scholarly journals Treating ischaemic stroke with intravenous tPA beyond 4.5 hours under the guidance of a MRI DWI/T2WI mismatch was safe and effective

2019 ◽  
Vol 4 (1) ◽  
pp. 8-13 ◽  
Author(s):  
Qing-ke Bai ◽  
Zhen-guo Zhao ◽  
Lian-jun Lu ◽  
Jian Shen ◽  
Jian-ying Zhang ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Contrast Material ◽  
Final Analysis ◽  
National Institutes Of Health ◽  
Haemorrhagic Transformation ◽  
Intravenous Tissue Plasminogen Activator ◽  
Hyperintense Signal ◽  
Rapid Sequence ◽  
Tissue Plasminogen ◽  
Sequence Study

PurposeClinical trials have provided evidence that treating patients with acute ischaemic stroke (AIS) beyond 4.5 hours was feasible. Among them using MRI diffusion-weighted imaging/fluid attenuation inversion response (DWI/FLAIR) mismatch to guide intravenous tissue plasminogen activator (tPA) was successful. Our study explored the outcome and safety of using DWI/T2-weighted imaging (T2WI) mismatch to guide intravenous tPA therapy for patients with AIS between 4.5 hours and 12 hours of onset.MethodThis was a retrospective study. Records of 1462 AIS patients with the time of onset of <12 hours were reviewed. Those had MRI rapid sequence study and had hyperintense signal on DWI but normal T2WI and received intravenous tPA up to 12 hours of onset were included in the analysis. Their demographics, risk factors, post-tPA complications, National Institutes of Health Stroke Scale (NIHSS) scores and outcome were recorded and analyse. χ2 was used to compare the intergroup variables. SAS was used to perform statistical calculation. A p<0.05 was considered statistically significant.ResultsOf 1462 identified, 601 (41%) patients were entered into the final analysis. Among them, 327 (54%) had intravenous tPA within 4.5 hours of onset and 274 (46%) were treated between 4.5–12 hours. After intravenous tPA, 426 cases (71%) had >4 pints of improvement on NIHSS score within 24 hours. Postintravenous tPA, 32 (5.32%) cases had haemorrhagic transformation. 26 (4.33%) were asymptomatic ICH and 4 (0.67%) died. At 90 days, 523 (87%) achieved a modified Rankin scale of 0–2.ConclusionUsing MRI DWI/T2WI mismatch to identify patients with AIS for intravenous tPA between 4.5 hours and 12 hours was safe and effective. The outcome was similar to those used DWI/PWI or DWI/FLAIR mismatch as the screening tool. However, obtaining DWI/T2WI was faster and avoided the need of contrast material.

scholarly journals GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate: evidence from the Chinese Stroke Center Alliance

2021 ◽  
pp. svn-2020-000633
Author(s):  
Suxi Zheng ◽  
Tian Jie Lyu ◽  
Zixiao Li ◽  
Hongqiu Gu ◽  
Xin Yang ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Plasminogen Activator ◽  
Acute Ischaemic Stroke ◽  
Emergency Services ◽  
Influential Factors ◽  
Adherence Rate ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Per Capita ◽  
Stroke Center

BackgroundTimely delivery of intravenous tissue plasminogen activator (IV-rt PA) is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic. This paper focuses on investigating influential factors associated with the administration of IV-rt PA, primarily per capita gross regional product (GRP) and healthcare system factors.MethodsThe study included 980 hospitals in the Chinese Stroke Center Alliance where 158 003 patients who had an acute ischaemic stroke received IV-rt PA between August 2015 and August 2019. The adherence rate to IV-rt PA within 4.5 hours time window in each hospital was the primary outcome. Influential factors were grouped into two categories: macroeconomic status and hospital characteristics. The outcome was analysed using multivariable linear regression.ResultsGRP per capita (β=2.37, p<0.001), hospital stroke centre certification (β=3.77, p<0.001), number of neurologists (β=0.12, p<0.001), existence of emergency services for neurological treatment (β=7.43, p=0.014), presence of emergency department (β=10.03, p=0.019) and cooperating with emergency centre (β=4.65, p=0.029) were significantly positively associated with the adherence rate to IV-rt PA.ConclusionsHigher GRP per capita, affluent neurological personnel, well-equipped emergency services for neurological treatment and routine cooperation with the emergency centre were important for enhancing the adherence rate to IV-rt PA among patients who had an acute ischaemic stroke in China.

