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    Direct admission to stroke centers reduces treatment delay and improves clinical outcome after intravenous thrombolysis. Kim Dae-Hyun,Bae Hee-Joon,Han Moon-Ku,Kim Beom Joon,Park Sang-Soon,Park Tai Hwan,Lee Kyung Bok,Kang Kyusik,Park Jong-Moo,Ko Youngchai,Lee Soo Joo,Choi Jay Chol,Kim Joon-Tae,Cho Ki-Hyun,Hong Keun-Sik,Cho Yong-Jin,Kim Dong-Eog,Lee Jun,Lee Juneyoung,Oh Mi Sun,Yu Kyung-Ho,Lee Byung-Chul,Nah Hyun-Wook,Cha Jae-Kwan Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia We aimed to examine whether direct access to hospitals offering intravenous thrombolysis is associated with functional outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis. We enrolled patients who received intravenous thrombolysis within 4.5hours of symptom onset using a prospective multicenter registry database. Patients referred directly from the field to organized stroke centers were compared with those who were transferred from non-thrombolysis-capable hospitals in terms of clinical outcomes at 90days after intravenous recombinant tissue plasminogen activator treatment. We also investigated onset-to-door time and onset-to-needle time according to admission mode. A total of 820 patients (mean age of 67.3years and median National Institutes of Health Stroke Scale score of 9) were enrolled. Seventeen percent of patients with AIS who received intravenous thrombolytic therapy at 12 hospitals (n=142) were transferred from other hospitals. The direct admission group had a shorter median onset-to-admission time (63 versus 121minutes, P<0.001) and onset-to-needle time (110 versus 161minutes, P<0.001) as compared with the indirect admission group. Direct admission was associated with a good outcome with an odds ratio of 1.57 (95% confidence interval: 1.02-2.39, P=0.036) after adjustment for baseline variables. Direct admission to a hospital with intravenous thrombolysis facilities available at all times was associated with shorter onset-to-needle time and better outcome in patients with AIS undergoing thrombolytic therapy. Our findings support the implementation of regional stroke care programs transporting patients directly to stroke centers to promote faster treatment and to achieve better outcomes. 10.1016/j.jocn.2015.06.038
    Acute ischemic stroke thrombolysis with tenecteplase: An institutional experience from South India. Owais Mohammed,Panwar Ajay,Valupadas Chandrasekhar,Veeramalla Madhavarao Annals of African medicine Objective:Outcome assessment of intravenous (IV) thrombolysis with tenecteplase in acute ischemic stroke. Materials and Methods:We consecutively enrolled acute ischemic stroke patients who underwent IV thrombolysis with tenecteplase from October 2016 to May 2017. Primary clinical efficacy outcome was defined as an improvement in the National Institute of Health Stroke Scale (NIHSS) score of ≥4 points at 24 h (h). Secondary clinical efficacy outcome was the favorable outcome on modified Rankin scale at 90 days defined as a score of 0 or 1. The safety endpoints were death rate at 90 days and symptomatic intracranial hemorrhage (SICH). Results:Mean NIHSS scores at baseline and 24 h were 13 (±3.81) and 9.29 (±5.74), respectively, the difference being statistically significant (P = 0.016). In this study, nine patients (64%) met the primary clinical efficacy outcome and eleven (78.5%) patients met the secondary clinical efficacy outcome. Only 1 (7%) patient developed SICH and additionally, aspiration pneumonia with subsequent death. Conclusion:This study confirms the efficacy and safety of tenecteplase for stroke thrombolysis in our clinical setting. Tenecteplase appears to be a suitable option for stroke thrombolysis in resource-limited settings, considering its cost-effectiveness, and ease of administration. 10.4103/aam.aam_50_17
    Evaluation of the implementation of a 24-hr stroke thrombolysis emergency treatment for patients with acute ischaemic stroke. Zhao Jun,Li Xingqiang,Liang Yingchun,Zhao Liang,Zhang Xinping,Liu Yunlin Journal of clinical nursing AIMS AND OBJECTIVES:To assess the trends of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) among patients with acute ischaemic stroke (AIS) admitted to our hospital between 2012-2014 and investigate the effects of a 24-hr stroke thrombolysis emergency treatment on the intrahospital clinical data and outcomes of these patients treated with IV rt-PA thrombolysis. BACKGROUND:Although prenotification of stroke by emergency medical services has been endorsed by the national recommendations and implemented in some developed countries, the development in China is limited. DESIGN:A retrospective, single-centre, observational study. METHODS:Patients with AIS admitted to our hospital between January 2012-December 2014 were included; those who received IV rt-PA thrombolysis within 4.5 hr of onset were investigated. Demographic characteristics, including age and sex, and clinical data and outcomes, including onset-to-treatment time (OTT), door-to-needle time (DNT), premorbid modified Rankin Scale score and proportion of patients treated per year, were all recorded. RESULTS:The proportion of patients with AIS who received thrombolytic therapy within 4.5 hr increased from 2012-2014. The baseline characteristics of all patients were similar. Since the implementation of 24-hr stroke thrombolysis emergency treatment in 2013, the median DNT significantly decreased in 2014 after implementation (42 min) compared with that in 2012 before implementation (81 min) (p < .05). Moreover, the admission-to-imaging time (37 vs. 33 vs. 36 min) and OTT (176 vs. 147 vs. 124 min) significantly decreased during the 3 years (p < .05). CONCLUSIONS:The 24-hr stroke thrombolysis emergency treatment reduced in-hospital delay before thrombolytic therapy but had no effect on the functional outcomes of the patients with AIS. RELEVANCE TO CLINICAL PRACTICE:This study provides opportunities to improve the experiences in using 24-h stroke thrombolysis emergency treatment in patients with AIS in clinical practice. 10.1111/jocn.14272
    [Intravenous thrombolysis for acute ischemic stroke. A four years’ experience in a Chilean public hospital]. Soto V Álvaro,Morales I Gladys,Grandjean B Marcela,Pollak W Débora,Del Castillo C Carolina,García F Pía,Von Johnn A Alexis,Riquelme G Alfonso Revista medica de Chile BACKGROUND:Intravenous thrombolysis (IVT) with alteplase (tissue plasminogen activator) is the standard pharmacological treatment in acute ischemic stroke (AIS), reducing disability in patients. AIM:To report the results a thrombolysis protocol during four years in a regional public hospital. MATERIAL AND METHODS:Data from 106 consecutive patients aged 68 ± 13 years (57% men) who were treated with IVT, from May 2012 until April 2016, was analyzed. RESULTS:The median door-to-needle time was 80 minutes (interquartile range = 57-113). The median National Institute of Health Stroke Scale (NIHSS) scores on admission and at discharge were was 11.5 and 5 points respectively. At discharge, 27% of hospitalized patients had a favorable outcome (n = 99), defined as having 0 to 1 points in the modified Rankin scale. Symptomatic intracerebral hemorrhage and mortality rates were 5.7 and 13.1%, respectively. The thrombolysis rate rose from 0.7% in 2012 to 6% in 2016. CONCLUSIONS:The implementation of 24/7 neurology shifts in the Emergency Department allowed us to increase the amount and quality of IVT in our hospital, as measured by the rate of thrombolysis and by process indicators such as door-to-needle time. 10.4067/S0034-98872017000400007
    Trends in New Zealand stroke thrombolysis treatment rates. Liu Qiliang,Ranta Annemarei Anna,Abernethy Ginny,Barber P Alan The New Zealand medical journal AIMS:To describe trends in treatment delays and short-term outcome over the first 18 months of the New Zealand stroke thrombolysis register. METHODS:The National Stroke Network introduced a central register of all ischaemic stroke patients treated with intravenous alteplase on January 1, 2015. The aim was to increase thrombolysis treatment rates and drive improvements in safety. RESULTS:From January 1, 2015 to June 30, 2016, alteplase was given to 623 patients [344 men, mean (range) age 70 (22-98) years] out of a total of 8,857 ischaemic and unspecified stroke patients, giving a thrombolysis rate of 7.0%. Between the first and second halves of the audit, there were more patients thrombolysed [350 of 4,456 (7.9%) versus 273 of 4,401 (6.8%); p=0.001] and more treated within 60 minutes of hospital arrival [137 of 325 (42%) versus 71 of 250 (28%), p=0.001]. Door-to-needle time reduced from 77 minutes to 64 minutes (p=0.002) and the onset-to-treatment reduced from 162 minutes to 140 minutes (p=0.070). Rates of symptomatic intracranial haemorrhage (4.3% patients) and survival at day seven (93%) were stable. CONCLUSIONS:There have been improvements in stroke thrombolysis rates and treatment delays in New Zealand hospitals since the institution of the National Stroke Network thrombolysis register. The Network will continue to adjust key performance indicators, and stroke thrombolysis targets for individual DHBs have been increased to 8% for 2017 and 10% for 2018.
    Stroke Thrombolysis Protocol Shortens "Door-to-Needle Time" and Improves Outcomes-Experience at a Tertiary Care Center in Qatar. Ibrahim Faisal,Akhtar Naveed,Salam Abdul,Kamran Saadat,Deleu Dirk,D'Souza Atlantic,Imam Yahya,Bourke Paula,Joseph Sujatha,Santos Mark,Khan Rabia,Bhutta Zain A,Bhagat Anjushri,Shuaib Ashfaq Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND AND PURPOSE:To assess the effect of acute thrombolysis protocol on "door-to-needle time" (DTN) and improvement in outcome following acute stroke (AS). METHODS:The charts of all patients receiving intravenous (IV) thrombolysis for AS between January 2008 and June 2015 were reviewed for DTN, complications, and clinical outcome. Good prognosis was defined as modified Rankin Scale (mRS) score of less than 2 at 90 days. In January 2014, a protocol for faster DTN was introduced. We reviewed the prognosis before and after the introduction of the new protocol. RESULTS:Up to 204 patients received IV recombinant tissue plasminogen activator (r-tPA) (mean age 52.5 ± 12.4 years). Mean door-to-CT time improved from 42.5 ± 41.1 to 27.1 ± 26.3 minutes (P < .001); DTN improved from 83.26 ± 47.7 to 47.09 ± 25.7 minutes (P < .001). Complications were reduced from 15.7% to 8.8% (P = .14). The mRS score of less than or equal to 2 improved from 47.1% to 73.3% at 90 days (P = .001). After implementing new protocol, thrombolysis rate increased to 11.8% in 2014 (before 3.3% in 2011, 4.9% in 2012, and 4.4% in 2013), P < .0001. NIHSS (National Institutes of Health Stroke Scale) score at admission (P = .002), hypodensity on initial CT brain (P = .041), protocol implementation (P = .014), and reduced length of stay (P = .004) were associated with outcome at 90 days (mRS score ≤2). CONCLUSION:Implementation of specific protocols to reduce DTN in patients receiving IV r-tPA leads to reduction in complications and improves outcome. 10.1016/j.jstrokecerebrovasdis.2016.03.047
    Circadian rhythms may not influence the outcomes of thrombolysis in patients with ischemic stroke: A study from China. Ding Jiayue,Bai Zhuoxuan,Zhou Da,Li Xiangyu,Rajah Gary Benjamin,Ding Yuchuan,Han Jie,Ji Xunming,Meng Ran Chronobiology international Circadian rhythms can affect physical or mental activities as well as the time of stroke onset. The impact of circadian rhythms on acute ischemic stroke (AIS) patients treated by recombinant alteplase (rt-PA) is still incongruent. This study aims to consider whether the outcomes of thrombolysis differ depending on stroke onset time and rt-PA infusion time in patients with AIS. A total of 447 AIS patients, who underwent rt-PA intravenous infusion within 4.5 hours after stroke onset, were enrolled in this study consecutively from June 2010 through December 2016. All of the patients were grouped based on the stroke onset time and rt-PA infusion time into two exact 12-hour intervals as daytime (06:01-18:00) and nighttime (18:01-06:00) and further divided into four subgroups at 6-hour time intervals (00:01-06:00, 06:01-12:00, 12:01-18:00 and 18:01-24:00). Major neurological improvement at 1 hour, 24 hours and 7 days, 7-day mortality rate and 24-hour hemorrhage transformation was recorded. The results showed that a total of 295 patients (66.4%) appeared with AIS and 252 (56.4%) were treated during daytime. Higher NIHSS at admission was observed when stroke occurred in nighttime, especially during 00:01-06:00. Patients with stroke onset in nighttime especially during 18:01-24:00 had a significant shorter onset-door time and onset-needle time. No differences of the major neurological improvement at 1 hour, 24 hours and 7 days, 24-hour hemorrhagic transformation and 7-day fatality rate were found among either 12-hour time frames or 6-hour time frames according to the time of stroke onset or rt-PA infusion. In conclusion, there was no evidence to predict that circadian rhythms could influence the outcomes of AIS patients treated with rt-PA in China, although stroke onset during nighttime might aggravate neurological impairment before treatment. Further, multicenter and prospective clinical trials with larger number of subjects are still needed to draw more reliable conclusions. 10.1080/07420528.2018.1494602
