. Predictors of Rapid Brain Imaging in Acute Stroke. Stroke 2012; 43:1279-84. [DOI: 10.1161/strokeaha.111.626374] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam G. Kelly
- From the Department of Neurology (A.G.K.), University of Rochester Medical Center, Rochester, NY; Duke Clinical Research Institute (A.S.H., D.O.), Durham, NC; the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; and the Department of Neurology (L.H.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anne S. Hellkamp
- From the Department of Neurology (A.G.K.), University of Rochester Medical Center, Rochester, NY; Duke Clinical Research Institute (A.S.H., D.O.), Durham, NC; the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; and the Department of Neurology (L.H.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - DaiWai Olson
- From the Department of Neurology (A.G.K.), University of Rochester Medical Center, Rochester, NY; Duke Clinical Research Institute (A.S.H., D.O.), Durham, NC; the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; and the Department of Neurology (L.H.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Eric E. Smith
- From the Department of Neurology (A.G.K.), University of Rochester Medical Center, Rochester, NY; Duke Clinical Research Institute (A.S.H., D.O.), Durham, NC; the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; and the Department of Neurology (L.H.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee H. Schwamm
- From the Department of Neurology (A.G.K.), University of Rochester Medical Center, Rochester, NY; Duke Clinical Research Institute (A.S.H., D.O.), Durham, NC; the Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; and the Department of Neurology (L.H.S.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE, Sonnenberg FA, Schulman S, Vandvik PO, Spencer FA, Alonso-Coello P, Guyatt GH, Akl EA. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S-e636S. [PMID: 22315273 PMCID: PMC3278065 DOI: 10.1378/chest.11-2302] [Citation(s) in RCA: 307] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA). METHODS We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. RESULTS In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B). CONCLUSIONS These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.
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Affiliation(s)
- Maarten G Lansberg
- Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA
| | - Martin J O'Donnell
- HRB-Clinical Research Faculty, National University of Ireland Galway, Galway, Ireland
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH
| | | | | | - Neil E Schwartz
- Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA
| | - Frank A Sonnenberg
- Division of General Internal Medicine, UMDNJ/Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sam Schulman
- Department of Medicine, McMaster University, ON, Canada
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | | | | | - Gordon H Guyatt
- Department of Medicine, McMaster University, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- State University of New York at Buffalo, Buffalo, NY; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
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Willey JZ, Stillman J, Rivolta JA, Vieira J, Doyle MM, Linares G, Marchidann A, Elkind MSV, Boden-Albala B, Marshall RS. Too good to treat? Outcomes in patients not receiving thrombolysis due to mild deficits or rapidly improving symptoms. Int J Stroke 2011; 7:202-6. [PMID: 22103880 DOI: 10.1111/j.1747-4949.2011.00696.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Among ischemic stroke patients arriving within the treatment window, rapidly improving symptoms or having a mild deficit (i.e. too good to treat) is a common reason for exclusion. Several studies have reported poor outcomes in this group. We addressed the question of early neurological deterioration in too good to treat patients in a larger prospective cohort study. METHODS Admission and discharge information were collected prospectively in acute stroke patients who presented to the emergency room within three-hours from onset. The primary outcome measure was change in the National Institutes of Health Stroke Scale from baseline to discharge. Secondary outcomes were discharge National Institutes of Health Stroke Scale >4, not being discharged home, and discharge modified Rankin scale. RESULTS Of 355 patients who presented within three-hours, 127 (35·8%) had too good to treat listed as the only reason for not receiving thrombolysis, with median admission National Institutes of Health Stroke Scale = 1 (range = 0 to 19). At discharge, seven (5·5%) showed a worsening of National Institutes of Health Stroke Scale ≥1, and nine (7·1%) had a National Institutes of Health Stroke Scale >4. When excluding prior stroke (remaining n = 97), discharge status was even more benign: only five (5·2%) had a discharge National Institutes of Health Stroke Scale >4, and two (2·1%) patients were not discharged home. CONCLUSION We found that a small proportion of patients deemed too good to treat will have early neurological deterioration, in contrast to other studies. Decisions about whether to treat mild stroke patients depend on the outcome measure chosen, particularly when considering discharge disposition among patients who have had prior stroke. The decision to thrombolyze may ultimately rest on the nature of the presentation and deficit.
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Affiliation(s)
- Joshua Z Willey
- Division of Stroke, Department of Neurology, Columbia University Medical Center, New York, NY, USA.