scholarly journals Comparison of outcome of patients with acute minor ischaemic stroke treated with intravenous t-PA, DAPT or aspirin

2020 ◽  
pp. svn-2019-000319
Author(s):  
Peng Wang ◽  
Mengyuan Zhou ◽  
Yuesong Pan ◽  
Xia Meng ◽  
Xingquan Zhao ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
National Institutes Of Health ◽  
Minor Stroke ◽  
Post Hoc Analysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Ischemic Attack ◽  
Post Hoc

BackgroundWhether to treat minor stroke with intravenous tissue plasminogen activator (t-PA) treatment or antiplatelet therapy is a dilemma. Our study aimed to explore whether intravenous t-PA treatment, dual antiplatelet therapy (DAPT) and aspirin have different efficacies on outcomes in patients with minor stroke.MethodsA post hoc analysis of patients with acute minor stroke treated with intravenous t-PA within 4.5 hours from a nationwide multicentric electronic medical record and patients with acute minor stroke treated with DAPT and aspirin from the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack Database. Minor stroke was defined by a score of 0–3 on the National Institutes of Health Stroke Scale at randomisation. Favourable functional outcome (defined as modified Rankin Scale (mRS) score of 0–1 or 0–2 at 3 months).ResultsCompared with those treated with intravenous t-PA, no significant association with 3-month favourable functional outcome (defined as mRS score of 0–1) was found neither in patients treated with aspirin (87.8% vs 89.4%; OR, 0.83; 95% CI, 0.46 to 1.50; p=0.53) nor those treated with DAPT (87.4% vs 89.4%; OR, 0.84; 95% CI, 0.46 to 1.52; p=0.56). Similar results were observed for the favourable functional outcome defined as mRS score of 0–2 at 3 months.ConclusionsIn our study, no significant advantage of intravenous t-PA over DAPT or aspirin was found. Due to insufficient sample size, our study is probably unable to draw such a conclusion that that intravenous t-PA was superior or non-superior to DAPT.

scholarly journals Assessment of the Functional Status of Patients with Ischaemic Stroke Receiving Thrombolytic Treatment

2020 ◽  
Vol 9 (1) ◽  
pp. 12-19
Author(s):  
Kazimiera Hebel ◽  
◽  
Przemysław Kowiański ◽  
Katarzyna Rogoza ◽  
◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Functional Status ◽  
Intravenous Thrombolysis ◽  
Cerebral Haemorrhage ◽  
National Institutes Of Health ◽  
Cerebral Stroke ◽  
Thrombolytic Treatment ◽  
Total Study Population ◽  
Study Objective ◽  
Haemorrhagic Transformation

Introduction. Intravenous thrombolysis is a gold standard in the treatment of acute ischaemic stroke. It causes reperfusion in the region of ischaemia and as a result it has a positive effect on functional outcomes of patients. The sooner this treatment is introduced the higher efficacy can be expected. Aim. The study objective was to assess the functional status of patients with ischaemic stroke, undergoing thrombolytic treatment and the incidence of thrombolysis complications. Material and Methods. Retrospective studies were conducted on a group of 109 patients hospitalised due to ischaemic cerebral stroke and qualified for thrombolytic treatment. The functional status was assessed with the use of the modified Rankin Scale and National Institutes of Health Stroke Scales on admission and discharge day. The study group included 55 males and 54 females (respectively: 50.5% and 49.5% of the total study population). The subject age was between 32 and 96 years, with the mean age of 69.8. Results. The average time between the onset of symptoms and initiation of thrombolytic treatment was 182 minutes. The National Institutes of Health Stroke Scale at the moment of qualification for treatment was 10.11 points, and the Rankin Scale was 2.88 points. On the day of discharge, the values were 5.81 and 2.05, respectively. A statistically significant (p < 0.0001) improvement in the functional status was observed in the group of patients who had no intra cerebral haemorrhage after thrombolysis. The most common complication of thrombolytic treatment was haemorrhagic transformation of the ischaemic stroke focus — 27 cases (24.77%). Death occurred in 9 subjects (8.26% of total), including 6 cases in males (10.91% of males) and was related to haemorrhagic transformation of the ischaemic stroke focus (p = 0.000). Conclusions. The implemented treatment of stroke resulted in improvement of the functional status. The most frequent complication was haemorrhagic conversion of stroke. (JNNN 2020;9(1):12–19) Key Words: stroke, thrombolysis, functional status

scholarly journals Enrollment bias: frequency and impact on patient selection in endovascular stroke trials