    Sex-Related Differences in Management and Outcome of Acute Ischemic Stroke in Eligible Patients to Thrombolysis. Fraticelli Laurie,Freyssenge Julie,Claustre Clément,Buisson Marielle,Bischoff Magali,Nighoghossian Norbert,Derex Laurent,El Khoury Carlos, Cerebrovascular diseases (Basel, Switzerland) BACKGROUND:Literature has highlighted sex-based differences in the natural course of stroke and in response to treatment with intravenous tissue plasminogen activator (tPA). OBJECTIVES:We aimed to compare the management and outcome of acute ischemic stroke (AIS) among women and men on a French registry based on a federated network of emergency physicians and neurologists. METHOD:We included 2,790 patients received tPA between 2010 and 2016 from the stroke centers in the RESUVal area. We provided age-adjusted analysis and multivariate models for determining the role of sex in the outcome measures. RESULTS:After age-adjustment, women presented more moderate to severe stroke at admission with more proximal occlusions. Among tPA eligible patients, the therapeutic strategy and in-hospital hemorrhagic complications were proportionally identical whatever the sex. The total ischemic time from onset symptom to thrombolysis did not differ from women to men. Age-adjusted 3-month mortality did not differ between women and men, and the determinants of mortality were age (relative risk [RR] 1.56 [1.37-1.78], p < 0.0001), proximal occlusion (RR 2.5 [1.88-3.33], p < 0.0001), and at least one complication (RR 2.43 [1.89-3.13], p < 0.0001). The determinants of poor functional outcome at 3 months were the sex (RR 1.22 [1.01-1.48] for women, p = 0.0385) and the occurrence of onset symptom in rural landscape (RR 1.26 [1.03-1.55], p = 0.0219) compared to urban landscape. CONCLUSIONS:We provided an exhaustive overview and real-life professional practices conditions in thrombolyzed AIS. Despite a later prehospital management in neurovascular units and more severe strokes at admission, women and men had both similar outcomes at hospital discharge and in 3-month survival, but women were associated to worst functional outcome at 3 months. 10.1159/000500901
    Effect of educational television commercial on pre-hospital delay in patients with ischemic stroke. Nishijima Haruo,Kon Tomoya,Ueno Tatsuya,Haga Rie,Yamazaki Keishi,Yagihashi Kei,Funamizu Yukihisa,Arai Akira,Suzuki Chieko,Nunomura Jin-Ichi,Baba Masayuki,Tomiyama Masahiko Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology Administering intravenous recombinant tissue plasminogen activator (r-tPA) within 4.5 h or endovascular procedures within 8 h of ischemic stroke onset may reduce the risk of disability. The effectiveness of media campaigns to raise stroke awareness and shorten pre-hospital delay is unclear. We studied 1144 consecutive ischemic stroke patients at Aomori Prefectural Central Hospital, Japan, between March 2010 and February 2014. From March 2012, the government sponsored an educational campaign based on a television commercial to improve knowledge of stroke symptoms and encourage ambulance calls for facial palsy, arm palsy, or speech disturbance. For the 544 and 600 patients admitted before and during the intervention, respectively, we recorded the National Institutes of Health Stroke Scale score, stroke type, the time when patients or bystanders recognized stroke symptoms, and hospital arrival time. Pre-hospital delay, as the time interval from awareness of stroke to hospital arrival, was categorized as 0-3, 3-6, and 6+ h. The mean pre-hospital delay was shorter (12.0 vs 13.5 h; P = 0.0067), the proportion of patients arriving within 3 h was larger (55.7 vs 46.5 %; P = 0.0021), and the proportion arriving after 6 h was smaller (32.7 vs 39.5 %; P = 0.0162) in the intervention group than in the pre-intervention group. There was no significant difference in the proportion of patients treated with r-tPA (6 and 7.5 % of the intervention and pre-intervention groups, respectively). A television-based public education campaign potentially reduced pre-hospital delay for ischemic stroke patients, but the r-tPA treatment rate was unchanged. 10.1007/s10072-015-2372-1
    Driving stroke quality improvement at scale in EDs across a nationwide network of hospitals: strategies and interventions. Shpak Max,Korwek Kimberly,Nadasdy Zoltan,Ramakrishnan Anurekha,Cowperthwaite Matthew,Ankrom Kristen,Jennings Jon,Moody Ashley,Orndorff Kevin,Fanale Christopher Emergency medicine journal : EMJ OBJECTIVES:Reducing the treatment time while increasing the proportion of eligible stroke patients who receive intravenous tissue plasminogen activator (tPA) has been a priority for many quality improvement efforts. Recent studies have primarily focused on identifying interventions that reduce door-to-needle (DTN) time, while comparatively little has been done to determine whether these interventions also improve tPA rates. METHODS:In order to investigate interventions related to process improvements, an electronic dashboard serving as a stroke performance tool was implemented to store and retrieve patient outcome data. These data were used to study the efficacy of interventions designed to facilitate triage of stroke patients in the ED, and determine the individual interventions associated with the most significant improvements in the fraction of patients receiving tPA and in reducing the DTN time. Stroke performance data from the dashboard collected over a 2-year period (2015-2017) from 89 US hospitals were analysed with respect to interventions implemented by individual facilities, as verified by a hospital survey. RESULTS:A statistically significant association was found between increases in the fraction of patients receiving tPA and reductions in DTN time over the study period. These improvements in outcomes were most strongly associated with process interventions that allocate stroke-specific physical and human resources in the ED, most notably a designated emergency room space for stroke, and with workflows that decrease the time to key checkpoints for determining a patient's eligibility for tPA. CONCLUSIONS:Data from the stroke performance tool was leveraged to identify the programmes and process interventions that lead to improved patient outcomes and allow EDs to better prioritise process interventions and resources. 10.1136/emermed-2018-208257
    Validation of a Smartphone Application in the Evaluation and Treatment of Acute Stroke in a Comprehensive Stroke Center. Martins Sheila C O,Weiss Gustavo,Almeida Andrea G,Brondani Rosane,Carbonera Leonardo A,de Souza Ana Claudia,Martins Magda Carla O,Nasi Guilherme,Nasi Luiz A,Batista Carlos,Sousa Fabrício B,Rockenbach Márcio A B C,Gonçalves Felipe M,Vedolin Leonardo M,Nogueira Raul G Stroke Background and Purpose- The increasing demand and shortage of experts to evaluate and treat acute stroke patients has led to the development of remote communication tools to aid stroke management. We aimed to evaluate the JOIN App smartphone system-a low-cost tool for rapid clinical and neuroimaging data sharing to expedite decision-making in stroke. Methods- Consecutive acute ischemic stroke patients treated at a University Hospital in Brazil from December 2014 to December 2015 were evaluated. The analysis included all patients presenting with acute ischemic stroke who underwent initial evaluation by neurology residents followed by JOIN teleconsultation with a stroke neurologist on call for management decisions. An expert panel of stroke neurologists and neuroradiologists revised all cases using a standard Picture Archiving and Communication System imaging workstation within 24 hours and analyzed the decision made with remote assistance during the emergency setting. Results- A total of 720 stroke codes were evaluated with 442 acute ischemic stroke qualifying. Seventy-eight (18%) patients were treated with intravenous thrombolysis. The main reasons for tPA (tissue-type plasminogen activator) exclusion were symptom onset >4.5 hours (n=295; 67%) and hypodense middle cerebral artery territory area >1/3 (n=31; 7%). The agreement rates between Picture Archiving and Communication System versus JOIN-based thrombolysis decisions were 100% for the stroke (unblinded) and 99.3% for the neuroradiologist (blinded) experts. The use of the application resulted in a significant reduction in the door-to-needle times across the pre- versus postimplementation periods (median, 90 [interquartile range, 75-106] versus 63 [interquartile range, 61-117] minutes; =0.03). The rates of 90-day excellent outcomes (modified Rankin Scale, 0-1) were 51.3%; 90-day mortality, 2.6%; and symptomatic intracranial hemorrhage, 3.8%. Conclusions- The JOIN smartphone system allows rapid sharing of clinical and imaging data to facilitate decisions for stroke treatment. The remote application-based decisions seem to be as accurate as the physical presence of stroke experts and might lead to faster times to treatment. This system represents an easily implementable low-cost telemedicine solution for centers that cannot afford the full-time presence of stroke specialists. 10.1161/STROKEAHA.119.026727
    Country-Wide Analysis of Systemic Factors Associated With Acute Ischemic Stroke Door to Needle Time. McVerry Ferghal,Hunter Annemarie,Dynan Kevin,Matthews Maureen,McCormick Michael,Wiggam Ivan,Vahidassr Djamil,McErlean Fintan,Stevenson Mike,Hopkins Emer,McKee Jacqueline,Kelly James,Kennedy Fiona,McCarron Mark O Frontiers in neurology Pre-hospital, in-hospital, and patient factors are associated with variation in door to needle (DTN) time in acute ischemic stroke (AIS). Publications are usually from large single centers or multicenter registries with less reporting on national results. All AIS patients treated with intravenous tissue plasminogen activator (iv-tPA) over 4 years (2013-2016) in Northern Ireland were recorded prospectively, including patient demographics, pre-hospital care, thrombolysis rate, and DTN time. Logistic regression was performed to identify factors associated with DTN time. One thousand two hundred and one patients from 10,556 stroke admissions (11.4%) were treated with iv-tPA. Median NIHSS was 10 (IQR 6-17). Median DTN time was 54 min (IQR 36-77) with 61% treated < 60 min from arrival at hospital. National thrombolysis numbers increased over time with improving DTN time ( = 0.002). Arrival method at hospital (ambulance OR 2.3 CI1.4-3.8) pre-alert from ambulance (pre-alert OR = 5.3 CI3.5-8.1) and time of day (out of hours, = 650, OR 0.20 CI 0.22-0.38) all < 0.001, were the independent factors in determining DTN time. Variation in DTN time between centers occurred but was unrelated to volume of stroke admissions. Ambulance transport with pre-hospital notification and time of day are associated with shorter DTN time on a national level. Most thrombolysis was delivered outside of normal working hours but these patients are more likely to experience treatment delays. Re-organization of stroke services at a whole system level with emphasis on pre-hospital care and design of stroke teams are required to improve quality and equitable care in AIS nationally. 10.3389/fneur.2019.00676
    Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area. Zhang Sheng,Zhang Jungen,Zhang Meixia,Zhong Genlong,Chen Zhicai,Lin Longting,Lou Min Aging and disease Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) can improve clinical outcome in eligible patients with acute ischemic stroke (AIS). However, its efficacy is strongly time-dependent. This study was aimed to examine whether prehospital notification by emergency medical service (EMS) providers could reduce onset to needle time (ONT) and improve neurological outcome in AIS patients who received IVT. We prospectively collected the consecutive clinical and time data of AIS patients who received IVT during one year after the initiation of prehospital notification procedure (PNP). Patients were divided into three groups, including patients that transferred by EMS with and without PNP and other means of transportation (non-EMS). We then compared the effect of EMS with PNP and EMS use only on ONT, and the subsequent neurological outcome. Good outcome was defined as modified Rankin Scale score of 0-2 at 3-months. In 182 patients included in this study, 77 (42.3%) patients were transferred by EMS, of whom 41 (53.2%) patients entered PNP. Compared with non-EMS group, EMS without PNP group greatly shortened the onset to door time (ODT), but EMS with PNP group showed both a significantly shorter DNT (41.3 ± 10.7 min vs 51.9±23.8 min, t=2.583, p=0.012) and ODT (133.2 ± 90.2 min vs 174.8 ± 105.1 min, t=2.228, p=0.027) than non-EMS group. Multivariate analysis showed that the use of EMS with PNP (OR=2.613, p=0.036), but not EMS (OR=1.865, p=0.103), was independently associated with good outcome after adjusting for age and baseline NIHSS score. When adding ONT into the regression model, ONT (OR=0.994, p=0.001), but not EMS with PNP (OR=1.785, p=0.236), was independently associated with good outcome. EMS with PNP, rather than EMS only, improved stroke outcome by shortening ONT. PNP could be a feasible strategy for better stroke care in Chinese urban area. 10.14336/AD.2017.0601
