Decline in mild stroke presentations and intravenous thrombolysis during the COVID-19 pandemic

Introduction: Ischemic stroke patients with mild deficits were largely excluded from pivotal trials of IV rt-PA. The balance of benefit versus risk of intravenous thrombolysis for this large, understudied patient cohort is uncertain. The PRISMS trial is underway to test the benefit of IV rt-PA for treatment of mild stroke. Objective: To characterize baseline features of the first 100 patients enrolled in this prospective cohort of exclusively mild stroke. Methods: The PRISMS trial is a Phase 3b, double-blind, 75-center, 948-subject study evaluating IV rt-PA administered within three hours of mild stroke onset to improve 90-day functional outcome (modified Rankin Scale 0 or 1). Mild stroke is defined as NIHSS ≤5 and not “clearly disabling” (i.e., inability to return to work or perform basic activities of daily living based on current deficits). Patients are randomized 1:1 to IV rt-PA 0.9 mg/kg with aspirin placebo or IV rt-PA placebo with aspirin 325 mg. Here we describe baseline characteristics, including clinical presentations by NIHSS item, of the first 100 enrolled patients. The study team remains fully blinded to patient treatment assignment and outcomes. Results: The 100th subject was enrolled on June 15, 2015. Baseline characteristics are presented in the Table. Median NIHSS was 2 (IQR 1-3). Clinical presentations of each patient by abnormal NIHSS items are shown in the Figure. Dysarthria, facial palsy, and sensory loss were the most common deficits. Conclusions: This initial 100-patient PRISMS cohort is consistent with expectations. Upon completion, the PRISMS trial will determine the benefit of IV rt-PA for mild stroke.

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To Treat or Not to Treat: Importance of Functional Dependence in Deciding Intravenous Thrombolysis of “Mild Stroke” Patients

Journal of Clinical Medicine ◽

10.3390/jcm9030768 ◽

2020 ◽

Vol 9 (3) ◽

pp. 768 ◽

Cited By ~ 2

Author(s):

Giovanni Merlino ◽

Carmelo Smeralda ◽

Simone Lorenzut ◽

Gian Luigi Gigli ◽

Andrea Surcinelli ◽

...

Keyword(s):

Functional Outcome ◽

Independent Predictor ◽

Functional Dependence ◽

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Stroke Patients ◽

Positive Functional ◽

Disability Outcome ◽

Mild Stroke

Intravenous thrombolysis (IVT) in patients with a low National Institutes of Health Stroke Scale (NIHSS) score of 0–5 remains controversial. IVT should be used in patients with mild but nevertheless disabling symptoms. We hypothesize that response to IVT of patients with “mild stroke” may depend on their level of functional dependence (FD) at hospital admission. The aims of our study were to investigate the effect of IVT and to explore the role of FD in influencing the response to IVT. This study was a retrospective analysis of a prospectively collected database, including 389 patients stratified into patients receiving IVT (IVT+) and not receiving IVT (IVT −) just because of mild symptoms. Barthel index (BI) at admission was used to assess FD, dividing subjects with BI score < 80 (FD+) and with BI score ≥ 80 (FD−). The efficacy endpoints were the rate of positive disability outcome (DO+) (3-month mRS score of 0 or 1), and the rate of positive functional outcome (FO+) (mRS score of zero or one, plus BI score of 95 or 100 at 3 months). At the multivariate analysis, IVT treatment was an independent predictor of DO+ (OR 3.12, 95% CI 1.34−7.27, p = 0.008) and FO+ (OR: 4.70, 95% CI 2.38−9.26, p = 0.001). However, FD+ IVT+ patients had a significantly higher prevalence of DO+ and FO+ than those FD+ IVT–. Differently, IVT treatment did not influence DO+ and FO+ in FD– patients. In FD+ patients, IVT treatment represented the strongest independent predictor of DO+ (OR 6.01, 95% CI 2.59–13.92, p = 0.001) and FO+ (OR 4.73, 95% CI 2.29–9.76, p = 0.001). In conclusion, alteplase seems to improve functional outcome in patients with “mild stroke”. However, in our experience, this beneficial effect is strongly influenced by FD at admission.