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Ballard DW, Reed ME, Huang J, Kramer BJ, Hsu J, Chettipally U. Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke? Am J Emerg Med 2011; 30:1152-62. [PMID: 22100484 DOI: 10.1016/j.ajem.2011.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/12/2011] [Accepted: 08/25/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification. METHODS A retrospective cohort study of 30,461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages. RESULTS There were 15,687 precertification ED visits and 11,040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival. CONCLUSIONS Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.
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Affiliation(s)
- Dustin W Ballard
- Kaiser Permanente Department of Emergency Medicine (San Rafael), CA 94901, USA.
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Tsivgoulis G, Kotsis V, Giannopoulos S. Intravenous Thrombolysis for Acute Ischaemic Stroke: Effective Blood Pressure Control Matters. Int J Stroke 2011; 6:125-7. [DOI: 10.1111/j.1747-4949.2010.00570.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In this Leading opinion we summarise the observational evidence endorsing current guidelines that advocate effective blood pressure control before and during an rtPA infusion and indicate that a more active blood pressure-lowering approach immediately after intravenous thrombolysis appears to be a promising therapeutic option that should be formerly evaluated in a randomised clinical trial setting. Acute ischaemic stroke is a highly treatable neuroemergency and the efficacy of the available treatment is not only related to the speed by which it is administered but also by the effective control of modifiable adverse outcome predictors including elevated blood pressure levels.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Vasilios Kotsis
- Third Department of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
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Leifer D, Bravata DM, Connors J(B, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R. Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations. Stroke 2011; 42:849-77. [DOI: 10.1161/str.0b013e318208eb99] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Scott PA, Frederiksen SM, Kalbfleisch JD, Xu Z, Meurer WJ, Caveney AF, Sandretto A, Holden AB, Haan MN, Hoeffner EG, Ansari SA, Lambert DP, Jaggi M, Barsan WG, Silbergleit R. Safety of intravenous thrombolytic use in four emergency departments without acute stroke teams. Acad Emerg Med 2010; 17:1062-71. [PMID: 21040107 DOI: 10.1111/j.1553-2712.2010.00868.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective was to evaluate safety of intravenous (IV) tissue plasminogen activator (tPA) delivered without dedicated thrombolytic stroke teams. METHODS This was a retrospective, observational study of patients treated between 1996 and 2005 at four southeastern Michigan hospital emergency departments (EDs) with a prospectively defined comparison to the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke study cohort. Main outcome measures were mortality, intracerebral hemorrhage (ICH), systemic hemorrhage, neurologic recovery, and guideline violations. RESULTS A total of 273 consecutive stroke patients were treated by 95 emergency physicians (EPs) using guidelines and local neurology resources. One-year mortality was 27.8%. Unadjusted Cox model relative risk (RR) of mortality compared to the NINDS tPA treatment and placebo groups was 1.20 (95% confidence interval [CI] = 0.87 to 1.64) and 1.04 (95% CI = 0.76 to 1.41), respectively. The rate of significant ICH by computed tomography (CT) criteria was 6.6% (odds ratio [OR] = 1.03, 95% CI = 0.56 to 1.90 compared to the NINDS tPA treatment group). The proportions of symptomatic ICH by two other prespecified sets of clinical criteria were 4.8 and 7.0%. The rate of any ICH within 36 hours of treatment was 9.9% (RR = 0.94, 95% CI = 0.58 to 1.51 compared to the NINDS tPA group). The occurrence of major systemic hemorrhage (requiring transfusion) was 1.1%. Functional recovery by the modified Rankin Scale score (mRS = 0 to 2) at discharge occurred in 38% of patients with a premorbid disability mRS < 2. Guideline deviations occurred in the ED in 26% of patients and in 25% of patients following admission. CONCLUSIONS In these EDs there was no evidence of increased risk with respect to mortality, ICH, systemic hemorrhage, or worsened functional outcome when tPA was administered without dedicated thrombolytic stroke teams. Additional effort is needed to improve guideline compliance.
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Affiliation(s)
- Phillip A Scott
- Department of Emergency Medicine, University of Michigan, Ann Arbor, USA.
