scholarly journals Graduating neurology residents’ experience with use of intravenous tPA for acute ischemic stroke

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 324-324
Author(s):  
Brett L Cucchiara ◽  
Scott E Kasner
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Patient ◽  
Current Treatment ◽  
Acute Stroke Patient ◽  
Career Plans ◽  
Stroke Team ◽  
Faculty Supervision

45 Background: Intravenous tPA was approved as a treatment for acute ischemic stroke in 1996. One potential barrier to increased use of tPA has been lack of experience and training among neurologists. To date, there has been no formal assessment of neurology residents’ experience with tPA during their training. Methods: A 12 item survey was sent in March 2000 to all graduating neurology residents as identified by AMA-GME files. Follow-up surveys were sent in April and May to non-responders. Survey items established residents’ experience and confidence with assessment of the acute stroke patient and use of tPA. Responses were assessed using a 5 point Likert scale. Presence of a dedicated stroke team, ongoing stroke clinical trials, and post-residency career plans were also assessed. Results: Of 398 graduating residents for whom addresses were available, 287 (72%) responded. 80% of respondents had personally treated a patient with tPA; 33% had done so without direct faculty supervision. 12% had neither treated nor observed a patient being treated with tPA. 89% had cared for an acute stroke patient in the first hours after administration of tPA. 73% felt comfortable independently treating acute stroke patients with tPA. 65% of residents had formal NIHSS training. Nearly all residents felt confident in their ability to identify hemorrhage (99%) and early infarct signs (94%) on CT. Residents whose institutions had a stroke team were more likely to have provided post-tPA care (93% vs 71%, p<0.001), to have had formal NIHSS training (69% vs 44%, p<0.001), and to feel comfortable independently treating patients with tPA (75% vs 62%, p=0.08). There was no association between career plans (academics vs private practice) and any survey items. Conclusion: One fifth of graduating neurology residents had never personally treated an acute stroke patient with tPA; one in ten had never seen tPA administered. One quarter did not feel comfortable independently treating with tPA. Experience with current treatment for acute stroke should be considered an essential part of neurology residency training. Stroke teams may be helpful in accomplishing this goal.

scholarly journals Myocardial Infarction Following t-PA for Acute Stroke

2007 ◽  
Vol 34 (4) ◽  
pp. 417-420 ◽  
Author(s):  
M. Mehdiratta ◽  
C. Murphy ◽  
A. Al-Harthi ◽  
P. A. Teal
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Patient ◽  
Acute Stroke Patient ◽  
Cardiac Thrombus ◽  
Acute Mi ◽  
Wall Motion Abnormalities ◽  
Cardiac Catherization

Background and Purpose:Complications of intravenous (IV) thrombolysis with tissue plasminogen activator (t-PA) for acute stroke are commonly related to hemorrhage, anaphylaxis, or arterial re-occlusion. Embolic complications of t-PA are beginning to be recognized with increased use of t-PA for acute ischemic stroke. We hypothesize that disruption of intra-cardiac thrombus may result in myocardial infarction (MI) after use of t-PA for acute ischemic stroke.Summary of Cases:We describe three cases of acute MI immediately following IV t-PA infusion for acute stroke. In patient #1 apical thrombus was visualized on cardiac echocardiogram accounting for the MI after t-PA for acute stroke. Patient #2 had fresh thrombus seen on cardiac catherization after use of t-PA for acute stroke. Patient #3 developed a significant troponin rise 15 hours after the t-PA for stroke infusion with an echocardiogram revealing new wall motion abnormalities. Patient # 1 and #2 died secondary to multi-organ failure.Discussion:Acute MI immediately following t-PA treatment for stroke is a rare but serious complication. The disruption of intra-cardiac thrombus and subsequent embolization to the coronary arteries may be an important mechanism in the development of MI after t-PA treatment for acute ischemic stroke.