    Prehospital and intra-hospital time delays in posterior circulation stroke: results from the Austrian Stroke Unit Registry. Sommer Peter,Seyfang Leonhard,Posekany Alexandra,Ferrari Julia,Lang Wilfried,Fertl Elisabeth,Serles Wolfgang,Töll Thomas,Kiechl Stefan,Greisenegger Stefan Journal of neurology Therapeutic effect of recombinant tissue-plasminogen activator (rt-PA) is time dependent. There is limited evidence whether localization of stroke within the posterior circulation (PCS) is associated with a treatment delay. We aimed to analyze within a nationwide multicenter cohort whether duration of pre- and intra-hospital patient management differs between patients with PCS and anterior circulation strokes (ACS). We studied onset-to-door-times (ODT) and door-to-needle-times (DNT) of all patients with acute ischemic stroke (IS) enrolled in the Austrian Stroke Unit Registry according to infarct localization. Classification into PCS and ACS was based on clinical presentation applying the criteria used in the Oxfordshire Community Stroke Project. Relationships between ODT, respectively, DNT and explanatory variables were modeled by multivariate linear regression. Between 2003 and 2015, 71010 patients with IS were enrolled, 11,924 with PCS and 59,086 with ACS. Overall, the ODT was significantly longer in PCS: median (IQR): 170 (25th, 75th‰: 79,420) min versus 110 (60,240); p < 0.001; this finding held true in multivariable analysis. In 10535 rt-PA-treated patients (1022 PCS/9832 ACS), ODT and DNT were significantly longer among those with PCS: ODT: median: 80 min (55,120) versus 72 (50,110), p < 0.001; DNT: 57 (35.90) versus 45 (30.67), p < 0.001. In the multivariate model, PCS was significantly associated with delay in the DNT. In conclusion, in this large nationwide cohort, patient management was significantly slower in PCS as compared to ACS. Increasing awareness about these delays and further elaboration of the underlying causes may translate into higher proportions of patients with PCS receiving rt-PA. 10.1007/s00415-016-8330-x
    How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care. Paul Christine L,Ryan Annika,Rose Shiho,Attia John R,Kerr Erin,Koller Claudia,Levi Christopher R Implementation science : IS BACKGROUND:Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke. METHODS:Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted. RESULTS:Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05). CONCLUSIONS:In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients. 10.1186/s13012-016-0414-6
    Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Huang Qiang,Zhang Jing-Ze,Xu Wen-Deng,Wu Jian Medicine The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management. 10.1097/MD.0000000000011205
    Improvement in Door-to-Needle Time in Patients with Acute Ischemic Stroke via a Simple Stroke Activation Protocol. Tan Benjamin Y Q,Ngiam Nicholas J H,Sunny Sibi,Kong Wan Yee,Tam Howen,Sim Tiong Beng,Leong Benjamin S H,Bhartendu Chandra,Paliwal Prakash R,Seet Raymond C S,Chan Bernard P L,Teoh Hock Luen,Sharma Vijay K,Yeo Leonard L L Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND:In acute ischemic stroke (AIS), treatment with intravenous tissue-type plasminogen activator (IV-tPA) is time-sensitive. All stroke centers make continual efforts to reduce door-to-needle time (DNT) with varying success. We present the impact of modifications to our stroke activation protocol on DNT. METHODS:We included 404 consecutive patients with AIS receiving IV-tPA between January 2014 and December 2016. First changes in stroke activation protocol were made in March 2015 in the form of prenotification by paramedics, direct transfer from ambulance to computed tomography (CT) scanner, and rapid en route neurological assessment by an emergency physician and neurologist. In March 2016, a second amendment was made where a stroke nurse accompanied the patient to expedite various steps in the treatment pathway, including endovascular treatment in eligible cases. RESULTS:Both protocol amendments resulted in improvement in DNT and door-to-CT time from 84 ± 47 minutes before intervention to 69 ± 33 minutes after protocol amendment 1 to 59 ± 37 minutes after protocol amendment 2. In particular, the second amendment (144 patients) showed significant shortening of DNT compared with the 137 patients before (59 ± 37 minutes versus 69 ± 33 minutes, P = .020), with a higher percentage achieving the target of 60 minutes (68.1% versus 48.2%, P < .001). This finding was attributed to a reduction in both door-to-CT time and CT-to-needle time. This improvement remained consistent over subsequent months. CONCLUSIONS:The application of a simple systems-based, multidisciplinary stroke activation protocol may help in significant reduction in DNT. Encouraging increased patient ownership by stroke nurses appeared to be a promising approach for timely administration of definitive acute therapies. 10.1016/j.jstrokecerebrovasdis.2018.01.005
    Sex Differences and Functional Outcome After Intravenous Thrombolysis. Spaander Fianne H,Zinkstok Sanne M,Baharoglu Irem M,Gensicke Henrik,Polymeris Alexandros,Traenka Christopher,Hametner Christian,Ringleb Peter,Curtze Sami,Martinez-Majander Nicolas,Aarnio Karoliina,Nolte Christian H,Scheitz Jan F,Leys Didier,Hochart Anais,Padjen Visnja,Kägi Georg,Pezzini Alessandro,Michel Patrik,Bill Olivier,Zini Andrea,Engelter Stefan T,Nederkoorn Paul J, Stroke BACKGROUND AND PURPOSE:Women have a worse outcome after stroke compared with men, although in intravenous thrombolysis (IVT)-treated patients, women seem to benefit more. Besides sex differences, age has also a possible effect on functional outcome. The interaction of sex on the functional outcome in IVT-treated patients in relation to age remains complex. The purpose of this study was to compare outcome after IVT between women and men with regard to age in a large multicenter European cohort reflecting daily clinical practice of acute stroke care. METHODS:Data were obtained from IVT registries of 12 European tertiary hospitals. The primary outcome was poor functional outcome, defined as a modified Rankin scale score of 3 to 6 at 3 months. We stratified outcome by age in decades. Safety measures were symptomatic intracranial hemorrhage and mortality at 3 months. RESULTS:In this cohort, 9495 patients were treated with IVT, and 4170 (43.9%) were women with a mean age of 71.9 years. After adjustments for baseline differences, female sex remained associated with poor functional outcome (odds ratio, 1.15; 95% confidence interval, 1.02-1.31). There was no association between sex and functional outcome when data were stratified by age. Symptomatic intracranial hemorrhage rate was similar in both sexes (adjusted odds ratio, 0.93; 95% confidence interval, 0.73-1.19), whereas mortality was lower among women (adjusted odds ratio, 0.83; 95% confidence interval, 0.70-0.99). CONCLUSIONS:In this large cohort of IVT-treated patients, women more often had poor functional outcome compared with men. This difference was not dependent on age. 10.1161/STROKEAHA.116.014739
    High Plasma D-Dimer Indicates Unfavorable Outcome of Acute Ischemic Stroke Patients Receiving Intravenous Thrombolysis. Hsu Po-Jen,Chen Chih-Hao,Yeh Shin-Joe,Tsai Li-Kai,Tang Sung-Chun,Jeng Jiann-Shing Cerebrovascular diseases (Basel, Switzerland) BACKGROUND:D-dimer is a fibrin degradation product and a possible marker of thromboembolic events. The aim of this study was to investigate the relationship between D-dimer levels and outcome in acute ischemic stroke (AIS) patients receiving intravenous thrombolysis. METHODS:This retrospective study included AIS patients who received intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and provided plasma D-dimer level within 24 h after stroke onset during 2009 and 2014 at a single medical center. Unfavorable outcome was defined as modified Rankin scale ≥3 at 3 months after stroke. Symptomatic intracerebral hemorrhage (ICH) was defined as a deterioration of at least 4 points on the National Institutes of Health Stroke Scale within 36 h post thrombolysis. RESULTS:Of 347 patients receiving intravenous rt-PA, 159 (mean age 67.6 ± 13.1 year, 59.7% male) fulfilled the inclusion criteria. In univariate analysis, patients with unfavorable outcome (n = 79) had significantly higher levels of D-dimer than those with favorable outcome (median ln D-dimer = 1.4 vs. 0.7 μg/ml, p < 0.001). After adjustment for clinical variables, a higher level of D-dimer remained significantly associated with an unfavorable outcome (OR 1.90, 95% CI 1.27-2.86, p = 0.002) and the occurrence of symptomatic ICH (OR 2.97, 95% CI 1.15-7.70, p = 0.025). CONCLUSION:The D-dimer level within 24 h after stroke onset can be an early outcome indicator in AIS patients receiving rt-PA therapy. 10.1159/000445037
    Impact of Prehospital Intervention on Delay Time to Thrombolytic Therapy in a Stroke Center with a Systemized Stroke Code Program. Kim Dae-Hyun,Nah Hyun-Wook,Park Hyun-Seok,Choi Jae-Hyung,Kang Myong-Jin,Huh Jae-Taeck,Cha Jae-Kwan Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND:The use of emergency medical services (EMS) and notification to hospitals by paramedics for patients with suspected stroke are crucial determinants in reducing delay time to acute stroke treatment. The aim of this study is to investigate whether EMS use and prehospital notification (PN) can shorten the time to thrombolytic therapy in a stroke center with a systemized stroke code program. METHODS:Beginning in January 2012, stroke experts in our stroke center received direct calls via mobile phone from paramedics prenotifying the transport of patients with suspected stroke. We compared baseline characteristics and prehospital/in-hospital delay time in stroke patients treated with intravenous recombinant tissue plasminogen activator for 44 months with and without EMS use and/or PN. RESULTS:Intravenous thrombolytic therapy was performed on 274 patients. Of those patients, 215 (78.5%) were transported to the hospital via EMS and 59 (21.5%) were admitted via private modes of transportation. The patients who used EMS had shorter median onset-to-arrival times (62 minutes versus 116 minutes, P < .001). There was no difference in in-hospital delay time between the 2 groups. In 28 cases (13%) of EMS transport, EMS personnel called the clinical staff to notify the incoming patient. Prenotification by EMS was associated with shorter median door-to-imaging time (9 minutes versus 12 minutes, P = .045) and door-to-needle time (20 minutes versus 29 minutes, P = .011). CONCLUSIONS:We found that EMS use reduces prehospital delay time. However, EMS use without prenotification does not shorten in-hospital processing time in a stroke center with a systemized stroke code program. 10.1016/j.jstrokecerebrovasdis.2016.02.011
    Phased changes in strategies can reduce delay of intravenous thrombolysis administration to 15 min. Itabashi Ryo,Shigehatake Yuya,Yazawa Yukako,Endo Kaoru,Saito Takuya,Fukuma Kazuki,Furui Eisuke,Mori Etsuro Journal of the neurological sciences OBJECTIVES:The present study aimed to determine whether phased changes in strategies including the Helsinki model affect the delay of intravenous thrombolysis (IVT) using tissue plasminogen activator (tPA) to treat acute ischemic stroke. METHOD:We retrospectively studied 516 consecutive patients treated with IVT in our department between October 2005 and December 2018. We implemented a system of hospital pre-notification in 2005, when IVT was initially implemented at our center. We then improved the IVT strategy by simplifying brain imaging (July 2011), premixing tPA (April 2014), locating a blood cell counter in the emergency room (June 2015), manually administering a tPA bolus before preparing a continuous infusion (January 2016), awarding a prize to members of the acute stroke team (November 2016), and completing registration before arrival and sending patients directly to computed tomography (February 2017). We analyzed the effects of these strategic changes on annual median door-to-needle times (DTN). RESULTS:The DTN was annually reduced, from a median of 90 [interquartile range, 55-98] minutes in 2006 to 15 [12-24.25] minutes in 2017. By 2017, 94% of patients were treated within 60 min of arrival. Multivariate logistic regression analysis revealed that initial NIHSS score ≤ 4 (OR 2.67, 95% CI 1.3-5.7) and anticoagulation before onset (OR 6.00, 95% CI 2.47-14.58) were independently associated with 20 min or more of DTN in 186 patients treated from 2016 to 2018. CONCLUSIONS:Phased strategic change to reduce the delay in delivering IVT reduced median DTN to 15 min at a single Japanese stroke center. 10.1016/j.jns.2019.06.015