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Sharma SR, Sharma N. Hyperacute thrombolysis with recombinant tissue plasminogen activator of acute ischemic stroke: feasibility and effectivity from an Indian perspective. Ann Indian Acad Neurol 2010; 11:221-4. [PMID: 19893677 PMCID: PMC2771988 DOI: 10.4103/0972-2327.44556] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Revised: 06/17/2008] [Accepted: 07/04/2008] [Indexed: 11/04/2022] Open
Abstract
UNLABELLED Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries like India, especially in areas such as western Utter Pradesh, where it is overly crowded and there is poor affordability. AIM This study was done to evaluate recombinant tissue plasminogen activator r-tpa in acute ischemic stroke in hyper acute phase, in selected patients of western Utter Pradesh, in terms of feasibility and effectivity. DESIGN Open, non randomized study. MATERIALS AND METHODS Thirty two patients were classified using Trial of ORG 10172 in Acute Stroke treatment (TOAST) criteria (large artery atherosclerotic = 8; cardio embolic = 6; small vessel occlusion = 14; other determined etiology = 2; undetermined etiology = 2). The mean time to reach the hospital was 2 h (1.15-3.0), the mean door to CT scan 20 min (10-40) and door to r-tpa injection was 30 min (24-68). The National Institute of Health Stroke Scale (NIHSS) scores ranged from 11-22 (mean 15.5 +2.7). The dose of r-tpa administered was 0.9 mg/kg. RESULTS Twenty one patients (65.6%) showed significant improvement on the NIHSS score, at 48 h (4 points). (Mean change = 10; range = 4-17). At one month, 25 (78%) recorded improvement on the Barthel index (mean change = 45%). One developed frontal lobe hemorrhage and another developed recurrent stroke; one died of aspiration; and four showed no improvement. Modified Rankin score (m RS) was administered at the end of three months to 28 patients (90%); however, the rest could not be directly observed. The average modified Rankin Score was 1.2 (0-2). CONCLUSIONS Hyperacute thrombolysis was found feasible and effective in selected patients with AIS from western Utter Pradesh and who had poor affordability.
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Affiliation(s)
- S R Sharma
- Department of Neurology, S. R. M. S. Institute of Medical Sciences, Utter Pradesh, India.
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Michaels AD, Spinler SA, Leeper B, Ohman EM, Alexander KP, Newby LK, Ay H, Gibler WB. Medication errors in acute cardiovascular and stroke patients: a scientific statement from the American Heart Association. Circulation 2010; 121:1664-82. [PMID: 20308619 DOI: 10.1161/cir.0b013e3181d4b43e] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Liu GT, Volpe NJ, Galetta SL. Retrochiasmal disorders. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
BACKGROUND The majority of strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and could improve recovery after stroke. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in highly selected patients within three hours of stroke. OBJECTIVES To assess the safety and efficacy of thrombolytic agents in patients with acute ischaemic stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched October 2008), MEDLINE (1966 to October 2008) and EMBASE (1980 to October 2008). We contacted researchers and pharmaceutical companies, attended relevant conferences and handsearched pertinent journals. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in patients with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria and extracted data. We assessed trial quality. We verified the extracted data with the principal investigators of all major trials. We obtained both published and unpublished data if available. MAIN RESULTS We included 26 trials involving 7152 patients. Not all trials contributed data to each outcome. The trials tested urokinase, streptokinase, recombinant tissue plasminogen activator, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke; three trials started treatment up to nine hours and one small trial up to 24 hours after stroke. About 55% of the data (patients and trials) come from trials testing intravenous tissue plasminogen activator. Very few of the patients (0.5%) were aged over 80 years. Many trials had some imbalances in key prognostic variables. Several trials did not have complete blinding of outcome assessment. Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of patients who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.81, 95% confidence interval (CI) 0.73 to 0.90). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.49, 95% CI 2.81 to 4.33) and death by three to six months after stroke (OR 1.31, 95% CI 1.14 to 1.50). Treatment within three hours of stroke appeared more effective in reducing death or dependency (OR 0.71, 95% CI 0.52 to 0.96) with no statistically significant adverse effect on death (OR 1.13, 95% CI 0.86 to 1.48). There was heterogeneity between the trials in part attributable to concomitant antithrombotic drug use (P = 0.02), stroke severity and time to treatment. Antithrombotic drugs given soon after thrombolysis may increase the risk of death. AUTHORS' CONCLUSIONS Overall, thrombolytic therapy appears to result in a significant net reduction in the proportion of patients dead or dependent in activities of daily living. This overall benefit was apparent despite an increase both in deaths (evident at seven to 10 days and at final follow up) and in symptomatic intracranial haemorrhages. Further trials are needed to identify which patients are most likely to benefit from treatment and the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh, UK, EH4 2XU
