Abstract 3251: Relationship Between tPA and Factor VIII Levels in Patients with Acute Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tiffany R Chang ◽  
Karen C Albright ◽  
Rebecca Kruse-Jarres ◽  
Cindy Lessinger ◽  
Amelia K Boehme ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Factor Viii ◽  
Acute Ischemic Stroke ◽  
Surrogate Marker ◽  
Factor Viii Level ◽  
Before And After ◽  
Viii Level ◽  
The Mean ◽  
Stroke Center ◽  
Iv Tpa

Background: Factor VIII levels may be screened as part of a hypercoagulable work-up in patients with ischemic stroke. However, it is unknown how treatment with IV tPA may affect these levels during the acute phase of ischemic stroke. Methods: From our prospective registry, we identified patients who presented with acute ischemic stroke to our stroke center between July 2008 and April 2011 and determined if factor VIII levels had been measured during the acute hospitalization. We compared mean factor VIII levels using independent sample t test in patients not treated with IV tPA to post-tPA treatment levels using independent samples t tests. Results: Of the 72 patients who had factor VIII levels checked during admission, 25 (34.7%) received IV tPA. The mean factor VIII level was observed to be lower in patients who were treated with tPA (140.8 vs 180.5, p=0.048). Patients who experienced averted stroke (36%, 9/25) had significantly lower mean factor VIII level than patients who completed infarction on diffusion-weighted MRI (64%, 16/25) (132.7 vs 175.2, p=0.002). Of patients with post-tPA factor VIII levels, the mean factor VIII level of those whose samples were drawn within 24 hours of tPA were not different than the mean factor VIII level of those whose samples were drawn more than 24 hours after tPA (p=0.784). Conclusion: Our observations found that factor VIII levels were lower in both patients treated with IV tPA and in patients with averted stroke. As factor VIII levels were drawn after thrombolytic therapy was administered, this raises the question of whether tPA lowers factor VIII levels or if factor VIII can serve as a potential surrogate marker for recanalization. Prospective studies examining factor VIII levels (1) before and after treatment with IV tPA and (2) in comparison to recanalization are needed to clarify this interesting observation.

Abstract WP399: Reduced Cost and Decreased Length of Stay Associated with Acute Ischemic Stroke Care Provided by Nurse Practitioners: A Single Primary Stroke Center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Leah Roering ◽  
Michelle Peterson ◽  
Muhammad Shah Miran ◽  
Melissa Freese ◽  
Kenneth Shea ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Length Of Stay ◽  
Acute Ischemic Stroke ◽  
Nurse Practitioners ◽  
Acute Care Hospital ◽  
Stroke Care ◽  
Care Hospital ◽  
Medical Provider ◽  
The Mean ◽  
Stroke Center

Background: Nurse practitioner (NP) have a wider role in modern stroke centers providing quality evidence based care to patients in both in and outpatient settings for acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients. We studied the outcome measures, length of stay (LOS) and cost before and after implementation of nurse practitioners as the primary medical provider in a community based stroke center. Methods: St Cloud hospital is acute care hospital with dedicated stroke service responsible for workup and management of all patients admitted with AIS and TIA. From March 2014-March 2015, all patients were primarily managed by stroke neurologists with or without support of NP, representing physician driven arm. From June 2015-March 2016 all non-critical patients were managed primarily by NP, representing the NP driven arm of care. For this analysis, we excluded all patients with subarachnoid hemorrhage or intracerebral hemorrhage. Using ICD codes, we abstracted LOS and hospitalization cost for all patients, and compared between two arms. Results: A total of 822 patients were included in physician arm and 336 in NP arm. The mean age was 72±14 years for both arms, and 54.4% were male in physician arm and 57.4% were male in NP arm. The mean total LOS for the physician arm was 3.1 ±3.3 days while 2.9±3.6 for NP arm (p=0.6). The total cost for physician arm was $11,286.70 ±$10,920.90 while the NP arm was $10,277.30± $10,142.30 (p=0.1). Conclusion: There is a trend towards lower cost and length of stay with implementation of NP as primary stroke provider for patients admitted with acute ischemic stroke.