Abstract TP384: Acute Ischemic Stroke During the Hospital Stay - Who is at Risk?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Melissa Richardson ◽  
Brooke Sinha
Keyword(s):  
Atrial Fibrillation ◽  
At Risk ◽  
Ischemic Stroke ◽  
Hospital Stay ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Increased Risk ◽  
Stroke Team ◽  
History Of ◽  
Time Of Admission

Background: Patients who are admitted to the hospital with a non-stroke diagnosis (NSD) may be at risk for an acute ischemic stroke (AIS). Identifying stroke symptoms for admitted patients with NSD in time for consideration of acute stroke intervention is challenging. Because ‘time is brain’, learning more about patients who may be at risk for AIS during the hospital stay could impact our ability to detect stroke early and improve the patient’s chance for consideration of acute stroke intervention. Purpose: To identify the characteristic(s) of patients who may experience AIS during the hospital stay for NSD so that they may have an opportunity for timely consideration of acute stroke intervention. Methods: The population consisted of patients admitted to the hospital for NSD who had a stroke team activation during the hospital stay (n=46). Records were reviewed over a six month period. These patients records were reviewed for common characteristics that may help predict the risk of AIS. Results: Of these patient records, 46 stroke teams were activated for admitted patients with NSD, 23 (50%) had atrial fibrillation or a history of atrial fibrillation (AF) , and 14 (30%) had AIS during the hospital stay . Comparing the two groups, 13 patients experienced AIS during the hospital stay in the clinical setting of AF (28%). Conclusions: Patients admitted with NSD who also have AF may be at increased risk of AIS during the hospital stay. Consideration should be given for these patients to have serial neurological exams from the time of admission in order to detect stroke symptoms to improve their chance at consideration for acute stroke intervention.

Abstract 3967: Interdisciplinary Emergency Department (ED) Acute Stroke Case Review Decreases Door to Needle (DTN) Times

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Melissa T Fritz ◽  
Sandy Fritzlar
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Case Review ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stroke Team ◽  
Process Oriented ◽  
Stroke Case ◽  
Iv Tpa

Background: Stroke is one of the leading causes of death and the leading cause of disability in the United States. Previous studies suggest that the quicker that intravenous tissue plasminogen activator (IV tPA) is administered, the safer and more effective it is, thus lowering the odds of in hospital mortality and symptomatic intracranial hemorrhage. Objective: To investigate whether implementing a process oriented, interdisciplinary bimonthly review of acute ischemic stroke cases would decrease DTN times and ultimately lead to the consistent administration of IV tPA within 60 minutes of arrival to the ED. Methods: To decrease the IV tPA DTN times, the stroke team at United Hospital in St. Paul, Minnesota developed a new ED stroke review process in July 2010 to analyze each acute ischemic stroke case. The cases were compiled into a document that contained time specific goals for each step of the acute stroke code process. Members of the stroke team would review the data prior to the meeting and if there was a delay (ie outside of the timed goal for lab result) in their department they would investigate the cause. At the meeting, the team would identify best practice efficiencies and barriers, leading to changes in the process. Formal follow up with each department and key learnings were sent to staff on a monthly basis. Results: In 2010, there were 82 patients admitted with an acute ischemic stroke, within 3.5 hours from time last known well, and 28 patients received IV tPA 34% (28/82). From January to June, 2011 there have been 46 acute ischemic stroke patients and 18 patients received IV tPA (18/46) 39%. The mean DTN time was 88 minutes in 2010 vs. 70 minutes in 2011; mean age was 64 vs. 66.5; % female was 46% (13/28) vs. 67% (12/18); median NIH Stroke Scale was 6 vs. 6. The percentage of patients treated with IV tPA within 60 minutes of hospital arrival increased from 21.4% (6/28) in 2010 to 50% (9/18) from January to June 2011 (p=0.022). Conclusions: The DTN times significantly decreased after the implementation of a process oriented, interdisciplinary ED acute stroke case review. The percentage of patients receiving IV tPA within 60 minutes increased from 21.4% to 50% over a 18 month period.