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Bang OY. Multimodal MRI for ischemic stroke: from acute therapy to preventive strategies. J Clin Neurol 2009; 5:107-19. [PMID: 19826561 PMCID: PMC2760715 DOI: 10.3988/jcn.2009.5.3.107] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 07/17/2009] [Accepted: 07/17/2009] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose Conventional therapies for ischemic stroke include thrombolytic therapy, prevention of inappropriate coagulation and thrombosis, and surgery to repair vascular abnormalities. Over 10 years have passed since the US Food and Drug Administration approved intravenous tissue plasminogen activator for use in acute stroke patients, but most major clinical trials have failed during the last 2 decades, including large clinical trials for secondary prevention and neuroprotection. These results suggest the presence of heterogeneity among stroke patients. Neuroimaging techniques now allow changes to be observed in patients from the acute to the recovery phase. The role of MRI in stroke evaluation and treatment is discussed herein. Main Contents Three MRI strategies are discussed with relevant examples. First, the following MRI strategies for acute ischemic stroke are presented: diffusion-perfusion mismatch, deoxygenation (oxygen extraction and cerebral metabolic rate of oxygen), and blood-brain barrier permeability derangement in selected patients for recanalization therapy. Second, multimodal MRI for identifying stroke mechanisms and the specific causes of stroke (i.e., patent foramen ovale, infective endocarditis, and nonbacterial thrombotic endocarditis) are presented, followed by MRI strategies for prevention of recurrent stroke: plaque images and flow dynamics for carotid intervention. Expectations The studies reviewed herein suggest that using MRI to improve the understanding of individual pathophysiologies will further promote the development of rational stroke therapies tailored to the specifics of each case.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Micieli G, Marcheselli S, Tosi PA. Safety and efficacy of alteplase in the treatment of acute ischemic stroke. Vasc Health Risk Manag 2009; 5:397-409. [PMID: 19475777 PMCID: PMC2686258 DOI: 10.2147/vhrm.s4561] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
After publication of the results of the National Institute of Neurological Disorders and Stroke study, the application of intravenous thrombolysis for ischemic stroke was launched and has now been in use for more than 10 years. The approval of this drug represented only the first step of the therapeutic approach to this pathology. Despite proven efficacy, concerns remain regarding the safety of recombinant tissue-type plasminogen activator for acute ischemic stroke used in routine clinical practice. As a result, a small proportion of patients are currently treated with thrombolytic drugs. Several factors explain this situation: a limited therapeutic window, insufficient public knowledge of the warning signs for stroke, the small number of centers able to administer thrombolysis on a 24-hour basis and an excessive fear of hemorrhagic complications. The aim of this review is to explore the clinical efficacy of treatment with alteplase and consider the hemorrhagic risks.
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Affiliation(s)
- Giuseppe Micieli
- Neurology and Stroke Unit, IRCCS Istituto Clinico Humanitas, Rozzano, MI, Italy.
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Hakimelahi R, González RG. Neuroimaging of ischemic stroke with CT and MRI: advancing towards physiology-based diagnosis and therapy. Expert Rev Cardiovasc Ther 2009; 7:29-48. [PMID: 19105765 DOI: 10.1586/14779072.7.1.29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Acute ischemic stroke is the third leading cause of death and the major cause of significant disability in adults in the USA and Europe. The number of patients who are actually treated for acute ischemic stroke is disappointingly low, despite availability of effective treatments. A major obstacle is the short window of time following stroke in which therapies are effective. Modern imaging is able to identify the ischemic penumbra, a key concept in stroke physiology. Evidence is accumulating that identification of a penumbra enhances patient management, resulting in significantly improved outcomes. Moreover, unexpectedly large proportions of patients have a substantial ischemic penumbra beyond the traditional time window and are suitable for therapy. The widespread availability of modern MRI and computed tomography systems presents new opportunities to use physiology to guide ischemic stroke therapy in individual patients. This article suggests an evidence-based alternative to contemporary acute ischemic stroke therapy.