    Clinical characteristics and risk score for poor clinical outcome of acute ischemic stroke patients treated with intravenous thrombolysis therapy. Yue Yun-Hua,Li Zhi-Zhang,Hu Liang,Zhu Xiao-Qiong,Xu Xu-Shen,Sun Hong-Xian,Wan Zhi-Wen,Xue Jie,Yu De-Hua Brain and behavior BACKGROUND:Tissue plasminogen activator (t-PA) is an effective therapy for acute ischemic stroke, but some patients still have poor clinical outcome. In this study, we investigated clinical characteristics of stroke patients and determined predictors for poor clinical outcome in response to t-PA treatment. METHODS:Clinical data from 247 patients were retrospectively reviewed. Clinical parameters that were associated with survival of patients were analyzed. Areas under receiver operating characteristic curves (ROC) were used to determine the feasibility of using various combinations of the clinical parameters to predict poor clinical response. The clinical outcome was defined according to the changes in Modified Rankin Scale. RESULTS:Overall, 145 patients had improved/complete recovery, 73 had no change, and 29 had worsening conditions or died during the in-clinic period. A univariate analysis showed that baseline characteristics including age, CRP, blood glucose level, systolic blood pressure, and admission NIHSS were significantly different (p < 0.05) among patients with different clinical outcome. A further multivariate analysis was then performed. Variables associated with poor clinical outcome (worsening/death) (p < 0.1) were included in the logistic regression model. Four parameters were retained in the model: Age, CRP, Blood glucose level, and Systolic blood pressure (ACBS). To allow a convenient usage of the ACBS classifier, the parameters were put into a scoring system, and the score at 7.7 was chosen as a cut-off. The ROC curve of this ACBS classifier has an area under the curve (AUC) of 0.7788, higher than other individual parameters. The ACBS classifier provided enhanced sensitivity of 69.2% and specificity of 74.3%. CONCLUSION:The ACBS classifier provided a satisfactory power in estimating the patients' clinical outcome. After further validating, the classifier may provide important information to clinicians for making clinical decisions. 10.1002/brb3.1251
    Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. Ma Henry,Campbell Bruce C V,Parsons Mark W,Churilov Leonid,Levi Christopher R,Hsu Chung,Kleinig Timothy J,Wijeratne Tissa,Curtze Sami,Dewey Helen M,Miteff Ferdinand,Tsai Chon-Haw,Lee Jiunn-Tay,Phan Thanh G,Mahant Neil,Sun Mu-Chien,Krause Martin,Sturm Jonathan,Grimley Rohan,Chen Chih-Hung,Hu Chaur-Jong,Wong Andrew A,Field Deborah,Sun Yu,Barber P Alan,Sabet Arman,Jannes Jim,Jeng Jiann-Shing,Clissold Benjamin,Markus Romesh,Lin Ching-Huang,Lien Li-Ming,Bladin Christopher F,Christensen Søren,Yassi Nawaf,Sharma Gagan,Bivard Andrew,Desmond Patricia M,Yan Bernard,Mitchell Peter J,Thijs Vincent,Carey Leeanne,Meretoja Atte,Davis Stephen M,Donnan Geoffrey A, The New England journal of medicine BACKGROUND:The time to initiate intravenous thrombolysis for acute ischemic stroke is generally limited to within 4.5 hours after the onset of symptoms. Some trials have suggested that the treatment window may be extended in patients who are shown to have ischemic but not yet infarcted brain tissue on imaging. METHODS:We conducted a multicenter, randomized, placebo-controlled trial involving patients with ischemic stroke who had hypoperfused but salvageable regions of brain detected on automated perfusion imaging. The patients were randomly assigned to receive intravenous alteplase or placebo between 4.5 and 9.0 hours after the onset of stroke or on awakening with stroke (if within 9 hours from the midpoint of sleep). The primary outcome was a score of 0 or 1 on the modified Rankin scale, on which scores range from 0 (no symptoms) to 6 (death), at 90 days. The risk ratio for the primary outcome was adjusted for age and clinical severity at baseline. RESULTS:After 225 of the planned 310 patients had been enrolled, the trial was terminated because of a loss of equipoise after the publication of positive results from a previous trial. A total of 113 patients were randomly assigned to the alteplase group and 112 to the placebo group. The primary outcome occurred in 40 patients (35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group (adjusted risk ratio, 1.44; 95% confidence interval [CI], 1.01 to 2.06; P = 0.04). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted risk ratio, 7.22; 95% CI, 0.97 to 53.5; P = 0.05). A secondary ordinal analysis of the distribution of scores on the modified Rankin scale did not show a significant between-group difference in functional improvement at 90 days. CONCLUSIONS:Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group. (Funded by the Australian National Health and Medical Research Council and others; EXTEND ClinicalTrials.gov numbers, NCT00887328 and NCT01580839.). 10.1056/NEJMoa1813046
    Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal. Nepal Gaurav,Yadav Jayant Kumar,Basnet Babin,Shrestha Tirtha Man,Kharel Ghanshyam,Ojha Rajeev BMC neurology BACKGROUND:Intravenous thrombolysis has been recently introduced in Nepal for the management of acute ischemic stroke. Pre-hospital delay is one of the main reasons that hinder thrombolytic therapy. The objective of this study was to evaluate the status of prehospital delay and thrombolysis in Nepal. METHODS:Data were prospectively collected from patients of both genders, age >  18 years who arrived at the emergency department (ED) with symptoms and neuroimaging findings consistent with an ischemic stroke. Patient data were obtained from ED form and standard questionnaires were used to assess factors resulting in prehospital delay. Modified Rankin scale and National Institute of Health stroke scale were used to assess the degree of disability and severity of stroke respectively. RESULTS:A total of 228 patients were enrolled in the study between August 2017 and August 2018. Only 46 (20.17%) patients arrived within the time frame for thrombolysis. Onset at daytime (OR: 4.07; 95% CI: 1.65-10.1; p = 0.001), stroke symptoms facial deviation (OR: 5.03; 95% CI: 2.47 to 10.26; p = 0.000) and speech disturbances (OR: 2.34; 95% CI: 1.06 to 5.1; p = 0.021), identification of stroke (OR: 22.36; 95% CI: 9.42-53.04;p = 0.000), rushing to ED after onset of symptoms (OR: 2.93; 95% CI: 1.5-5.7; p = 0.001), awareness of treatment of stroke (OR: 10.21; 95% CI: 4.8-21.6; p = 0.000), direct presentation (OR: 4.2; 95% CI: 2.09-8.66; p = 0.000), the distance less than 20 km (OR: 7.9; 95% CI: 3.8-16.5; p = 0.000), and education above high school (OR:4.85; 95% CI: 2.2-10.5; p = 0.000) were associated with early arrival. Heavy traffic, income below 1000 USD per annum and diabetes mellitus were associated with delayed arrival to ED. Out of 46 early arrival patients, only 30 patients (13.15%) received tissue plasminogen activator during the study period, while others were deprived because of their inability to afford the treatment cost. CONCLUSION:Community-based intervention to spread awareness, establishing comprehensive stroke centers, training specialists, improving emergency services, establishment of telestroke facilities and encouraging the use of low-cost tenecteplase as an alternative to alteplase can help improve care for stroke patients in Nepal. 10.1186/s12883-019-1378-3
    Management of acute central retinal artery occlusion: Intravenous thrombolysis is feasible and safe. Préterre Cécile,Godeneche Gaelle,Vandamme Xavier,Ronzière Thomas,Lamy Matthias,Breuilly Christophe,Urbanczyk Cédric,Wolff Valérie,Lebranchu Pierre,Sevin-Allouet Mathieu,Guillon Benoit International journal of stroke : official journal of the International Stroke Society Background Although acute central retinal artery occlusion is as a stroke in the carotid territory (retinal artery), its management remains controversial. The aim of this study was to assess the feasibility and safety of intravenous thrombolysis delivered within 6 h of central retinal artery occlusion in French stroke units. Methods We performed a retrospective analysis of patients treated with intravenous alteplase (recombinant tissue-plasminogen activator), based on stroke units thrombolysis registers from June 2005 to June 2015, and we selected those who had acute central retinal artery occlusion. The feasibility was assessed by the ratio of patients that had received intravenous alteplase within 6 h after central retinal artery occlusion onset among those who had been admitted to the same hospital for acute central retinal artery occlusion. All adverse events were documented. Results Thirty patients were included. Visual acuity before treatment was limited to "hand motion", or worse, in 90% of the cases. The mean onset-to-needle time was 273 min. The individuals treated with intravenous alteplase for central retinal artery occlusion represented 10.2% of all of the patients hospitalized for central retinal artery occlusion in 2013 and 2014. We observed one occurrence of major bleeding, a symptomatic intracerebral hemorrhage. Conclusion When applied early on, intravenous thrombolysis appears to be feasible and safe, provided that contraindications are given due consideration. Whether intravenous thrombolysis is more effective than conservative therapy remains to be determined. In order to conduct a well-designed prospective randomized control trial, an organized network should be in place. 10.1177/1747493016687578
    Early Use of Statin in Patients Treated with Alteplase for Acute Ischemic Stroke. Geng Jieli,Song Yeping,Mu Zhihao,Xu Qun,Shi Guowen,Sun Yameng,Chen Ying,Lin Yan,Pan Yuanmei,Yu Lin,Yang Guo-Yuan,Li Yansheng Acta neurochirurgica. Supplement Studies have reported that statin usage before stroke can increase the incidence of intracerebral hemorrhage after thrombolytic treatment. However, whether the administration of statin at an early stage of ischemic stroke increases hemorrhage occurrence is unknown. The aim of this study was to assess the effect of statin on neurological imaging and functional outcomes after intravenous alteplase treatment, within 24 h of acute ischemic stroke attack. A total of 119 consecutive acute ischemic stroke patients treated by intravenous alteplase were recruited, of which 71 patients (59.7 %) were given statin therapy within 24 h of stroke onset. The physiological parameters, including demography, vascular risk factors, and clinical characteristics were recorded. The occurrence of intracerebral hemorrhage (ICH), symptomatic intracerebral hemorrhage (sICH), 90-day functional outcomes, and mortality in the patients were further analyzed. There were 24 occurrences of ICH after alteplase treatment (20.2 %) and there was no difference when patients were treated with statin (p = 0.280). Multivariate logistic regression analysis showed no significant correlation between the administration of statin and the occurrence of ICH (p = 0.230) or sICH (p = 0.949). There was a trend toward better neurological function with higher statin dose. The use of statin in the early stage of ischemic stroke is safe and does not increase the risk of intracerebral hemorrhage after alteplase treatment, suggesting that a clinical trial of early statin treatment on a large scale following thrombolysis is needed for further evaluation. 10.1007/978-3-319-18497-5_47
    Idarucizumab in Dabigatran-Treated Patients with Acute Ischemic Stroke Receiving Alteplase: A Systematic Review of the Available Evidence. Pikija Slaven,Sztriha Laszlo K,Sebastian Mutzenbach J,Golaszewski Stefan M,Sellner Johann CNS drugs BACKGROUND AND PURPOSE:Current guidelines do not recommend the use of intravenous recombinant tissue plasminogen activator in patients with acute ischemic stroke who receive direct oral anticoagulants. While the humanized monoclonal antibody idarucizumab can quickly reverse the anticoagulant effects of the thrombin inhibitor dabigatran, safety data for subsequent tissue plasminogen activator treatment are sparse. Here, we review current knowledge about dabigatran reversal prior to systemic reperfusion treatment in acute ischemic stroke. METHODS:We performed a systematic review of all published cases of intravenous tissue plasminogen activator treatment following the administration of a dabigatran antidote up to June 2017 and added five unpublished cases of our own. We analyzed clinical and radiological outcomes, symptomatic post-thrombolysis intracranial hemorrhage, and other serious systemic bleeding. Additional endpoints were allergic reaction to idarucizumab, and venous thrombosis in the post-acute phase. RESULTS:We identified a total of 21 patients (71% male) with a median age of 76 years (interquartile range 70-84). The median National Institute of Health Stroke Scale score at baseline was 10 (n = 20, interquartile range 5-11) and 18/20 patients (90%) had mild or moderate stroke severity. The time from symptom onset to start of tissue plasminogen activator was 155 min (n = 18, interquartile range 122-214). The outcome was unfavorable in 3/19 patients (16%). There was one fatality as a result of a symptomatic post-thrombolysis intracranial hemorrhage, and two patients experienced an increase in the National Institute of Health Stroke Scale compared with baseline. One patient had a recurrent stroke. No systemic bleeding, venous thrombosis, or allergic reactions were reported. CONCLUSION:Experience with idarucizumab administration prior to tissue plasminogen activator treatment in acute ischemic stroke is limited. Initial clinical experience in less severe stroke syndromes and short time windows seems favorable. Larger cohorts are required to confirm safety, including bleeding complications and the risk of thrombosis. 10.1007/s40263-017-0460-x
    Treatment With Intravenous Alteplase for Acute Ischemic Stroke After Reversal of Dabigatran With Idarucizumab: A Case Study. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses 10.1097/JNN.0000000000000428