Serum Sphingosine-1-Phosphate Levels Are Associated With Severity and Outcome in Patients With Cerebral Ischemia

Stroke ◽  
2021 ◽  
Author(s):  
Edzard Schwedhelm ◽  
Laura Schwieren ◽  
Steffen Tiedt ◽  
Mirjam von Lucadou ◽  
Nils-Ole Gloyer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Adverse Events ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
National Institutes Of Health ◽  
Stroke Severity ◽  
Regression Analyses ◽  
Cox Regression Analysis ◽  
Sphingosine 1 Phosphate

Background and Purpose: The aim of this study was to examine whether sphingosine-1-phosphate (S1P) levels in patients with acute stroke are associated with stroke severity and outcome. Methods: In a prospective stroke cohort (MARK-STROKE), 374 patients with acute ischemic stroke or transient ischemic attack were enrolled (mean age: 67.9±13.0 years, sex: 64.7% male), and serum-S1P at admission was analyzed with tandem mass spectrometry. In addition to cross-sectional analyses, 79 adverse events (death, stroke, myocardial infarction, rehospitalization) were recorded in 270 patients during follow-up. Regression analyses were adjusted for age, sex, low-density lipoprotein cholesterol, and vascular risk factors. Results were validated in an independent stroke cohort with 219 patients with acute ischemic stroke (CIRCULAS). Results: Low serum-S1P was associated with higher National Institutes of Health Stroke Scale score at admission and with anterior circulation nonlacunar infarcts determined by multivariate regression analyses. During a follow-up of 294±170 days, patients with S1P in the lowest tertile (<1.33 µmol/L) had more adverse events (Kaplan-Meier analysis, P =0.048 for trend). In adjusted Cox regression analysis, the lowest S1P tertile was associated with a worse outcome after stroke (hazard ratio, HR 0.51 [95% confidence interval 0.28–0.92]). Results were confirmed in an independent cohort, ie, low S1P levels were associated with higher National Institutes of Health Stroke Scale, larger infarct volumes and worse outcome after 90 days (β-coefficient: –0.03, P =0.026; β-coefficient: −0.099, P =0.009 and odds ratio 0.52 [0.28–0.96], respectively). Conclusions: Our findings imply a detrimental role of low S1P levels in acute stroke and therefore underpin the therapeutic potential of S1P-mimics.

Mechanical thrombectomy using a Solitaire stent retriever in the treatment of pediatric acute ischemic stroke

2019 ◽  
Vol 23 (3) ◽  
pp. 363-368 ◽  
Author(s):  
Bing Zhou ◽  
Xiao-Chuan Wang ◽  
Jun-Yi Xiang ◽  
Ming-Zhao Zhang ◽  
Bo Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Balloon Dilation ◽  
Stent Retriever ◽  
National Institutes Of Health ◽  
Clinical Prognosis ◽  
Nihss Score ◽  
Grade 3

OBJECTIVEMechanical thrombectomy using a Solitaire stent retriever has been widely applied as a safe and effective method in adult acute ischemic stroke (AIS). However, due to the lack of data, the safety and effectiveness of mechanical thrombectomy using a Solitaire stent in pediatric AIS has not yet been verified. The purpose of this study was to explore the safety and effectiveness of mechanical thrombectomy using a Solitaire stent retriever for pediatric AIS.METHODSBetween January 2012 and December 2017, 7 cases of pediatric AIS were treated via mechanical thrombectomy using a Solitaire stent retriever. The clinical practice, imaging, and follow-up results were reviewed, and the data were summarized and analyzed.RESULTSThe ages of the 7 patients ranged from 7 to 14 years with an average age of 11.1 years. The preoperative National Institutes of Health Stroke Scale (NIHSS) scores ranged from 9 to 22 with an average of 15.4 points. A Solitaire stent retriever was used in all patients, averaging 1.7 applications of thrombectomy and combined balloon dilation in 2 cases. Grade 3 on the modified Thrombolysis In Cerebral Infarction scale of recanalization was achieved in 5 cases and grade 2b in 2 cases. Six patients improved and 1 patient died after thrombectomy. The average NIHSS score of the 6 cases was 3.67 at discharge. The average modified Rankin Scale score was 1 at the 3-month follow-up. Subarachnoid hemorrhage after thrombectomy occurred in 1 case and that patient died 3 days postoperatively.CONCLUSIONSThis study shows that mechanical thrombectomy using a Solitaire stent retriever has a high recanalization rate and excellent clinical prognosis in pediatric AIS. The safety of mechanical thrombectomy in pediatric AIS requires more clinical trials for confirmation.