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Choice of intravenous thrombolysis therapy in patients with mild stroke complaining of acute dizziness

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2021.11.020 ◽

2021 ◽

Author(s):

Tianming Shi ◽

Zheyu Zhang ◽

Bo Jin ◽

Jingwen Wang ◽

Huadong Wu ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Mild Stroke ◽

Thrombolysis Therapy

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Abstract P79: Decline in Mild Stroke Presentations and Intravenous Thrombolysis During the Covid-19 Pandemic: The Society of Vascular and Interventional Neurology Registry

Stroke ◽

10.1161/str.52.suppl_1.p79 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Mudassir Farooqui ◽

Santiago Ortega-Gutierrez ◽

Alicia Zha ◽

Alexandra L Czap ◽

Sebaugh Jacob ◽

...

Keyword(s):

Primary Outcome ◽

Clinical Presentation ◽

Severe Disease ◽

Intravenous Thrombolysis ◽

Stroke Severity ◽

Newly Diagnosed ◽

Stroke Patients ◽

Multicenter Observational Study ◽

Mild Stroke ◽

Iv Tpa

Introduction: To evaluate overall ischemic stroke rates, specific subtypes, and clinical presentation during the COVID-19 pandemic in a multicenter observational study from eight states across US. Methods: We compared all ischemic strokes admitted between January 2019 and May 2020, grouped as; March-May 2020 (COVID-19 period), March-May 2019 (seasonal pre-COVID period) and November 2019-January 2020 (immediate pre-COVID-19 period). Primary outcome was stroke severity at admission measured by NIHSS stratified as mild (0-7), moderate (8-14), and severe (>14) symptoms. Secondary outcomes were number of large vessel occlusions (LVOs), stroke etiology, IV-tPA rates, and disposition. Results: Of the 7,969 patients diagnosed with acute stroke during the study period, 933 (12%) presented in the COVID-19 period, 1319 (17%), and 1254 (16%) presented in the seasonal pre-COVID-19 and immediate pre-COVID-19 periods, respectively. Significant decline was observed in the weekly mean volume of newly diagnosed strokes (98±7.3 vs 50±20, p<0.01 and 95±10.5 vs 50±20, p<0.01), LVOs (16.5±3.8 vs 8.3±5.9, p<0.01 and 14.3± 4.5 vs 8.3±5.9, p<0.01), and IV-tPA (5.3±2.9 vs 10.9±3.4 and 12.7±4.1, p<0.01). Mean weekly proportion of LVOs remained the same, when compared with seasonal pre-COVID-19 period (18%±5 vs 16%±7, p=0.24) and immediate pre-COVID-19 period (17.4%±4 vs. 16%±7, p=0.32). Additionally, these patients presented with less severe disease (NIHSS<14; aOR: 0.63, 95%CI: 0.41-0.97, p=0.035) during the COVID-19 period as compared to immediate pre-COVID-19 period. Conclusions: We observed a decrease in newly diagnosed stroke cases and rates of IV-tPA administration, while the LVO frequency remained unchanged during the COVID-19 pandemic. Additionally, these stroke patients had more severe presentations.

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Intravenous Thrombolysis and Endovascular Thrombectomy in Acute Ischemic Stroke with Minor Symptom

Journal of the Korean Neurological Association ◽

10.17340/jkna.2021.1.2 ◽

2021 ◽

Vol 39 (1) ◽

pp. 10-18

Author(s):

Dae-Hyun Kim

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Recurrent Stroke ◽

Intravenous Thrombolysis ◽

Treatment Decision ◽

Recombinant Tissue Plasminogen Activator ◽

Large Artery ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Mild Stroke

More than 50% of all patients with ischemic stroke initially present with mild symptoms. Despite the mild clinical presentation, a high percentage of these patients develop stroke progression with consequent disability, recurrent stroke, or death at follow-up. Intravenous thrombolysis with recombinant tissue plasminogen activator within 4.5 hours has been proven to be an effective treatment for acute ischemic stroke, but the risk-benefit ratio of this therapeutic approach remains still unclear in patients with mild stroke. Many patients with mild stroke are frequently excluded from thrombolysis. Large artery occlusion is an important predictor of early neurological deterioration or poor outcomes in patients with mild ischemic stroke. However, current guidelines do not recommend endovascular thrombectomy in patients with National Institutes of Health Stroke Scale score of <6 points. Some previous retrospective cohort studies have reported that endovascular thrombectomy showed promising results in cases of acute mild ischemic stroke with large vessel occlusion. Treatment decisions in patients with mild ischemic stroke should be individualized depending on clinical and radiological features. In this review, we discuss the prognosis of mild strokes, efficacy of intravenous thrombolysis and endovascular thrombectomy, and the role of neurovascular imaging in treatment decision making in this patient population.