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Affiliation(s)
- Reza Hakimelahi
- Neuroradiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Shaw GJ, Meunier JM, Huang SL, Lindsell CJ, McPherson DD, Holland CK. Ultrasound-enhanced thrombolysis with tPA-loaded echogenic liposomes. Thromb Res 2009; 124:306-10. [PMID: 19217651 DOI: 10.1016/j.thromres.2009.01.008] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 11/21/2008] [Accepted: 01/10/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Currently, the only FDA-approved therapy for acute ischemic stroke is the administration of recombinant tissue plasminogen activator (tPA). Echogenic liposomes (ELIP), phospholipid vesicles filled with gas and fluid, can be manufactured to incorporate tPA. Also, transcranial ultrasound-enhanced thrombolysis can increase the recanalization rate in stroke patients. However, there is little data on lytic efficacy of combining ultrasound, echogenic liposomes, and tPA treatment. In this study, we measure the effects of pulsed 120-kHz ultrasound on the lytic efficacy of tPA and tPA-incorporating ELIP (t-ELIP) in an in-vitro human clot model. It is hypothesized that t-ELIP exhibits similar lytic efficacy to that of rt-PA. METHODS Blood was drawn from 22 subjects after IRB approval. Clots were made in 20-microL pipettes, and placed in a water tank for microscopic visualization during ultrasound and drug treatment. Clots were exposed to combinations of [tPA]=3.15 microg/ml, [t-ELIP]=3.15 microg/ml, and 120-kHz ultrasound for 30 minutes at 37 degrees C in human plasma. At least 12 clots were used for each treatment. Clot lysis over time was imaged and clot diameter was measured over time, using previously developed imaging analysis algorithms. The fractional clot loss (FCL), which is the decrease in mean clot width at the end of lytic treatment, was used as a measure of lytic efficacy for the various treatment regimens. RESULTS The fractional clot loss FCL was 31% (95% CI: 26-37%) and 71% (56-86%) for clots exposed to tPA alone or tPA with 120 kHz ultrasound. Similarly, FCL was 48% (31-64%) and 89% (76-100%) for clots exposed to t-ELIP without or with ultrasound. CONCLUSIONS The lytic efficacy of tPA containing echogenic liposomes is comparable to that of tPA alone. The addition of 120 kHz ultrasound significantly enhanced lytic treatment efficacy for both tPA and t-ELIP. Liposomes loaded with tPA may be a useful adjunct in lytic treatment with tPA.
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Affiliation(s)
- George J Shaw
- Department of Emergency Medicine, Greater Cincinnati/Northern Kentucky Stroke Team University of Cincinnati, Cincinnati, OH 45267-0769, USA.
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Clark WM, Madden KP. Keep the three hour TPA window: the lost study of Atlantis. J Stroke Cerebrovasc Dis 2009; 18:78-9. [PMID: 19110151 DOI: 10.1016/j.jstrokecerebrovasdis.2008.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Accepted: 11/13/2008] [Indexed: 11/25/2022] Open
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Scott PA. Enhancing community delivery of tissue plasminogen activator in stroke through community-academic collaborative clinical knowledge translation. Emerg Med Clin North Am 2009; 27:115-36, ix. [PMID: 19218023 PMCID: PMC2674264 DOI: 10.1016/j.emc.2008.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Improving the clinical outcomes of stroke patients depends on the adoption of proven new therapies throughout the broader medical community. Approximately 1% of stroke patients in community settings are receiving tissue plasminogen activator (tPA) therapy 12 years after US Food and Drug Administration approval. Knowledge translation, the process by which the results of clinical investigations are adopted by clinicians and incorporated into routine practice, is important but often overlooked. This article reviews the history of tPA use in stroke as a case study of a breakdown of knowledge translation in emergency medicine. It reviews knowledge translation concepts and theory and explores practical community-academic collaborative methods based on these tenets to enhance acute stroke care delivery in the community setting.
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Affiliation(s)
- Phillip A Scott
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48106-0381, USA.
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Wechsler LR, Zaidi S. PRACTICE ISSUES IN NEUROLOGY. Continuum (Minneap Minn) 2008. [DOI: 10.1212/01.con.0000275648.22698.2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Shaw GJ, Meunier JM, Lindsell CJ, Holland CK. Tissue plasminogen activator concentration dependence of 120 kHz ultrasound-enhanced thrombolysis. ULTRASOUND IN MEDICINE & BIOLOGY 2008; 34:1783-92. [PMID: 18468773 PMCID: PMC2614894 DOI: 10.1016/j.ultrasmedbio.2008.03.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 03/03/2008] [Accepted: 03/12/2008] [Indexed: 05/11/2023]
Abstract
It has been known for some time that the application of ultrasound can enhance the efficacy of thrombolytic medications such as recombinant tissue plasminogen activator (rt-PA). Potential clinical applications of this ultrasound-enhanced thrombolysis (UET) include the treatment of myocardial infarction, acute ischemic stroke, deep venous thrombosis and other thrombotic disorders. It may be possible to reduce the dose of rt-PA while maintaining lytic efficacy; however there is little data on the rt-PA concentration dependence of UET. In this work, the rt-PA concentration dependence of clot lysis resulting from 120 kHz UET exposure was measured in an in vitro human clot model. Clots were exposed to rt-PA for 30 min, with (UET treated) or without 120 kHz ultrasound (rt-PA treated) at 37 degrees C, and the clot width measured as a function of time. The rt-PA concentration ranged from 0-10 microg/mL. The initial lytic rate for the UET-treated group was greater than that of the rt-PA group at almost all rt-PA concentrations, and exhibited a maximum over concentration values of 1-3 microg/mL.