    Successful intravenous Alteplase for a centenarian woman with acute ischaemic stroke. He Chaoming,Sun Yanyan,Yan Bo,Chen Haiyun,Zheng Yu,Tang Ying Clinical and experimental pharmacology & physiology We report a case of a 105-year-old woman who was treated with Alteplase for acute ischaemic stroke (AIS). On arrival, this centenarian woman had sudden-onset aphasia and right-sided hemiparesis, her baseline National Institutes of Health Stroke Scale (NIHSS) score was 21. An acute noncontrast brain CT scan showed only mild white matter disease. After assessing the patient's risk-benefit ratio, the patient was administered intravenous Alteplase (0.9 mg/kg) 2.5 hours after symptom onset. Her right hemiparesis and aphasia eased within 24 hours after Alteplase treatment. At discharge, her NIHSS score had decreased to 1, leaving only mild right facial palsy unresolved. Few clinical data are available on centenarian patients with AIS who undergo intravenous thrombolysis. There are no data on what is the best method to use to manage centenarians. Our successful thrombolysis case indicates that biologically young centenarians may profit from thrombolysis, despite the very high age. 10.1111/1440-1681.13067
    Renal Dysfunction and In-Hospital Outcomes in Patients With Acute Ischemic Stroke After Intravenous Thrombolytic Therapy. Rao Zhen-Zhen,Gu Hong-Qiu,Wang Xian-Wei,Xie Xue-Wei,Yang Xin,Wang Chun-Juan,Zhao Xingquan,Xian Ying,Wang Yi-Long,Li Zi-Xiao,Xiao Rui-Ping,Wang Yong-Jun, Journal of the American Heart Association Background The impact of estimated glomerular filtration rate (eGFR) on clinical short-term outcomes after stroke thrombolysis with tissue plasminogen activator remains controversial. Methods and Results We analyzed 18 320 ischemic stroke patients who received intravenous tissue plasminogen activator at participating hospitals in the Chinese Stroke Center Alliance between June 2015 and November 2017. Multivariate logistic regression models were used to evaluate associations between eGFR (<45, 45-59, 60-89, and ≥90 mL/min per 1.73 m) and in-hospital mortality and symptomatic intracerebral hemorrhage, adjusting for patient and hospital characteristics and the hospital clustering effect. Of the 18 320 patients receiving tissue plasminogen activator, 601 (3.3%) had an eGFR <45, 625 (3.4%) had an eGFR 45 to 59, 3679 (20.1%) had an eGFR 60 to 89, and 13 415 (73.2%) had an eGFR ≥90. As compared with eGFR ≥90, eGFR values <45 (6.7% versus 0.9%, adjusted odds ratio, 3.59; 95% CI, 2.18-5.91), 45 to 59 (4.0% versus 0.9%, adjusted odds ratio, 2.00; 95% CI, 1.18-3.38), and 60 to 89 (2.5% versus 0.9%, adjusted odds ratio, 1.67; 95% CI, 1.20-2.34) were independently associated with increased odds of in-hospital mortality. However, there was no statistically significant association between eGFR and symptomatic intracerebral hemorrhage. Conclusions eGFR was associated with an increased risk of in-hospital mortality in acute ischemic stroke patients after treatment with tissue plasminogen activator. eGFR is an important predictor of poststroke short-term death but not of symptomatic intracerebral hemorrhage. 10.1161/JAHA.119.012052
    Digestive and urologic hemorrhage after intravenous thrombolysis for acute ischemic stroke: Data from a Chinese stroke center. Chang Hong,Wang Xiaojuan,Yang Xin,Song Haiqing,Qiao Yuchen,Liu Jia The Journal of international medical research Objective Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is considered the most effective treatment method for AIS; however, it is associated with a risk of hemorrhage. We analyzed the risk factors for digestive and urologic hemorrhage during rt-PA therapy. Methods We retrospectively analyzed patients with AIS who underwent intravenous thrombolysis with rt-PA during a 5-year period in a Chinese stroke center. Data on the demographics, medical history, laboratory test results, and clinical outcomes were collected. Results 338 patients with AIS were eligible and included. Logistic regression multivariate analysis showed that gastric catheter was significantly correlated with digestive hemorrhage, while age and urinary catheter were significantly correlated with urologic hemorrhage. Most hemorrhagic events were associated with catheterization after 1 to 24 hours of rt-PA therapy. Conclusions In summary, gastric and urinary catheters were correlated with digestive and urologic hemorrhage in patients with AIS undergoing rt-PA therapy. Well-designed controlled studies with large samples are required to confirm our findings. 10.1177/0300060516686515
    Intravenous thrombolysis in stroke patients taking novel oral anticoagulants: experience with the low-dose 0.6 mg/kg of recombinant tissue-type plasminogen activator. Case reports. Plastino Massimiliano,Bosco Domenico,Giofrè Laura,Cristiano Dario,Galati Franco,Postorino Paolo,Consoli Arturo,Fava Antonietta,Consoli Domenico Journal of the neurological sciences 10.1016/j.jns.2018.07.003
    Intravenous Thrombolysis in Acute Ischemic Stroke After Idarucizumab Reversal of Dabigatran Effect: Analysis of the Cases From Taiwan. Fang Chen-Wen,Tsai Yi-Te,Chou Ping-Chen,Chen Hsi-Ming,Lu Chien-Ming,Tsao Chen-Rong,Chen Chih-Lin,Sun Mu-Chien,Shih Yu-Song,Hsieh Cheng-Yang,Chen Lu-An,Chen Po-Lin,Yeh Jung-Tze,Li Yi-Heng Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND:Asians with atrial fibrillation carry a higher risk of ischemic stroke than non-Asians even under treatment of nonvitamin K antagonist oral anticoagulants. The purpose of the study was to observe the feasibility of intravenous thrombolytic therapy after administering a reversal agent, idarucizumab, in dabigatran-treated patients with acute ischemic stroke in Taiwan. METHODS:Dabigatran-treated patients with acute ischemic stroke who received intravenous recombinant tissue plasminogen activator (rt-PA) after idarucizumab reversal were enrolled in the retrospective nationwide study. The clinical data, treatment course, and outcomes were recorded. Stroke severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) score. Any intracerebral hemorrhage (ICH) after rt-PA was detected by neuroimaging studies. RESULTS:Ten dabigatran-treated patients (6 men, mean age 71.10 ± 7.96 years) with acute ischemic stroke were included. Before stroke, the mean CHADS-VASc score was 4.50 ± 1.57 and 8 patients (80%) received dabigatran 110 mg twice daily. All patients were treated with 5 g idarucizumab, following which the activated partial thromboplastin time normalized. Intravenous rt-PA (mean dose .78 mg/kg) was initiated a mean time of 11.11 minutes after idarucizumab infusion. The NIHSS score improved significantly after thrombolysis (16.0 ± 6.67 at admission to 9.38 ± 4.75 at discharge, P = .016). ICH developed in 3 patients (30%). Two of them were asymptomatic and 1 patient suffered from symptomatic ICH leading to mortality. CONCLUSION:Our data reconfirmed the feasibility of intravenous rt-PA for Asian stroke patients after reversal of dabigatran effect with idarucizumab. 10.1016/j.jstrokecerebrovasdis.2018.11.029
    Correlation of Changes in Leukocytes Levels 24 Hours after Intravenous Thrombolysis With Prognosis in Patients With Acute Ischemic Stroke. Chen Jie,Zhang Zengrui,Chen Luyun,Feng Xiaowen,Hu Wangwang,Ge Wanqian,Li Xianmei,Jin Pingping,Shao Bei Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association OBJECTIVE:Leukocytes play a crucial role in inflammation and immune response. This study aims to demonstrate the value of changes in leukocytes levels 24 hours after intravenous thrombolysis to predict prognosis in acute ischemic stroke (AIS). METHODS:From Jan 2016 to Oct 2017, the patients who suffered AIS to our center within 4.5 hours of symptom onset were all treated with recombinant tissue-type plasminogen activator. Data from 213 AIS patients were analyzed. Patients were divided into 4 groups: persistent leukocytosis (PL), transient leukocytosis (TL), leukocytosis 24 hours (L24H) and no leukocytosis (NL). By comparison, the factors with statistically significant were selected in pairwise multiple comparisons. Good clinical outcome was defined as the Modified Rankin Scale score of 2 or lower. Multivariate logistic regression was used to assess the association of the indicators with clinical outcome. RESULTS:By pairwise multiple comparisons, PL and L24H had higher baseline National Institutes of Health Stroke Scale (NIHSS) score than NL and were likely to lead poor clinical outcomes. TL had a better prognosis than L24H. As the results of multivariable analyses shown, PL and L24H were risk factors to poor functional outcomes (odds ratio [OR] = 2.668, 95% confidence interval [CI] = 1.139-6.249, P = .024; OR = 6.648, 95%CI = 2.048-21.584, P = .002). CONCLUSION:Persistent leukocytosis and leukocytosis 24 hours both had higher baseline NIHSS scores, more serious stroke and were more likely to lead to unfavorable outcome. Therefore, changes in leukocytes levels 24 hours after intravenous thrombolysis could be predicted the short-term functional outcome of AIS patients. 10.1016/j.jstrokecerebrovasdis.2018.06.014
    Thrombolytic Therapy of Acute Ischemic Stroke during Early Pregnancy. Landais Anne,Chaumont Hugo,Dellis Rachel Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association Thrombolytic treatment (recombinant tissue plasminogen activator [rt-PA]) has established efficacy in acute ischemic stroke, but pregnancy has been an exclusion criterion for all clinical trials that validated alteplase in acute stroke, so our knowledge about its use in this condition is limited. Herein we report the successful use of intravenous rt-PA thrombolysis, uncomplicated by neither hemorrhage development nor other complication in a woman who was 13 weeks pregnant with acute ischemic stroke. The brain magnetic resonance imaging diffusion-weighted sequences showed increased signal in the territory of the left middle cerebral artery. Our case had a good maternal and fetal outcome, and advocates that the use of thrombolytics may be feasible in pregnant patients and help to avoid residual neurologic deficits. A summary of published cases in the early aspect of pregnancy and outcomes is presented. Risks and benefits to mother and fetus must be weighted up, but intravenous thrombolysis must not be considered as an absolute contraindication, even in early pregnancy. 10.1016/j.jstrokecerebrovasdis.2016.12.010
    Tissue Plasminogen Activator Prescription and Administration Errors within a Regional Stroke System. Chung Lee S,Tkach Aleksander,Lingenfelter Erin M,Dehoney Sarah B,Rollo Jeannie,de Havenon Adam,DeWitt L Dana,Grantz Matthew R,Wang Haimei,Wold Jana J,Hannon Peter M,Weathered Natalie R,Majersik Jennifer J Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND:Intravenous (IV) tissue plasminogen activator (tPA) utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer. METHODS:Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010-11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and for association with outcomes. RESULTS:We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at the CSC, and 68% at CHs (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, P < .001), the most common being incorrect dosage for body weight (19% CSC, 55% CH, P < .001). Of the 27 overdoses, there were 3 deaths due to systemic hemorrhage or ICH. Nonetheless, outcomes (parenchymal hematoma, mortality, modified Rankin Scale score) did not differ between CSC and CH patients nor between those with and without errors. CONCLUSION:Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors. 10.1016/j.jstrokecerebrovasdis.2015.11.014
    Treatment With Intravenous Alteplase for Acute Ischemic Stroke After Reversal of Dabigatran With Idarucizumab: A Case Study. Jala Sheila,O'Brien Elizabeth The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses Treatment options for anticoagulated patients presenting with ischemic stroke are limited. Off-label use of idarucizumab to rapidly reverse the anticoagulant effect of dabigatran may ensure eligibility for thrombolytic therapy with alteplase. This case describes a 77-year-old white male who presented to the hospital 89 minutes after sudden onset of right-sided hemiparesis, dysarthria, and facial palsy. Significant history included atrial fibrillation and previous right-sided cortical stroke. Medication reconciliation revealed he was taking dabigatran 150 mg twice a day, with the last dose being 179 minutes before presentation. Neuroimaging revealed no new infarct or hemorrhage, and 60 minutes after arrival, a decision was made to give idarucizumab to reverse the anticoagulant effect of dabigatran. In the absence of any contraindication, he was then treated with intravenous alteplase and idarucizumab. No adverse outcomes were noted, and at discharge, his new stroke symptoms were completely resolved. 10.1097/JNN.0000000000000412