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

2019 ◽  
Vol 24 (5) ◽  
pp. 558-571 ◽  
Author(s):  
Kartik Bhatia ◽  
Hans Kortman ◽  
Christopher Blair ◽  
Geoffrey Parker ◽  
David Brunacci ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Case Reports ◽  
Meta Analysis ◽  
Case Series ◽  
Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

Approach to and management of the acute stroke patient with atrial fibrillation: A literature review

2008 ◽  
Vol 3 (4) ◽  
pp. 326-332 ◽  
Author(s):  
Konstantinos Marmagkiolis ◽  
Ioannis G. Nikolaidis ◽  
Themos Politis ◽  
Lawrence Goldstein
Keyword(s):  
Atrial Fibrillation ◽  
Literature Review ◽  
Acute Stroke ◽  
Stroke Patient ◽  
Acute Stroke Patient

Abstract TP208: Sleep Disordered Breathing (SDB) - An Overlooked Modifiable Risk Factor in Acute Stroke Care

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Vishal Shah ◽  
Ashrai Gudlavalleti ◽  
Julius G Latorre
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Sleep Disordered Breathing ◽  
Modifiable Risk Factor ◽  
Inclusion Criteria ◽  
Risk Of Death ◽  
Disordered Breathing

Introduction: In patients with acute stroke, part of the acute management entails identifying the risk factors; modifiable or non modifiable. Early recognition of these factors is essential for optimizing therapeutic procedures, especially those with a known effective treatment. In this sense, Sleep Disordered Breathing (SDB) has also been suggested as a modifiable and independent risk factor for stroke as defined by international guidelines and some studies have demonstrated that patients with stroke and particularly Obstructive Sleep Apnea (OSA) have an increased risk of death or new vascular events. Pathogenesis of ischemic stroke in SDB is probably related to worsening of existing cardiovascular risk factors such as hypertension and hypoxia driven cardiac arrhythmia leading to higher prevalence of ischemic stroke in patients with sleep disordered breathing disease. Despite strong evidence linking SDB to ischemic stroke, evaluation for SDB is rarely performed in patients presenting with an acute ischemic stroke. Hypothesis: Evaluation of SDB is rarely performed in patients presenting with acute ischemic stroke. Methods: We performed a retrospective review of all patients above the age of 18 who were admitted to the acute stroke service at University Hospital July 2014 to December 2014. Demographic data, etiology of stroke as identified per TOAST criteria, modifiable risk factors, presenting NIHSS and frequency of testing for SDB and their results were collected. The data was consolidated and tabulated by using STATA version 14. Results: Total of 240 patients satisfied our inclusion criteria. Only 24 patients ie 10% of those who satisfied our inclusion criteria received evaluation for SDB. Out of those evaluated, 62.5% ie 15 patients out of 24 patients had findings concerning for significant desaturation. Only 2 providers out of 8 stroke physicians ie 25% tested for SDB in more than 5 patients. Conclusions: Our observations highlight the paucity in evaluation for SDB in acute ischemic stroke in a tertiary care setting. Being a modifiable risk factor, greater emphasis must be placed on evaluation for SDB in patients in patients with acute stroke. Education must be provided to all patients and providers regarding identification of these factors.

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