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kerrin Connelly ◽  
Rishi Gupta ◽  
Raul Nogueira ◽  
Arthur Yancey ◽  
Alexander Isakov ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Transport Protocol ◽  
Stroke Patients ◽  
Stroke Registry ◽  
The Public ◽  
State Office ◽  
Stroke Center ◽  
Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Vivien H Lee ◽  
Paul A Segerstrom ◽  
Ciarán J Powers ◽  
Sharon Heaton ◽  
Shahid M Nimjee ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Transfer Model ◽  
Transfer Time ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Er Status

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.

Abstract 202: The NIH Stroke Scale Can Miss Improvement After IV tPA For Acute Ischemic Stroke

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Elisabeth B Marsh ◽  
Erin Lawrence ◽  
Rafael H Llinas
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Post Treatment ◽  
Functional Improvement ◽  
Stroke Severity ◽  
Post Discharge ◽  
Significant Difference ◽  
The Mean ◽  
Iv Tpa

Background and Objective: The National Institute of Health Stroke Scale (NIHSS) is the most commonly used metric to evaluate stroke severity and improvement following intervention. Despite its advantages as a rapid, reproducible screening tool, it may be too insensitive to adequately capture functional improvement following treatment. We evaluated the difference in rate of improvement by previously accepted criteria (change of ≥4 NIHSS points) versus physician documentation in patients receiving IV tissue plasminogen activator (tPA) for acute ischemic stroke. Methods: Prospectively collected data on all patients receiving IV tPA over a 15 month period were retrospectively reviewed. NIHSS 24 hours post-treatment and on discharge were extrapolated based on examination and compared to NIHSS on presentation. NIHSS scores at post-discharge follow-up were also recorded. Two reviewers evaluated the medical record and determined improvement based on physician documentation. Using tests of proportion, ‘significant improvement’ by NIHSS was compared to physician documentation at each time point. Results: Forty-one patients were treated with IV tPA. The mean admission NIHSS was 8.6 and improved to 6.4 24 hours post-tPA. Twenty-nine of 41 patients (79%) were “better” by documentation; however only 11/41 (27%) met NIHSS criteria for improvement (p compared to documentation <0.001). On discharge, 20/41 patients (49%) met NIHSS criteria for improvement; however a significant difference between physician documentation remained (p=0.04). The mean post-discharge follow-up NIHSS score was 2.0. 20/21 patients (95%) were “better” compared to 16/21 (76%) meeting NIHSS criteria (p=0.08). Conclusion: The NIHSS may inadequately capture functional improvement post-treatment, especially in the days immediately following intervention.

scholarly journals Increased Factor VIII Level Lends Diversity to Ischemic Stroke Etiology

2008 ◽  
Vol 14 (3) ◽  
pp. 372-373
Author(s):  
Özlem Erol ◽  
Gamze Kara ◽  
Levent Özçakar ◽  
Ibrahim C. Haznedaroğlu
Keyword(s):  
Ischemic Stroke ◽  
Factor Viii ◽  
Factor Viii Level ◽  
Stroke Etiology ◽  
Viii Level

Abstract 159: Current Treatment with Clotting Factors Does not Improve Outcome from Intracranial Hemorrhage After Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Yazan J Alderazi ◽  
Niravkumar V Barot ◽  
Vivek Misra ◽  
James C Grotta ◽  
Sean I Savitz
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Conservative Management ◽  
Small Sample ◽  
Stroke Severity ◽  
Clotting Factors ◽  
Prognostic Variables ◽  
Before And After ◽  
Iv Tpa