    A Decade of Improvement in Door-to-Needle Time Among Acute Ischemic Stroke Patients, 2008 to 2017. Tong Xin,Wiltz Jennifer L,George Mary G,Odom Erika C,Coleman King Sallyann M,Chang Tiffany,Yin Xiaoping, ,Merritt Robert K Circulation. Cardiovascular quality and outcomes BACKGROUND:The clinical benefit of intravenous (IV) alteplase in acute ischemic stroke is time dependent. We assessed the overall temporal changes in door-to-needle (DTN) time and examine the factors associated with DTN time ≤60 and ≤45 minutes. METHODS AND RESULTS:A total of 496 336 acute ischemic stroke admissions were identified in the Paul Coverdell National Acute Stroke Program from 2008 to 2017. We used generalized estimating equations models to examine the factors associated with DTN time ≤60 and ≤45 minutes, and calculated adjusted odds ratios and 95% CI. Between 2008 and 2017, the percentage of acute ischemic stroke patients who received IV alteplase including those transferred, increased from 6.4% to 15.3%. After excluding those who received IV alteplase at an outside hospital, a total of 39 737 (8%) acute ischemic stroke patients received IV alteplase within 4.5 hours of the time the patient last known to be well. Significant increases were seen in DTN time ≤60 minutes (26.4% in 2008 to 66.2% in 2017, P<0.001), as well as DTN time ≤45 minutes (10.7% in 2008 to 40.5% in 2017, P<0.001). Patients aged 55 to 84 years were more likely to receive IV alteplase within 60 minutes, while those aged 55 to 74 years were more likely to receive IV alteplase within 45 minutes, as compared with those aged 18 to 54 years. Arrival by emergency medical service, and patients with severe stroke were more likely to receive IV alteplase within 60 and 45 minutes. Conversely, women, black patients as compared with white, and patients with a medical history of diseases associated with stroke were less likely to receive DTN time ≤60 or 45 minutes. CONCLUSIONS:Rapid improvements in DTN time were observed in the Paul Coverdell National Acute Stroke Program; however, opportunities to reduce disparities remain. 10.1161/CIRCOUTCOMES.118.004981
    YAMATO Study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy). Aoki Junya,Kimura Kazumi,Morita Naomi,Harada Masafumi,Metoki Norifumi,Tateishi Yohei,Todo Kenichi,Yamagami Hiroshi,Hayashi Kouji,Terasawa Yuka,Fujita Koji,Yamamoto Nobuaki,Deguchi Ichiro,Tanahashi Norio,Inoue Takeshi,Iwanaga Takeshi,Kaneko Nobuyuki,Mitsumura Hidetaka,Iguchi Yasuyuki,Ueno Yasushi,Kuramoto Yoji,Ogata Toshiyasu,Fujimoto Shigeru,Yokoyama Mutsumi,Nagahiro Shinji, Stroke BACKGROUND AND PURPOSE:We investigated whether administration of edaravone, a free radical scavenger, before or during tissue-type plasminogen activator (tPA) can enhance early recanalization in a major arterial occlusion. METHODS:The YAMATO study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy) is an investigator-initiated, multicenter (17 hospitals in Japan), prospective, randomized, and open-label study. Patients with stroke secondary to occlusion of the M1 or M2 portion of the middle cerebral artery and within 4.5 hours of the onset were studied. The subjects were randomly allocated to the early group (intravenous edaravone [30 mg] was started before or during tPA) and the late group (edaravone was started after tPA and the assessment of early recanalization). RESULTS:One-hundred sixty-five patients (96 men; median age [interquartile range], of 78 [69-85] years) were randomized 1:1 to either the early group (82 patients) or the late group (83 patients). Primary outcome, defined as an early recanalization 1.5 hour after tPA, was observed in 53% of the early group and in 53% of the late group (=1.000). About secondary outcomes, the rate of significant recanalization of ≥50% was not different between the 2 groups (28% versus 34%; =0.393). The symptomatic intracerebral hemorrhage has occurred in 4 patients (5%) in the early group and in 2 patients (2%) in the late group (=0.443). The favorable outcome (modified Rankin Scale score of 0-2) at 3 months was also similar between the groups (53% versus 57%; =0.738). CONCLUSIONS:The timing of edaravone infusion does not affect the rate of early recanalization, symptomatic intracerebral hemorrhage, or favorable outcome after tPA therapy. CLINICAL TRIAL REGISTRATION:URL: http://www.umin.ac.jp/ctr/index-j.htm. Unique identifier: UMIN000006330. 10.1161/STROKEAHA.116.015042
    Impaired fasting glucose is associated with unfavorable outcome in ischemic stroke patients treated with intravenous alteplase. Osei E,Fonville S,Zandbergen A A M,Koudstaal P J,Dippel D W J,den Hertog H M Journal of neurology OBJECTIVES:Hyperglycemia on admission and diabetes mellitus type II are associated with unfavorable outcome in stroke patients. We studied whether impaired fasting glucose (IFG) is associated with unfavorable outcome in ischemic stroke patients treated with intravenous alteplase as well and if IFG is a stronger prognostic factor than hyperglycemia on admission. METHODS:We studied 220 consecutive patients with ischemic stroke treated with intravenous alteplase. In all nondiabetic patients, fasting glucose was determined on day 2-5. IFG was defined as fasting glucose level of ≥ 5.6 mmol/L, hyperglycemia on admission as glucose levels ≥ 7.9 mmol/L. The primary effect measure was the adjusted common odds ratio (acOR) for a shift in the direction of worse outcome on the modified Rankin Scale at 3 months, estimated with ordinal logistic regression, and adjusted for common prognostic factors. RESULTS:The fasting glucose levels were available in 194 and admission glucose levels in 215 patients. Sixty-three (32.5%) had IFG, 58 (27%) hyperglycemia on admission and 32 (14.6%) pre-existent diabetes. Patients with IFG showed a shift towards worse functional outcome compared with patients with normal fasting glucose levels (acOR 2.77; 95% CI 1.54-4.97), which was stronger than hyperglycemia on admission (acOR 1.75; 95% CI 0.91-3.4). CONCLUSIONS:IFG is associated with unfavorable outcome after treatment with intravenous alteplase for acute ischemic stroke. IFG predicts unfavorable outcome better than hyperglycemia on admission. 10.1007/s00415-018-8866-z
    Analysis of related factors of orolingual angioedema after rt-PA intravenous thrombolytic therapy. Wang Y-X,Li Y-Q,Chen Y,Zhang C-H,Dong Z,Wang Z,Zhao S-N,Li C-H,Zhang P-L European review for medical and pharmacological sciences OBJECTIVE:Orolingual angioedema (OA) is a rare clinical complication with a potentially fatal risk that occurs after the intravenous application of alteplase (rt-PA) in patients with acute ischemic stroke. The purpose of this work is to investigate the related factors of OA in patients with acute ischemic stroke after the administration of intravenous thrombolytic therapy, to improve the predictive ability of OA during intravenous thrombolytic therapy, and to reduce the prevalence of complications. PATIENTS AND METHODS:We recruited 1223 cases of patients with acute ischemic stroke that were treated in the Department of Neurology No. 4 of the Tianjin Huanhu Hospital from June 2014 to April 2015. The clinical manifestations of rt-PA related OA were recorded, the clinical prevalence was counted, related factors of OA after intravenous thrombolytic therapy were analyzed, and the risk assessment of rt-PA related OA was conducted. RESULTS:14 cases of patients developed OA, with a prevalence rate of 1.14%. Among them, 5 had a history of urticaria, 4 of drug allergy, and 3 of food allergy. Among the 14 cases of patients, 10 developed OA in the process of intravenous thrombolysis and 4 after intravenous thrombolysis, 12 showed lip edema, 9 showed extensive swelling of tongue, 3 showed swelling of lateral tongue, 3 were complicated by respiratory distress, 10 showed infarction in the middle cerebral artery territory, and 6 had previously been given oral ACEI drugs. CONCLUSIONS:Orolingual angioedema is a rare complication that occurs after rt-PA intravenous thrombolytic therapy; when serious, it may endanger a patient's life. If patients take an oral hypotension such as ACEI drugs before the onset of OA, they have a history of allergies, or the lesion is an infraction in the dominated area of the middle cerebral artery, the risk of OA after rt-PA intravenous thrombolytic therapy will be increased. The prevalence of OA should be monitored during the rt-PA intravenous thrombolytic therapy process; timely detection and early intervention should be conducted, which can avoid serious adverse consequences. 10.26355/eurrev_201803_14496
    24/7 Neurocritical Care Nurse Practitioner Coverage Reduced Door-to-Needle Time in Stroke Patients Treated with Tissue Plasminogen Activator. Moran Jennifer L,Nakagawa Kazuma,Asai Susan M,Koenig Matthew A Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND:Stroke centers with limited on-site neurovascular physician coverage may experience delays in acute stroke treatment. We sought to assess the impact of providing 24/7 neurocritical care acute care nurse practitioner (ACNP) "stroke code" first responder coverage on treatment delays in acute stroke patients who received tissue plasminogen activator (tPA). METHODS:Consecutive acute ischemic stroke patients treated with intravenous tPA at a primary stroke center on Oahu between 2009 and 2014were retrospectively studied. 24/7 ACNP stroke code coverage (intervention) was introduced on July 1, 2011. The tPA utilization, door-to-needle (DTN) time, imaging-to-needle (ITN) time, and independent ambulation at hospital discharge were compared between the preintervention period (24 months) and the postintervention period (33 months). RESULTS:We studied 166 stroke code patients who were treated with intravenous tPA, 44 of whom were treated during the preintervention period and 122 of whom were treated during the postintervention period. After the intervention, the median DTN time was reduced from 53 minutes (interquartile range [IQR] 45-73) to 45 minutes (IQR 35-58) (P = .001), and the median ITN time was reduced from 36 minutes (IQR 28-64) to 21 minutes (IQR 16-31) (P < .0001). Compliance with the 60-minute target DTN improved from 61.4% (27 of 44 patients) in the preintervention period to 81.2% (99 of 122 patients) in the postintervention period (P = .004). The tPA treatment rates were similar between the preintervention and postintervention periods (P = .60). CONCLUSIONS:Addition of 24/7 on-site neurocritical care ACNP first responder coverage for acute stroke code significantly reduced the DTN time among acute stroke patients treated with tPA. 10.1016/j.jstrokecerebrovasdis.2016.01.033
    Use of Strategies to Improve Door-to-Needle Times With Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice: Findings from Target: Stroke. Xian Ying,Xu Haolin,Lytle Barbara,Blevins Jason,Peterson Eric D,Hernandez Adrian F,Smith Eric E,Saver Jeffrey L,Messé Steven R,Paulsen Mary,Suter Robert E,Reeves Mathew J,Jauch Edward C,Schwamm Lee H,Fonarow Gregg C Circulation. Cardiovascular quality and outcomes BACKGROUND:The implementation of Target: Stroke Phase I, the first stage of the American Heart Association's national quality improvement initiative to accelerate door-to-needle (DTN) times, was associated with an average 15-minute reduction in DTN times. TARGET:Stroke phase II was launched in April 2014 with a goal of promoting further reduction in treatment times for tissue-type plasminogen activator (tPA) administration. METHODS AND RESULTS:We conducted a second survey of Get With The Guidelines-Stroke hospitals regarding strategies used to reduce delays after Target: Stroke and quantify their association with DTN times. A total of 16 901 ischemic stroke patients were treated with intravenous tPA within 4.5 hours of symptom onset from 888 surveyed hospitals between June 2014 and April 2015. The patient-level median DTN time was 56 minutes (interquartile range, 42-75), with 59.3% of patients receiving intravenous tPA within 60 minutes and 30.4% within 45 minutes after hospital arrival. Most hospitals reported routinely using a majority of Target: Stroke key practice strategies, although direct transport of patients to computed tomographic/magenetic resonance imaging scanner, premix of tPA ahead of time, initiation of tPA in brain imaging suite, and prompt data feedback to emergency medical services providers were used less frequently. Overall, we identified 16 strategies associated with significant reductions in DTN times. Combined, a total of 20 minutes (95% confidence intervals 15-25 minutes) could be saved if all strategies were implemented. CONCLUSIONS:Get With The Guidelines-Stroke hospitals have initiated a majority of Target: Stroke-recommended strategies to reduce DTN times in acute ischemic stroke. Nevertheless, certain strategies were infrequently practiced and represent a potential immediate target for further improvements. 10.1161/CIRCOUTCOMES.116.003227