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Affiliation(s)
- George J Shaw
- Department of Emergency Medicine, University of Cincinnati College ofMedicine, Cincinnati, OH 45267-0769, USA.
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Meunier JM, Holland CK, Pancioli AM, Lindsell CJ, Shaw GJ. Effect of low frequency ultrasound on combined rt-PA and eptifibatide thrombolysis in human clots. Thromb Res 2008; 123:528-36. [PMID: 18619651 DOI: 10.1016/j.thromres.2008.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 04/14/2008] [Accepted: 05/16/2008] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Fibrinolytics such as recombinant tissue plasminogen activator (rt-PA) are used to treat thrombotic disease such as acute myocardial infarction (AMI) and ischemic stroke. Interest in increasing efficacy and reducing side effects has led to the study of adjuncts such as GP IIb-IIIa inhibitors and ultrasound (US) enhanced thrombolysis. Currently, GP IIb-IIIa inhibitor and fibrinolytic treatment are often used in AMI, and are under investigation for stroke treatment. However, little is known of the efficacy of combined GP IIb-IIIa inhibitor, fibrinolytic and ultrasound treatment. We measure the lytic efficacy of rt-PA, eptifibatide (Epf) and 120 kHz ultrasound treatment in an in-vitro human clot model. MATERIALS AND METHODS Blood was drawn from 15 subjects after IRB approval. Clots were made in 20 microL pipettes, and placed in a water tank for microscopic visualization during lytic treatment. Clots were exposed to control, rt-PA (rt-PA), eptifibatide (Epf), or rt-PA+eptifibatide (rt-PA + Epf), with (+US) or without (-US) ultrasound for 30 minutes at 37 degrees C in human plasma. Clot lysis was measured over time, using a microscopic imaging technique. The fractional clot loss (FCL) and initial lytic rate (LR) were used to quantify lytic efficacy. RESULTS AND CONCLUSIONS LR values for (- US) treated clots were 0.8+/-0.1(control), 1.8+/-0.3 (Epf), 1.5+/-0.2 (rt-PA), and 1.3+/-0.4 (rt-PA + Epf) (% clot width/minute) respectively. In comparison, the (+ US) group exhibited LR values of 1.6+/-0.2 (control), 4.3+/-0.4 (Epf), 6.3+/-0.4 (rt-PA), and 4.6+/-0.6 (rt-PA + Epf). For (- US) treated clots, FCL was 6.0+/-0.8 (control), 9.2+/-2.5 (Epf), 15.6+/-1.7 (rt-PA), and 28.0+/-2.2% (rt-PA + Epf) respectively. FCL for (+ US) clots was 13.5+/-2.4 (control), 20.7+/-6.4 (Epf), 44.4+/-3.6 (rt-PA) and 30.3+/-3.6% (rt-PA + Epf) respectively. Although the addition of eptifibatide enhances the in-vitro lytic efficacy of rt-PA in the absence of ultrasound, the efficacy of ultrasound and rt-PA is greater than that of combined ultrasound, rt-PA and eptifibatide exposure.