2015 ◽  
Vol 8 (4) ◽  
pp. 353-359 ◽  
Author(s):  
Sunil A Sheth ◽  
Jeffrey L Saver ◽  
Sidney Starkman ◽  
Ileana D Grunberg ◽  
Judy Guzy ◽  
...  
Keyword(s):  
First Generation ◽  
National Institutes Of Health ◽  
Stroke Therapy ◽  
Tertiary Referral Center ◽  
Prognostic Features ◽  
Intravenous Tissue Plasminogen Activator ◽  
Acute Cerebral Ischemia ◽  
Tissue Plasminogen ◽  
Scale Scores ◽  
Angiographic Data

BackgroundSelection bias may have affected enrollment in first generation endovascular stroke trials. We investigate, evaluate, and quantify such bias for these trials at our institution.MethodsDemographic, clinical, imaging, and angiographic data were prospectively collected on a consecutive cohort of patients with acute ischemic stroke who were enrolled in formal trials of endovascular stroke therapy (EST) or received EST in clinical practice outside of a randomized trial for acute cerebral ischemia at a single tertiary referral center from September 2004 to December 2012.ResultsAmong patients considered appropriate for EST in practice, 47% were eligible for trials, with rates for individual trials ranging from 17% to 70%. Compared with trial ineligible patients treated with EST, trial eligible patients were younger (67 vs 74 years; p<0.05), more often treated with intravenous tissue plasminogen activator (53% vs 34%; p<0.01), and had shorter last known well to puncture times (328 vs 367 min; p<0.05). Focusing on the largest trial with a non-interventional control arm, compared with trial eligible patients treated with EST outside the trial, enrolled patients presented later (274 vs 163 min; p<0.001), had higher National Institutes of Health Stroke Scale scores (20 vs 17; p<0.05), and larger strokes (diffusion weighted imaging volumes 49 vs 18; p<0.001).ConclusionsThe majority of patients felt suitable for EST at our institution were excluded from recent trials. Formal entry criteria succeeded in selecting patients with better prognostic features, although many of these patients were treated outside of trials. Acknowledging and mitigating these biases will be crucial to ongoing investigations.

Abstract WP61: Volumetric DWI Malignant Profile Assessment in Acute Ischemic Patients With Reperfusion Therapy.

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Shinichi Wada ◽  
Kazutaka Sonoda ◽  
Sohei Yoshimura ◽  
Shoichiro Sato ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Reperfusion Therapy ◽  
National Institutes Of Health ◽  
Roc Curve Analysis ◽  
Poor Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Magnetic Resonance Imaging Mri ◽  
Poor Outcomes ◽  
Iv Tpa

Background: The efficacy of endovascular therapy (EVT) in acute stroke has been established but the imaging criteria have not yet been assessed. Malignant profile is a magnetic resonance imaging (MRI) pattern that is associated with poor outcomes. We estimated this profile by volumetrically assessing diffusion weighted image (DWI) in patients treated with reperfusion therapy including intravenous tissue plasminogen activator (IV tPA) and endovascular therapy (EVT). Methods: Acute anterior ischemic stroke patients with baseline DWI before reperfusion therapy were included. Outcome was assessed by modified Rankin Scale (mRS) at discharge. DWI volume was measured by semi-automated software.Receiver operating characteristic (ROC) curve analysis was performed to identify optimal DWI volumes with poor outcome (mRS 5-6). Results: Total of 96 patients (43% women, mean age 72±13 years) were included in this study. Median (interquartile range: IQR) National Institutes of Health Stroke Scale was 9 (5-12) and median onset to MRI time was 108.5 (70-217) minutes. Median DWI volume was 4.4 (1.3-17) mL for overall patients. Median onset to IV tPA time for 60 (63%) patients were 120 (65-177) minutes. Median onset to puncture time for 36 (38%) EVT-treated patients was 208 (121.0-474.3) minutes; 29 of these 36 patients (81%) had Thrombolysis in Cerebral Infarction (TICI) score of 2B/3. Median discharge mRS was 2 (1-3) for overall and 6 cases (6%) had mRS 5-6. ROC analysis determined DWI volume with poor outcome as 49.5 mL (92.2% specificity and 50% sensitivity, AUC 0.75, p<0.001). Conclusion: Our study suggests the optimal volume of the malignant profile on DWI was approximately 50mL in reperfusion therapy eligible patients. Clinical outcome of patients exceeding the cutoff volume were very poor. The imaging criteria for reperfusion therapy including EVT should be well considered to achieve better outcomes.