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Contemporary Trends in the Treatment of Mild Ischemic Stroke with Intravenous Thrombolysis: Paul Coverdell National Acute Stroke Program

Cerebrovascular Diseases ◽

10.1159/000517969 ◽

2021 ◽

pp. 1-7

Author(s):

Ganesh Asaithambi ◽

Xin Tong ◽

Sallyann M. Coleman King ◽

Mary G. George

Keyword(s):

Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Intravenous Thrombolysis ◽

Estimating Equation ◽

National Institutes Of Health ◽

Generalized Estimating Equation ◽

Mild Stroke ◽

The Impact ◽

Program Data

Background: Presentation with mild symptoms is a common reason for intravenous thrombolysis (IVT) nonuse among acute ischemic stroke (AIS) patients. We examined the impact of IVT on the outcomes of mild AIS over time. Methods: Using the Paul Coverdell National Stroke Program data, we examined trends in IVT utilization from 2010 to 2019 among AIS patients presenting with National Institutes of Health Stroke Scale (NIHSS) scores ≤5. Outcomes adjudicated included rates of discharge to home and ability to ambulate independently at discharge. We used generalized estimating equation models to examine the effect of IVT on outcomes of AIS patients presenting with mild symptoms and calculated adjusted odds ratio (AOR) with 95% confidence intervals (CI). Results: During the study period, 346,762 patients presented with mild AIS symptoms. Approximately 6.2% were treated with IVT. IVT utilization trends increased from 3.7% in 2010 to 7.7% in 2019 (p < 0.001). Patients treated with IVT had higher median NIHSS scores upon presentation (IVT 3 [2, 4] vs. no IVT 2 [0, 3]). Rates of discharge to home (AOR 2.06, 95% CI: 1.99–2.13) and ability to ambulate at time of discharge (AOR 1.82, 95% CI: 1.76–1.89) were higher among those treated with IVT. Conclusion: There was an increased trend in IVT utilization among AIS patients presenting with mild symptoms. Utilization of IVT increased the odds of being discharged to home and the ability to ambulate at discharge independently in patients with mild stroke.

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Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

European Journal of Neurology ◽

10.1111/ene.14199 ◽

2020 ◽

Vol 27 (6) ◽

pp. 1039-1047 ◽

Cited By ~ 1

Author(s):

G. Tsivgoulis ◽

N. Goyal ◽

A. H. Katsanos ◽

K. Malhotra ◽

M. F. Ishfaq ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Large Vessel ◽

Stroke Severity ◽

Mild Stroke

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Abstract TP64: Intravenous Thrombolysis in Chinese Patients with Mild Stroke

Stroke ◽

10.1161/str.48.suppl_1.tp64 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Weiqi Chen ◽

Yuesong Pan ◽

Xingquan Zhao ◽

Liping Liu ◽

Hao Li ◽

...

Keyword(s):

Conditional Logistic Regression ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Chinese Patients ◽

Stroke Severity ◽

Large Artery ◽

Stroke Subtype ◽

Stroke Registry ◽

Good Outcome ◽

Mild Stroke

Objectives: Thrombolysis treatment for patients with mild stroke is controversial. The aim of this study is to investigate whether patients with mild stroke or its specific etiologic subtype could benefit from recombinant tissue plasminogen activator (rt-PA) therapy. Methods: Data were derived from two cohorts of patients with and without rt-PA treatment: (1) the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China database and (2) the China National Stroke Registry database. Patients with mild stroke (defined as National Institutes of Health Stroke Scale≤5) receiving the rt-PA therapy and without rt-PA therapy were matched in 1:2 for age, sex, stroke severity and etiologic subtype. Good functional outcome was defined as modified Rankin Scale 0-1 at 3 months. Odds ratios (ORs) with 95 % confidence intervals (CIs) were estimated using conditional logistic regression in total patients and by etiologic subtype, respectively. Results: A total of 134 rt-PA treated patients were matched to 249 non-rt-PA treated patients in the study. Among them, 104 (76%) rt-PA-treated patients with mild stroke had good outcome after 3 months compared with 173 (69.5%) non-rt-PA-treated matching cases (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.91-2.43; P=0.12). Compared with non-rt-PA treatment group, rt-PA-treated patients had good outcome after 3 months in those with stroke subtype of large-artery atherosclerosis (LAA) (80.5% vs 65.1%; OR, 2.19; 95%CI, 1.14-4.21; P=0.02). Conclusions: For patients with mild stroke, intravenous rt-PA treatment may be effective. Patients with stroke subtype of LAA could benefit more from intravenous rt-PA treatment.

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