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Affiliation(s)
- Jason M Meunier
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45267-0769, USA
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Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and Thrombolytic Therapy for Ischemic Stroke. Chest 2008; 133:630S-669S. [DOI: 10.1378/chest.08-0720] [Citation(s) in RCA: 266] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Segura T, Calleja S, Jordan J. Recommendations and treatment strategies for the management of acute ischemic stroke. Expert Opin Pharmacother 2008; 9:1071-85. [PMID: 18422467 DOI: 10.1517/14656566.9.7.1071] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Stroke is one of the leading causes of mortality and disability worldwide. From the establishment of the penumbra concept, ischemic stroke has been recognized as a dynamic process and two main therapeutic strategies have been designed: one that tries to reopen the occluded artery and the second aims to protect the penumbra brain tissue until the physiologic mechanisms-or the treatment-stop the ischemia. OBJECTIVE To review the most recent, high-quality evidence for acute stroke treatment. METHODS Systematic review of relevant published studies focused in several aspects of acute ischemic stroke management, from neuroprotection to thrombolysis. CONCLUSIONS After the publication of NINDS rt-PA study, the classical nihilistic approach to ischemic stroke started to change and thrombolytic treatment was approved in the treatment of patients with acute ischemic stroke presenting within 3 h from onset of symptoms. Advances in this field are proceeding on several fronts, including the use of next-generation plasminogen activators and glycoprotein IIb/IIIa inhibitors, refined patient selection with advanced magnetic resonance imaging sequences, endovascular approaches to thrombolysis and thrombectomy, and adjuvant use of ultrasound. Abrupt deprivation of oxygen and glucose to neuronal tissues elicits a series of pathologic cascades, leading to the spread of neuronal death. Of the numerous pathways identified, excessive activation of glutamate receptors, accumulation of intracellular Ca(2+) cations, abnormal recruitment of inflammatory cells, excessive production of free radicals and initiation of pathologic apoptosis are believed to play critical roles in ischemic damage, especially in the penumbral zone. Several neuroprotective agents designed to block these cascades have been investigated in animal models of cerebral ischemia and numerous agents have been found to reduce infarct size. However, translation of neuroprotective benefits from the laboratory bench to the emergency room has not been successful. Other measures, such as the relevance of body position in the acute phase of stroke, anticoagulant and antiplatelet agents or the effects of statins and antihypertensive therapy, are discussed in this paper, with an overview of the relevance of stroke units.
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Affiliation(s)
- Tomás Segura
- Hospital General Universitario de Albacete, Department of Neurology, Albacete-02006, Spain.
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Grotta J, Marler J. Intravenous rt-PA: a tenth anniversary reflection. ACTA ACUST UNITED AC 2008; 68 Suppl 1:S12-6. [PMID: 17963915 DOI: 10.1016/j.surneu.2007.07.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Accepted: 07/24/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical trials with rt-PA for treating AIS began 20 years ago in 1987, and the pivotal NINDS rt-PA Stroke Study was completed and published in 1995 with FDA approval in 1996, about 10 years ago. A large number of articles emanated from that study and have established the efficacy and generalizability of this treatment. METHODS Here we summarize the background of how the NINDS trial was developed and carried out and its main findings. RESULTS The NINDS rt-PA Stroke Study resulted from preclincal and pilot studies and paralleled similar studies carried out around the world. Its positive results, compared with the other trials, probably were due to the early time window for treatment and well-organized clinical and statistical centers. Many controversies have surrounded its use since its approval. As a result of the NINDS rt-PA Stroke Study, many new approaches to thrombolytic therapy are under evaluation. CONCLUSION The results of the NINDS rt-PA Stroke Study have affected the management of patients with acute stroke worldwide.
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Affiliation(s)
- James Grotta
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX 77030, USA.
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Mecozzi AC, Brown DL, Lisabeth LD, Barsan WG, Silbergleit R, Hickenbottom SL, Scott PA, Morgenstern LB. Determining intravenous rt-PA eligibility in the Emergency Department. Neurocrit Care 2007; 7:103-8. [PMID: 17763833 DOI: 10.1007/s12028-007-0065-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The purpose of this study was to assess the agreement of Emergency Department (ED) attendings, ED residents, and neurology residents compared with stroke neurologists in the assessment of intravenous rt-PA eligibility. METHODS A convenience sample of patients presenting with possible stroke symptoms to the University of Michigan Hospital ED from June 2003 to July 2004 was identified. A physician from each of four groups: ED attending, ED resident, neurology resident, and stroke neurology attending independently evaluated each patient for eligibility for intravenous (i.v.) rt-PA. Accuracy, sensitivity, and positive predictive value (PPV) with 95% confidence intervals (CI) were calculated by physician type, compared with the stroke neurologist, for eligibility for i.v. rt-PA. RESULTS Exactly 36 (49%) out of the 73 evaluated patients were diagnosed with acute ischemic stroke and 11 were deemed eligible for treatment with i.v. tPA by the stroke neurologist. Agreement with the stroke neurologist for rt-PA eligibility was 93% [95% CI: 84%, 98%] (sensitivity = 82% [48%, 98%], PPV = 82% [48%, 99%]) for the ED attendings, 79% [65%, 90%] (sensitivity = 75% [35%, 97%], PPV = 43% [18% 71%]) for the ED residents, and 84% [73%, 92%] (sensitivity = 100% [74%, 100%], PPV = 52% [31%, 73%]) for the neurology residents. There were two false positive cases identified by ED attendings, eight, by ED residents, and 11 by neurology residents. CONCLUSIONS This study suggests that the agreement between ED attendings and stroke neurologists for determination of rt-PA eligibility is good. There is room for improvement, however, in the determination of acute stroke therapy eligibility in the ED setting especially among trainees.