    Favourable renal outcomes after intravenous thrombolytic therapy for acute ischemic stroke: Clinical implication of kidney-brain axis. Chang Teng-Hsiang,Chiu Ping-Fang,Tsai Chun-Chieh,Chang Chin-Hua,Wu Chia-Lin,Kor Chew-Teng,Li Jhao-Rong,Kuo Cheng-Ling,Huang Ching-Shan,Chu Cheng-Chung,Lin Chih-Ming,Chang Chia-Chu Nephrology (Carlton, Vic.) AIM:Recombinant tissue plasminogen activator (rt-PA) administration is the most prevalent treatment for acute ischemic within golden time. However, the effects of rt-PA on the kidney function in such patients remain unknown. This study determined long-term renal outcomes in patients with acute ischemic stroke receiving systemic rt-PA. METHODS:We enroled patients who were hospitalized for acute ischemic stroke from January 2001 to January 2017. We applied 1:2 propensity score matching to eliminate various confounding variables. We defined surrogate renal outcomes as declining of estimated glomerular filtration rate (eGFR) greater than 30% and 50%, and chronic kidney disease (CKD) with eGFR less than 60 mL/min. We then compared the 1-year eGFR with paired t-test in patients treated with or without rt-PA. RESULTS:Overall, 343 of 1739 patients received rt-PA within golden time. After 1:2 propensity score matching, their baseline characteristics were grouped as treated with rt-PA (n = 235) or not (n = 394). rt-PA-treated patients exhibited slower renal progression, including the risk of eGFR declining greater than 30% (hazard ratio (HR), 0.72; P = 0.03), risk of declining eGFR greater than 50% (HR, 0.63; P = 0.046) and risk of CKD (HR, 0.61; P = 0.005). After 1-year cohort, the rt-PA group exhibited an improved renal outcome by the paired t-test (propensity match: ΔGFR = 9.1 (95% confidence interval: 6.3, 11.8), P < 0.001 in rt-PA group; ΔGFR = -1.1 (95% confidence interval: -2.9, 0.7), P = 0.23 in non-rt-PA group). In patients with eGFR less than 45 mL/min (n = 34), intracerebral haemorrhage was not reported. CONCLUSION:Patients receiving rt-PA for acute ischemic stroke exhibit favourable renal outcomes, and no increased incidence of intracerebral haemorrhage occurs in rt-PA patients with advanced CKD. 10.1111/nep.13516
    Early changes in fibrinogen after administration of alteplase are associated with the short-term efficacy of thrombolysis. Lu Tao,Xian Wenbiao,Liang Jiahui,Yang Hong,Weng Baohui Medicine The authors aimed to determine whether early changes in fibrinogen were associated with the efficacy of intravenous thrombolysis at 24 hours after alteplase infusion. The authors retrospectively reviewed a consecutive series of 56 patients with acute ischemic stroke treated with alteplase in the clinical database. The fibrinogen levels were monitored at the first and fourth hours after alteplase infusion. Additionally, the National Institutes of Health Stroke Scale (NIHSS) scores were recorded to define the short-term efficacy of intravenous thrombolysis before and 24 hours after alteplase infusion. The patients were distributed into amelioration, deterioration, and inefficiency groups according the short-term efficacy of intravenous thrombolysis. One-way ANOVA and post hoc analysis were used to compare the differences in the clinical characteristics among these groups. The relationships among changes in the fibrinogen levels, other potential risk factors, and NIHSS scores were examined using logistic regression analysis. Fifty-two patients (mean age, 65.71 ± 11.04 years; male, 57.7%) were finally enrolled in the study. The median NIHSS of these patients was 11 (range, 2-23), and the mean time from symptom onset to thrombolysis was 187.17 ± 67.53 minutes. The frequency of hypertension in the deterioration group was significantly higher than that in the inefficiency group (P = .01). Changes in the fibrinogen level were more significant in the amelioration group than in the other groups (P < .05). Logistic regression analysis revealed that changes in the fibrinogen levels between the first and fourth hours were positively associated with the short-term efficacy of alteplase infusion (odds ratio, 3.98; 95% confidence interval, 1.56-10.16; P = .004). Early changes in fibrinogen levels may be a potential predictor for the short-term efficacy of alteplase treatment in acute ischemic stroke. Additionally, these changes may be helpful for determining the short-term efficacy of alteplase treatment and early therapeutic strategies in clinical practice. 10.1097/MD.0000000000010241
    The Effect of Age and Sex on Clinical Outcome after Intravenous Recombinant Tissue Plasminogen Activator Treatment in Patients with Acute Ischemic Stroke. Buijs Julie E,Uyttenboogaart Maarten,Brouns Raf,de Keyser Jacques,Kamphuisen Pieter Willem,Luijckx Gert-Jan Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association BACKGROUND:There are conflicting results regarding the effect of intravenous (IV) recombinant tissue plasminogen activator (rtPA) stroke treatment between men and women. Studies evaluating the impact of sex differences on functional outcome in relation to different age groups are nonexistent. AIM:The objective of the study is to examine the influence of sex differences in relation to age on the prognosis after IV rtPA treatment in acute stroke patients. METHODS:In this cohort study, 887 patients with acute ischemic stroke were treated with rtPA. Functional outcome after 3 months was determined with the modified Rankin Scale (mRS). Good outcome was defined as an mRS score of 2 or lower. Age was stratified in decades (41-50, 51-60, 61-70, 71-80, and >80 years). Multivariable analyses were performed with adjustment for age, sex, stroke severity (National Institutes of Health Stroke Scale [NIHSS]), and stroke subtype (Trial of Org 10172 in Acute Stroke Treatment). RESULTS:Fifty-five percent of the patients were men. The mean age was 67.4 (men) and 72.0 (women) years. Fifty-six percent of the men and 45% of the women had a favorable outcome (P = .001). After adjustment for NIHSS score and stroke subtype, the women had a better outcome in the age group 51-60 years compared with men (odds ratio [OR] .38, 95% confidence interval [CI] .15-.96). In the age group >80 years, men had a better outcome than women (OR 2.69, 95% CI 1.21-5.96). There were no significant differences in the other age groups. CONCLUSION:Men and women have different prognoses after IV rtPA treatment for acute ischemic stroke, which also depends on age. Women in middle age appear to have a better outcome than men, whereas at a more advanced age men appear to have a better outcome than women. 10.1016/j.jstrokecerebrovasdis.2015.09.035
    Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature. Ryman Klayton M,Pace Wilson D,Smith Shawn,Fontaine Gabriel V Pharmacotherapy Acute ischemic stroke (AIS) during pregnancy is a rare but serious complication. Intravenous alteplase is the only medication approved for hyperacute treatment of AIS; however, it has not been evaluated prospectively in pregnancy. Pregnancy was an exclusion criterion in prospective AIS studies and was only recently removed as a relative contraindication in the 2018 American Heart Association/American Stroke Association Stroke guidelines. Due to the exclusion of pregnant women from randomized controlled trials, the safety of fibrinolytic therapy in pregnant patients is not well established. In this review, we report the use of intravenous alteplase for AIS in two pregnant patients, with temporally associated clinical improvement and without complications to either the mother or fetus. Additionally, we summarize a systematic review of the literature for both intravenous and intra-arterial alteplase use for AIS in pregnant patients. A total of 31 cases met inclusion criteria for this review of assessment of safety and efficacy of alteplase use in pregnancy. Existing case reports and guidelines support the use of alteplase for AIS in pregnant patients without contraindications. 10.1002/phar.2278
    Effects of edaravone, the free radical scavenger, on outcomes in acute cerebral infarction patients treated with ultra-early thrombolysis of recombinant tissue plasminogen activator. Lee Xian-Ru,Xiang Gui-Ling Clinical neurology and neurosurgery OBJECTIVES:Edaravone, a free radical scavenger, alleviates blood-brain barrier disruption in conjunction with suppression of the inflammatory reaction in acute cerebral infarction. Thrombolysis with recombinant tissue plasminogen activator (rtPA) is an established therapy for acute cerebral infarction patients. The purpose of this study was to assess the effects of edaravone on outcomes in acute cerebral infarction patients treated with ultra-early thrombolysis of iv-rt-PA. PATIENTS AND METHODS:We conducted a retrospective cohort study using the database of Ningbo First Hospital. We identified patients who were admitted with a primary diagnosis of acute cerebral infarction and treated with intravenous rtPA(iv-rtPA) within 3 h of symptom onset from March 1st in 2014 to October 31st in 2016.Thenceforth,the patients were divided into 2 groups by treatment with(edaravone group) or without edaravone(non-edaravone group). Glasgow Coma Scale (GCS) scores and mRS score at admission were used. Clinical background, risk factors for acute cerebral infarction hemorrhagic transformation, 7-day mortality, recanalization rate, bleeding complications and blood rheology indexes were collected. We also collected the following factors: National Institutes of Health Stroke Scale scores, barthel index. RESULTS:136 patients treated without edaravone during hospitalization were selected in non-edaravone group while edaravone group included 132 patients treated with edaravone during hospitalization. The patient baseline distributions were well balanced between non-edaravone group and edaravone group. The rate of hemorrhagic transformation in non-edaravone group was higher than that in edaravone group (P < 0.05). The NIHSS scores 7 days and 14 days after symptom onset were higher in non-edaravone group than in edaravone group (both P < 0.05). Edaravone group showed a higher recanalization rate and a lower bleeding complications rate at discharge than the non-edaravone group (both P < 0.05). The differences of all the blood rheology indexes between the two groups were statistically significant (all P < 0.05). CONCLUSIONS:Edaravone may improve outcomes of acute cerebral infarction patients treated with ultra-early thrombolysis of iv-rt-PA. 10.1016/j.clineuro.2018.02.026
    Streamlining the Process for Intravenous Tissue Plasminogen Activator. Lawrence Erin,Merbach Dawn,Thorpe Sherry,Llinas Rafael H,Marsh Elisabeth B The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses BACKGROUND:For ischemic stroke, the chance of improved recovery is directly impacted by length of time from symptom onset to administration of intravenous tissue plasminogen activator (IV tPA). Despite the importance of rapid treatment, stroke centers struggle with achieving consistent door-to-needle times of less than 60 minutes. METHODS:We implemented a change in our response to the acute stroke patient by adding a dedicated stroke nurse and a nursing flow sheet focused on critical benchmarks before treatment. We collected data on patients treated with IV tPA preintervention and postintervention to determine whether our process increased the number of patients receiving tPA in less than 60 minutes. One hundred thirty-eight patients (n = 78 pre and 60 post) treated between 2009 and 2013 were included. Student t tests and χ tests were used to compare door-to-needle times preintervention and postintervention. RESULTS:By implementing this new approach, the mean time to treatment decreased from 82 to 78 minutes (P = .583). The percentage of patients successfully treated within 60 minutes of arrival improved from 28% to 52% (P = .005). Stroke severity and need for additional imaging were associated with increased time to treatment. CONCLUSION:The use of a stroke nurse and a nursing flow sheet as part of the acute stroke assessment significantly increases the proportion of patients treated with IV tPA within 60 minutes from hospital arrival. 10.1097/JNN.0000000000000337
    Target Door-to-Needle Time for Tissue Plasminogen Activator Treatment with Magnetic Resonance Imaging Screening Can Be Reduced to 45 min. Sablot Denis,Ion Ioana,Khlifa Khaled,Farouil Geoffroy,Leibinger Franck,Gaillard Nicolas,Laverdure Alexandre,Bensalah Zoubir Mourad,Mas Julie,Fadat Bénédicte,Smadja Philippe,Ferraro-Allou Adélaïde,Bonnec Jean-Marie,Olivier Nadège,Dutray Anaïs,Tardieu Maxime,Dumitrana Adrian,Guibal Aymeric,Jurici Snejana,Bertrand Jean-Louis,Allou Thibaut,Arquizan Caroline,Bonafe Alain Cerebrovascular diseases (Basel, Switzerland) OBJECTIVE:The purpose of this study was to demonstrate that the median door-to-needle (DTN) time for intravenous tissue plasminogen activator (tPA) treatment can be reduced to 45 min in a primary stroke centre with MRI-based screening for acute ischaemic stroke (AIS). METHODS:From February 2015 to February 2017, the stroke unit of Perpignan general hospital, France, implemented a quality-improvement (QI) process. During this period, patients who received tPA within 4.5 h after AIS onset were included in the QI cohort. Their clinical characteristics and timing metrics were compared each semester and also with those of 135 consecutive patients with AIS treated by tPA during the 1-year pre-QI period (pre-QI cohort). RESULTS:In the QI cohort, 274 patients (92.5%) underwent MRI screening. While the demographic and baseline characteristics were not significantly different between cohorts, the median DTN time was significantly lower in the QI than in the pre-QI cohort (52 vs. 84 min; p < 0.00001). Within the QI cohort, the median DTN time for each semester decreased from 65 to 44 min (p < 0.00001) and the proportion of treated patients with a DTN time ≤45 min increased from 25 to 58.9% (p < 0.0001). Overall, DTN time improvement was associated with a better outcome at 3 months (patients with a modified Rankin Scale score between 0 and 2: 61.8% in the QI vs. 39.3% in the pre-QI cohort; p < 0.0001). CONCLUSIONS:A QI process can reduce the DTN within 45 min with MRI as a screening tool. 10.1159/000489568