scholarly journals Initial Stroke Severity Is the Major Outcome Predictor for Patients Who Do Not Receive Intravenous Thrombolysis due to Mild or Rapidly Improving Symptoms

2011 ◽  
Vol 2011 ◽  
pp. 1-3 ◽  
Author(s):  
Mu-Chien Sun ◽  
Tien-Bao Lai
Keyword(s):  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
National Institutes Of Health ◽  
Unfavorable Outcome ◽  
Stroke Severity ◽  
Outcome Predictor ◽  
Nihss Score ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Favorable Group

Intravenous tissue plasminogen activator thrombolysis for stroke is still under use. A substantial proportion of excluded patients for mild or improving symptoms are dependent at discharge. We prospectively recruited 49 patients who did not receive thrombolysis because of mild or improving symptoms. 32 had favorable outcome (mRS ≤ 2) and 17 had unfavorable outcome (mRS > 2) at discharge. Comparisons were made between the two groups. Age was older (72.5 ± 10.0 versus 64.7 ± 13.2 years, P = 0.037), and initial National Institutes of Health Stroke Scale (NIHSS) score (5.7 ± 4.0 versus 2.2 ± 2.1, P < 0.001) was higher in the unfavorable group. Diastolic blood pressure was higher in the favorable group (98 ± 15 versus 86 ± 18  mmHg; P = 0.018). Atrial fibrillation (3.1 versus 23.5%; P = 0.043) and ipsilateral artery stenosis (21.9 versus 58.8%; P = 0.012) were more frequently found in the unfavorable group. Percentage of patients excluded from thrombolysis due to improving symptoms was higher in the unfavorable group (40.6 versus 82.4%; P = 0.005). Initial NIHSS score, but not other factors, was identified by logistic regression analysis as a major independent predictor for unfavorable outcome (OR 1.44; 95%CI, 1.03–2.02).

scholarly journals Reducing Haemorrhagic Transformation after Thrombolysis for Stroke: A Strategy Utilising Minocycline

2013 ◽  
Vol 2013 ◽  
pp. 1-7 ◽  
Author(s):  
David J. Blacker ◽  
David Prentice ◽  
Anthony Alvaro ◽  
Timothy R. Bates ◽  
Michael Bynevelt ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Future Perspectives ◽  
The West ◽  
Haemorrhagic Transformation ◽  
Ischaemic Brain ◽  
Stroke Study ◽  
Tissue Plasminogen ◽  
Secondary Endpoints ◽  
Early Recruitment ◽  
Ct And Mri

Haemorrhagic transformation (HT) of recently ischaemic brain is a feared complication of thrombolytic therapy that may be caused or compounded by ischaemia-induced activation of matrix metalloproteinases (MMPs). The tetracycline antibiotic minocycline inhibits matrix MMPs and reduces macroscopic HT in rodents with stroke treated with tissue plasminogen activator (tPA). The West Australian Intravenous Minocycline and TPA Stroke Study (WAIMATSS) aims to determine the safety and efficacy of adding minocycline to tPA in acute ischaemic stroke. The WAIMATSS is a multicentre, prospective, and randomised pilot study of intravenous minocycline, 200 mg 12 hourly for 5 doses, compared with standard care, in patients with ischaemic stroke treated with intravenous tPA. The primary endpoint is HT diagnosed by brain CT and MRI. Secondary endpoints include clinical outcome measures. Some illustrative cases from the early recruitment phase of this study will be presented, and future perspectives will be discussed.

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