Objective & Background: Significant intracranial hemorrhage (sigICH), defined as either symptomatic intracerebral hemorrhage SICH or parenchymal hematoma type 2 (PH2), is a concerning complication of thrombolysis for acute ischemic stroke (AIS). While clotting factors have been incorporated into clinical protocols, the effectiveness of such treatment for sigICH has not been evaluated. We investigated the effects of clotting factors, fresh frozen plasma FFP and cryoprecipitate, in patients with sigICH post thrombolysis. Methods: We retrospectively evaluated all patients with sigICH after TPA for AIS in the prospective University of Texas at Houston Stroke registry; January 2007 - July 2011. We included all patients who received TPA for AIS and subsequently developed sigICH. Patients either received clotting factors (FFP or cryoprecipitate) or conservative management. The primary outcome measure was modified Rankin scale at discharge. The other outcome was death. We collected data on confounding variables: Stroke risk factors, infarct prognostic variables and intracerebral hematoma prognostic variables. Statistical analysis was by Fisher-exact, Chi-square and Mann-Whitney-U tests. Results: Out of 921 patients receiving TPA, sigICH occurred in 50. We excluded 3 because of enrollment in clinical trials. Out of 47 patients, 37 received IV TPA alone and 10 received IV TPA with subsequent intra-arterial therapy. Clotting factors were given in 22/47 (46.8%) patients; 18 received FFP & 9 received cryoprecipitate. The rest received no specific therapies for hemorrhage. There was no difference in stroke severity between groups before and after TPA. The incidence of hydrocephalus was higher in patients receiving clotting factors. There were no differences in outcomes at discharge in either group; the majority of patients in both groups had poor outcomes (mRS was >3). Mortality was high and not different between the two groups. Fibrinogen levels before and after clotting factors did not significantly differ from the patients who received only conservative management. Table 1. Conclusions: We found that clinical outcome of sigICH post TPA is poor. Furthermore, our data suggest that clotting factors do not improve the poor outcome associated with sigICH after t-PA. Our study is limited by small sample size, and the higher incidence of hydrocephalus in those receiving clotting factors may have influenced the outcomes. Nevertheless, our data suggest that new therapies are urgently needed for t-PA associated intracranial hemorrhage.

Abstract 2281: Full Dose IV-tPA Followed By IA Therapy For Acute Ischemic Stroke Does Not Increase Morbidity Or Mortality

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Jeffrey M Katz ◽  
Calvin Natanzon ◽  
Avi Setton ◽  
Richard Libman
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Control Group ◽  
Bridging Therapy ◽  
Full Dose ◽  
Tissue Plasminogen ◽  
Symptomatic Intracranial Hemorrhage ◽  
The Mean ◽  
Iv Tpa

Background and Purpose: “Bridging Therapy” is well described in the literature. However the dose of bridging tissue plasminogen activator (tPA) is a matter of debate given the well-established guideline of 0.9 mg/kg as the standard intravenous dose. Previous and ongoing bridging trials use lower doses of IV-tPA (0.6 mg/kg) with a goal of maximizing safety. Our aim was to explore whether full bridging dose IV-tPA at 0.9 mg/kg can be given safely in combination with intra-arterial (IA)-tPA. Methods: Data were collected prospectively on 47 consecutive patients with acute ischemic stroke who were treated with endovascular stroke therapy (EST, that is IA-tPA +/- mechanical embolectomy (ME)). Patients who were candidates for IV-tPA, who did not clinically improve after receiving full dose IV-tPA (0.9mg/Kg), underwent EST (bridging group, n=23, 15/23 IA-tPA + ME). These patients were compared to patients treated with EST alone because they were not candidates for IV-tPA (control group, n=24, 14/24 IA-tPA + ME). Symptomatic intracranial hemorrhage (ICH) rates were recorded, as defined in the NINDS IV-tPA trial. Death rates were recorded at one month and modified Rankin score was used to measure functional outcome (6 month mean follow-up). Results: Mean age was 62 years in the bridging group and 63 years in the control group. Baseline mean National Institute of Health Stroke Scale was 20 in the bridging group and 21 in the control group (p = 0.188). The mean IA-tPA dose was 14.4 mg in the bridging group and 18.3 mg in the control group (p = 0.371). There was an 8% risk of symptomatic ICH in the control group and no symptomatic ICH in the bridging group (p = 0.155). At 30 days, mortality was 17% in the bridging group and 29% in the control group (p = 0.313). The mean follow-up modified Rankin score was 3 in the bridging group and 4 in the control group (p = 0.20). Conclusion: This non-randomized retrospective cohort study suggests that full dose IV-tPA combined with IA-tPA administered during EST is safe in patients with acute ischemic stroke. Given the possibility that full bridging dose tPA may be more effective than lower dose IV-tPA, a prospective, randomized bridging trial using full dose IV-tPA may be warranted.