    The Impact of Discrepancy between Measured versus Stated Weight on Hemorrhagic Transformation and Clinical Outcomes after Intravenous Alteplase Thrombolysis. Shin Dong Hoon,Kang Min-Ju,Kim Jin Wook,Shin Dong-Jin,Park Hyeon-Mi,Sung Young Hee,Kim Eung Yeop Cerebrovascular diseases (Basel, Switzerland) BACKGROUND:An accurate measurement of patient weight is important in determining the dosage for intravenous alteplase thrombolysis. In most emergency rooms, however, weight is not measured. We investigated the difference between stated and measured weight and its effect on hemorrhagic transformation and clinical outcomes. METHODS:We enrolled 128 consecutive patients who had hyperacute stroke and were treated by alteplase. Alteplase dose was calculated using the weight provided by patient or guardian/caregiver, and the actual weight was measured after administration. Patients were classified into 2 groups: overused group (stated weight >measured weight) and underused group (measured weight ≥stated weight). The prevalence of hemorrhagic transformation on follow-up, determined by gradient-recalled echo MRI or non-enhanced CT, was compared between the 2 groups. The predictors for hemorrhage with progression, defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) by a value of 4 or more accompanied by hemorrhage, were determined using multivariable logistic regression analysis and included the overused or underused alteplase and baseline clinical and laboratory findings. RESULTS:Sixty-six (51.6%) of 128 patients were in the underused group and 62 patients (48.4%) in the overused group. The median difference between the stated and measured weights was 1.5 (interquartile range 0.56-3.81) kg, with the largest difference being 25.6 kg. Although there were no significant difference in baseline clinical and laboratory findings between the 2 groups, the overused group showed a significantly higher prevalence of hemorrhagic transformation (p = 0.012) and hemorrhage with progression (p = 0.025). The multivariable logistic regression analysis demonstrated that overused alteplase (OR 7.26; 95% CI 1.24-42.45; p = 0.028), baseline glucose (>144 mg/dL; OR 5.03; 95% CI 1.00-25.26; p = 0.050), and initial NIHSS (OR 1.13 per 1-point NIHSS increase; 95% CI 1.00-1.27; p = 0.047) in model 1 that use alteplase overdose as a categorical variable and overused alteplase (OR 1.67 1-mg increase; 95% CI 1.05-2.66; p = 0.027) in model 2 that use an overused alteplase dose as numerical variable were significant predictors for hemorrhage with progression. CONCLUSION:More alteplase usage than actual weight led to higher hemorrhagic transformation. As one of the predictors for clinical deterioration, it is important to administrate alteplase based on an accurately measured weight. 10.1159/000479941
    Administration of tissue plasminogen activator without coagulation results in a Chinese population. Qin Xiaoming,Zhao Songyao,Yin Liujie,Dou Hailing,Chen Jie,Wang Yifan,Li Mingzhe,Chen Ruifang,Fu Jing,Liu Wei,Liu Xin,Yang Gaiqing,Wang Runqing,Jia Xinzhou,Bu Shufang,Ma Dongpu,Wang Baoyu,Li Shize Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology Routine coagulation test before intravenous tissue plasminogen activator (tPA) use increases the door to needle time (DNT). We sought to evaluate the safety of tPA use without coagulation results and its impact on prognosis. In our stroke registry, tPA was delivered with coagulation results from December 2015 to April 2016 and without coagulation results from May 2016 to December 2016. Differences of demographics, clinical characteristic, and prognosis between these two groups were analyzed. In addition, logistic regression analysis was conducted to identify predictors for DNT of over 60 min. A total of 201 stroke patients were included in the final analysis. Of these, 81 patients received tPA with coagulation results and 120 patients without coagulation results. Only one (0.8%) patient with abnormal coagulation results met the exclusion criteria of tPA use in patients without coagulation results. The difference of DNT between groups with (mean, 61.7 min) and without (mean, 41.9 min) coagulation results was significant (P = 0.00). The group without coagulation results had a higher rate of favorable 90-day outcome (74.2 vs 70.4%) and lower rates of symptomatic intracranial hemorrhage/nonintracranial hemorrhage (4.9 and 22.2% vs 1.7 and 19.2%) than the group with coagulation results did; these differences were not statistically significant. In multivariate analysis, only tPA use with coagulation results was the predictor for DNT of over 60 min (P = 0.0030, OR = 2.44, 95% CI 1.28-4.65). The present study suggests that tPA could be delivered safely without coagulation results in patients without suspected coagulopathy, and avoiding coagulation tests reduces significantly the DNT interval. 10.1007/s10072-017-3239-4
    Effect of glycated hemoglobin index and mean arterial pressure on acute ischemic stroke prognosis after intravenous thrombolysis with recombinant tissue plasminogen activator. Liu Shi-Ying,Cao Wen-Feng,Wu Ling-Feng,Xiang Zheng-Bing,Liu Shi-Min,Liu Hai-Yan,Pan Yang,Nie Feng,Wu Xiao-Mu,Xie Xu-Fang Medicine To determine whether glycated hemoglobin and mean arterial pressure (MAP) during thrombolysis are prognostic factors of intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke (AIS).A total of 125 AIS patients, who received rt-PA intravenous thrombolysis in our hospital, were included into the present study, and divided into good prognosis group and poor prognosis group. Univariate and multivariate logistic regression analyses were used to determine the prognostic factors of AIS treated by rt-PA thrombolysis, Spearman correlation analysis was used to analyze the correlation of the accumulated cigarette consumption in the smoking subgroup and glycated hemoglobin in the diabetic subgroup with the prognosis after intravenous thrombolysis and the symptomatic intracranial hemorrhage (sICH).Univariate analysis revealed that the interval from onset to thrombolysis, baseline National Institutes of Health Stroke Scale (NIHSS) score, MAP during thrombolysis and DRAGON score were prognostic factors. Multivariate logistic regression analysis revealed that baseline NIHSS score and MAP during thrombolysis were independent prognostic factors for rt-PA thrombolysis. Furthermore, the glycated hemoglobin index was positively correlated with the incidence of sICH.The NIHSS score before thrombolysis and MAP during thrombolysis were independent factors for the prognosis of AIS treated by thrombolysis. The higher the glycated hemoglobin index of diabetic patients, the more likely they are to develop sICH, the glycated hemoglobin index was negatively correlated with the prognosis after intravenous thrombolysis. The accumulated cigarette consumption was negatively correlated with the prognosis after intravenous thrombolysis. 10.1097/MD.0000000000013216
    Acute Stroke Despite Dabigatran Anticoagulation Treated with Idarucizumab and Intravenous Tissue Plasminogen Activator. Bissig David,Manjunath Rashmi,Traylor Brittany R,Richman David P,Ng Kwan L Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association Dabigatran is a direct thrombin inhibitor used to reduce the risk of stroke in patients with nonvalvular atrial fibrillation. For patients who present with an acute stroke despite dabigatran therapy, clinical data on the use of intravenous tissue plasminogen activator (IV-tPA) is limited. There is an anticipated increased risk of symptomatic intracranial hemorrhage (sICH) when using IV-tPA in patients on dabigatran therapy. In 2015, the humanized monoclonal antibody fragment idarucizumab was approved for rapid (minutes) reversal of anticoagulant effects of dabigatran. Dabigatran reversal with idarucizumab before administration of IV-tPA might reduce the risk of sICH. We report a case of a 69-year-old stroke patient on dabigatran for paroxysmal atrial fibrillation who presented with an initial National Institutes of Health Stroke Scale (NIHSS) of 12. There was no early evidence of ischemic stroke or hemorrhage on head computed tomography, and coagulation studies implied therapeutic dabigatran levels. After controlling blood pressure, dabigatran was reversed with idarucizumab, and IV-tPA was administrated beginning 197 minutes after he was last seen at his baseline. Subsequent brain magnetic resonance imaging showed 2 punctate infarcts in the left temporal lobe and occipital lobe with no evidence of hemorrhage. The patient was discharged with an NIHSS of 1. Telephone follow-up 2 months later indicated that he was at his prestroke baseline, except for a complaint of worsened short-term memory. Idarucizumab reversal of dabigatran may reduce the risk of sICH and should be considered for acute stroke patients arriving in the IV-tPA time window. 10.1016/j.jstrokecerebrovasdis.2016.12.037
    Successful thrombolytic therapy with recombinant tissue plasminogen activator in ischemic stroke after idarucizumab administration for reversal of dabigatran: a case report. Ohtani Toshiyuki,Sintoku Ryosuke,Yajima Tasuku,Kaneko Naoyuki Journal of medical case reports BACKGROUND:Idarucizumab is a specific antidote for the anticoagulant dabigatran. Although its efficacy has been recently reported, the drug is still in postmarketing surveillance and requires case data in different emergency settings. A newer intravenous thrombolytic therapy with recombinant tissue plasminogen activator has been proposed after injection of idarucizumab in patients receiving dabigatran; however, the safety and efficacy of this therapy are equivocal because of the limited number of reported cases. We describe a case of a patient with acute lacunar stroke causing dysarthria and hemiparesis successfully treated with intravenous thrombolytic therapy with recombinant tissue plasminogen activator after reversal of dabigatran with idarucizumab. CASE PRESENTATION:A 67-year-old Asian woman was transferred to our emergency center 200 minutes after sudden onset of dysarthria and right-sided hemiparesis. She had been taking dabigatran for prevention of stroke recurrence caused by atrial fibrillation. Diffusion-weighted magnetic resonance imaging revealed a new lacunar infarction near old putamen infarctions. We treated her with intravenous thrombolytic therapy with recombinant tissue plasminogen activator after administering idarucizumab. The time to recombinant tissue plasminogen activator administration was 5 minutes from idarucizumab injection and 269 minutes from symptom onset. The patient's activated partial thromboplastin times were 68.0 and 43.2 seconds before and after the therapy, respectively. The patient's neurological symptoms improved significantly after the treatment, and she experienced no adverse events. CONCLUSIONS:Intravenous thrombolytic therapy with recombinant tissue plasminogen activator after reversal of dabigatran with idarucizumab may be safe and feasible in patients with acute ischemic stroke with lacunar infarct. Furthermore, intravenous thrombolytic therapy with recombinant tissue plasminogen activator could be used in patients in emergency settings until just before the end of the recommended time limit within which it needs to be administered because of the immediate effect of idarucizumab. 10.1186/s13256-019-2326-y
    Intravenous Recombinant Tissue Plasminogen Activator and Ischemic Stroke: Focused Update of 2010 Clinical Practice Advisory From the American Academy of Emergency Medicine. Meurer William J,Barth Bradley,Abraham Michael,Hoffman Jerome R,Vilke Gary M,DeMers Gerard The Journal of emergency medicine BACKGROUND:Stroke treatment is a continuum that begins with the rapid identification of symptoms and treatment with transition to successful rehabilitation. Therapies for acute ischemic stroke (AIS) may vary based on anatomic location, interval from symptom onset, and coexisting health conditions. Successful therapy requires a seamless systematic approach with coordination from prehospital environment through acute management at medical facilities to disposition and long-term care of the patient. The emergency physician must balance the benefits and risks of alteplase recombinant tissue plasminogen activator (rtPA) for AIS management. OBJECTIVE:We review the recent medical literature on the topic of AIS and assess intravenous rtPA for the following questions: 1) is there any applicable, new, high-quality evidence that the benefits of intravenous rtPA are justified in light of the harms associated with it, and 2) if so, does the evidence clarify which patients, if any, are most likely to benefit from the treatment. METHODS:A MEDLINE literature search from January 2010 to October 2016 and limited to human studies written in English for articles with keywords of cerebrovascular accident and (thromboly* OR alteplase). Guideline statements and nonsystematic reviews were excluded. Studies targeting differences between specific populations (males vs. females) were excluded. Studies identified then underwent a structured review from which results could be evaluated. RESULTS:Three hundred twenty-two papers on thrombolytic use were screened and nine appropriate articles were rigorously reviewed and recommendations given. CONCLUSIONS:No new studies published between 2010 and 2016 meaningfully reduced uncertainty regarding our understanding of the benefits and harms of intravenous rtPA for AIS. Discussions regarding benefit and harm should occur for patients, and risk prediction scores may facilitate the conversation. 10.1016/j.jemermed.2018.01.033