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Affiliation(s)
- Amy C Mecozzi
- Stroke Program, University of Michigan Medical School, TC 1920/0316, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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White CJ, Cates CU, Cowley MJ, Weiner BH, Carpenter JS, Hopkins LN, Jaff MR, Ramee SR, Rymer MM, Wholey MH. Interventional stroke therapy: current state of the art and needs assessment. Catheter Cardiovasc Interv 2007; 70:471-6. [PMID: 17721987 DOI: 10.1002/ccd.21336] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The primary therapeutic strategy for ischemic stroke, as for MI patients, is early reperfusion. Improvement in stroke treatment will require dedicated stroke centers to emulate MI quality indicators such as minimizing the "door-to-balloon time". A critical element in achieving this goal will be organizing the existing multidisciplinary pool of carotid interventionalists to provide the endovascular component of the acute care for ischemic stroke patients.
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Stroke pathophysiology: management challenges and new treatment advances. J Physiol Biochem 2007; 63:261-77. [DOI: 10.1007/bf03165789] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
The treatment of acute stroke changed dramatically since the publication of the NINDS trail for IV rt-PA for acute stroke. While this was not the first trial, it was the first positive trial. Subsequently there has been an explosion in acute treatment modalities since the NINDS trial showed that acute stroke treatment is feasible. The following chapter reviews the thrombolysis trials, the inclusion and exclusion criteria of intravenous and intra-arterial use of pharmacologic and mechanical thrombolysis in acute ischemic stroke. Also discussed are the new pharmacotherapies and mechanical devices that will hopefully expand the treatment window and make thrombolysis safer and more effective.
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Affiliation(s)
- Jaishri O Blakeley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Foerch C, Misselwitz B, Humpich M, Steinmetz H, Neumann-Haefelin T, Sitzer M. Sex Disparity in the Access of Elderly Patients to Acute Stroke Care. Stroke 2007; 38:2123-6. [PMID: 17525398 DOI: 10.1161/strokeaha.106.478495] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Sex differences in the management of acute coronary symptoms are well documented. We sought to determine whether sex disparities exist in acute stroke management, particularly with regard to early hospital admission and thrombolytic therapy. METHODS We analyzed a prospective, countywide, hospital-based stroke registry. Between 1999 and 2005, all cases with a final diagnosis of cerebral infarction (ICD-10 I63) or intracerebral hemorrhage (ICD-10 I61) were selected. Datasets with missing values for sex and time to admission, as well as datasets of patients transferred between hospitals in the acute phase, were excluded. Main outcome measures were the probability of being admitted within the first 3 hours of stroke onset and being treated with thrombolytic agents for both women and men, after adjustment for age, prestroke disability, severity of clinical symptoms, vascular risk factors, and final diagnosis. RESULTS Fifty-three thousand four hundred fourteen patients were included (49.3% female; mean+/-SD age, 72.1+/-12.5 years). Women had a 10% lower chance of being admitted within the first 3 hours than men (odds ratio=0.902, 95% CI=0.860 to 0.945, P<0.001). This chance further decreased in elderly women. Similarly, the chance of a female stroke patient being treated with thrombolysis was 13% lower than that of a male patient (odds ratio=0.867, 95% CI=0.782 to 0.960, P=0.006). For patients admitted within the 3-hour time window, the chance of being treated with thrombolysis was similar for women and men (odds ratio=0.915, 95% CI=0.809 to 1.035, P=0.156). CONCLUSIONS We identified sex disparities in acute stroke management in terms of early hospital admission and thrombolytic treatment. This is best explained by the sociodemographic fact that "surviving spouses" are more likely to be women than men. Attempts to overcome disadvantages in their access to acute stroke care should focus on increased social support.
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Affiliation(s)
- Christian Foerch
- Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the Early Management of Adults With Ischemic Stroke. Circulation 2007; 115:e478-534. [PMID: 17515473 DOI: 10.1161/circulationaha.107.181486] [Citation(s) in RCA: 657] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose—
Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.
Methods—
Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.
Results—
Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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