scholarly journals Delayed presentation of acute ischemic strokes during the COVID-19 crisis

2020 ◽  
Vol 12 (7) ◽  
pp. 639-642 ◽  
Author(s):  
Clemens M Schirmer ◽  
Andrew J Ringer ◽  
Adam S Arthur ◽  
Mandy J Binning ◽  
W Christopher Fox ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Public Awareness ◽  
Public Life ◽  
Baseline Period ◽  
Delayed Presentation ◽  
Stroke Patients ◽  
The Us ◽  
The Mean ◽  
Stroke Center

BackgroundThe COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US.MethodsThe interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020.ResultsThere were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02).ConclusionWe present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.

scholarly journals Remote Supervision of IV-tPA for Acute Ischemic Stroke by Telemedicine or Telephone Before Transfer to a Regional Stroke Center Is Feasible and Safe

Stroke ◽  
2010 ◽  
Vol 41 (1) ◽  
Author(s):  
Muhammad A. Pervez ◽  
Gisele Silva ◽  
Shihab Masrur ◽  
Rebecca A. Betensky ◽  
Karen L. Furie ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Remote Supervision ◽  
Stroke Center ◽  
Iv Tpa

Risk of Aneurysm Rupture After Thrombolysis in Patients With Acute Ischemic Stroke and Unruptured Intracranial Aneurysms

Neurology ◽  
2021 ◽  
Vol 97 (18) ◽  
pp. e1790-e1798
Author(s):  
Jyri Juhani Virta ◽  
Daniel Strbian ◽  
Jukka Putaala ◽  
Miikka Korja
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Radiology Reports ◽  
Stroke Study ◽  
Unruptured Intracranial Aneurysms ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and ObjectivesUnruptured intracranial aneurysms (UIAs) are considered to be a relative contraindication for IV thrombolysis (IVT) in acute ischemic stroke (AIS). Currently, however, data are limited on the risk of UIA rupture after IVT. Our objective was to assess whether IVT for AIS can lead to a UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs.MethodsThis was a prospective cohort study of consecutive patients treated in a comprehensive stroke center between 2005 and 2019. We assessed radiology reports and records at the Finnish Care Register for Health Care to identify patients with UIAs among all patients with AIS treated with IVT at the center. We analyzed patient angiograms for aneurysm characteristics and other brain imaging studies for ICHs after IVT. The main outcome was in-hospital ICHs attributable to a UIA rupture after IVT. Secondary outcomes were in-hospital symptomatic ICHs (European-Australian Cooperative Acute Stroke Study [ECASS-2] criteria, i.e., NIH Stroke Scale score increase ≥4 points) and any in-hospital ICHs.ResultsA total of 3,953 patients were treated with IVT during the 15-year study period. One hundred thirty-two (3.3%) of the 3,953 patients with AIS had a total of 155 UIAs (141 saccular and 14 fusiform). The mean diameter of UIAs was 4.7 ± 3.8 mm, with 18.7% being ≥7 mm and 9.7% ≥10 mm in diameter. None of the 141 saccular UIAs ruptured after IVT. Three patients (2.3%, 95% confidence interval [CI] 0.6%–5.8%) with large fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours, and 19 days after IVT. All 3 were administered anticoagulation treatments after IVT, and anticoagulation took effect during the UIA rupture. Any ICHs and symptomatic ICHs were detected in 18.9% (95% CI 12.9%–26.2%) and 8.3% (95% CI 4.4%–13.8%) of all patients with AIS, respectively.DiscussionIVT appears to be safe in patients with AIS with saccular UIAs, including larges UIAs (≥10 mm). Anticoagulation after AIS in patients with large fusiform posterior circulation UIAs may increase the risk of aneurysm rupture.

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