Abstract 3994: Obese Patients Receiving Intravenous Thrombolysis in Acute Ischemic Stroke Have lower Rates of Intracerebral hemorrhage and Mortality

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Ameer Hassan ◽  
Mikayel Grigoryan ◽  
Saqib Chaudhry ◽  
Adnan Qureshi
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multivariate Logistic Regression Analysis ◽  
Intravenous Thrombolysis ◽  
International Classification Of Diseases ◽  
The United States ◽  
Obese Patients ◽  
Stroke Patients ◽  
Intravenous Tissue Plasminogen Activator ◽  
Classification Of Diseases

Background: The current recommended dose of intravenous tissue plasminogen activator (IV rt-PA) for ischemic stroke patients weighing >100 kg is fixed at 90 mg and thus obese patients receive less than the recommend 0.9mg/kg dosage. We hypothesized that obese patients receive a lower dose of thrombolytics and they will have a lower rates of intracerebral hemorrhages (ICH), but lower rates of clinical benefit from IV rt-PA. Objective: To determine the relationship between obesity and clinical outcomes among acute ischemic stroke patients receiving IV rt-PA. Methods: Data were obtained from all states within the United States that contributed to the Nationwide Inpatient Sample. All patients admitted to US hospitals between 2002 and 2009 with a primary discharge diagnosis of stroke treated with IV thrombolysis (identified by the International Classification of Diseases, Ninth Revision procedure codes) were included. We analyzed whether the presence of obesity was associated with clinical outcome and ICH with multivariate logistic regression analysis after adjusting for potential confounders. Results: Of the 84,727 patients with ischemic stroke treated with IV rt-PA, 5,437 (6.4%) had concurrent obesity. The ICH rates between obese and non-obese patients was 4.3% versus 6.1% (p=0.005). After adjusting for age, sex, hypertension, diabetes mellitus, renal failure, hospital teaching status, and ICH, the presence of obesity was not associated with increased rates of self-care (odds ratio [OR] 0.929, 95% confidence interval [CI] 0.815-1.063, p=0.27), but was associated with decreased rates of mortality (OR 0.78, 95% CI 0.61 - 0.94, p=0.045) at discharge. Conclusion: Obese patients undergoing IV t-PA treatment for acute ischemic stroke appear to have lower rates of ICHs and mortality presumably due to lower weight adjusted thrombolytic dose.

Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam H De Havenon ◽  
Christopher Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

Abstract WP262: Intravenous Thrombolysis in Acute Ischemic Stroke Patients With Infective Endocarditis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mangala Gopal ◽  
Sushil Lakhani ◽  
Vivien Lee
Keyword(s):  
Ischemic Stroke ◽  
Infective Endocarditis ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Medical Risk ◽  
Good Functional Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean

Introduction: Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke. However during the hyperacute stroke evaluation, the exclusion of IE may be difficult. Methods: We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 with acute ischemic stroke who received IVtPA and identified patients who were diagnosed with infective endocarditis. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2. Results: Among 1022 acute ischemic stroke patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority, 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). All patients met criteria for IVtPA and there were no protocol violations. The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed MCA occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy with Thrombolysis in cerebral infarction scale 2A recanalization. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage on Hospital Day #2 due to mycotic cerebral aneurysm. The blood culture results included MRSE (1), Streptococci viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcome, and the mean 3 months mRS was 4.8 (range, 3 to 6). Conclusions: In a large series of acute ischemic stroke patients who received IVtPA, undiagnosed IE is rare (0.5%). Fever was not commonly present during initial evaluation. Despite affecting younger patients with initial mild deficits, patients with IE had poor functional outcomes.

scholarly journals Platelet-to-lymphocyte ratio at 24h after thrombolysis is a prognostic marker in acute ischemic stroke patients

2020 ◽  
Author(s):  
Yingying Sun ◽  
Meiqi Wang ◽  
Yan Wang ◽  
Xiuli Yan ◽  
Hang Jin ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multivariate Logistic Regression Analysis ◽  
Intravenous Thrombolysis ◽  
Multivariate Logistic Regression ◽  
Stroke Patients ◽  
Platelet To Lymphocyte Ratio ◽  
Poor Outcome ◽  
Before And After

Abstract Introduction: The role of Platelet-to-lymphocyte ratio (PLR) in outcomes of acute ischemic stroke, especially before and after intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA), has not been elucidated. Thus, the aim of this study was to evaluate the effect of PLR before and after rtPA on clinical outcomes.Methods: A total of 582 consecutive patients who had acute ischemic stroke diagnosed and received intravenous thrombolysis with rtPA were included in this study. We collected demographics, vascular risk factors, previous history of drugs and other clinical information for all patients. Specifically, blood samples for PLR values were collected on admission and at 24 hours after stroke. Multivariate logistic regression analysis was used to assess the association between PLR with the risk of poor outcome (mRS≥3), death and hemorrhagic transformation (HT). Results: Of 582 patients, 191 (32.8%) had a poor outcome, 40 (6.9%) died and 82 (14.1%) had HT. After adjustment for potential confounders, multivariate logistic regression analysis showed that higher PLR at 24h after rtPA was independently associated with an increased risk of poor outcome (OR=1.004; 95% CI:1.001-1.007; P=0.009) and the occurrence of death (OR=1.009; 95% CI:1.004-1.013; P<0.001), but not associated with the risk of HT (OR=1.003; 95% CI:0.999-1.007; P=0.165). In addition, PLR on admission was not associated with the risk of poor outcome, death and HT (all P>0.05).Conclusions: We found that PLR at 24h after rtPA can predict the risk of poor outcome and death in acute ischemic stroke patients, but PLR on admission cannot.

Abstract WP54: National Trends in Utilization and Outcomes of Endovascular Treatment in Acute Ischemic Stroke Patients in Pre- and Post-Stent Retriever Era in the United States

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Saqib A Chaudhry ◽  
Ameer E Hassan ◽  
Iqra N Akhtar ◽  
Mohammad Rauf A Chaudhry ◽  
Wei Huang ◽  
...  
Keyword(s):  
United States ◽  
Clinical Trials ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Multivariate Logistic Regression Analysis ◽  
The United States ◽  
Stent Retriever ◽  
Severe Disability ◽  
Stroke Patients

Introduction: Several studies have shown improved outcomes in ischemic stroke patients treated with mechanical thrombectomy in clinical trials after introduction of stent retrievers. The outcomes of patients undergoing endovascular treatment in general practice are expected to improve. We performed this analysis to evaluate trends in utilization of endovascular treatment in acute ischemic stroke and associated rates of death and disability in real world practice. Methods: We obtained data for patients admitted with primary diagnosis of ischemic stroke in United States from 2009-2016 using Nationwide Inpatient Sample. We determined the rate and pattern of utilization, and associated in-hospital outcomes of endovascular treatment among them. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition and compared between two time periods: 2009-2011 and 2013-2016 to represent pre and post stent retriever approvals in United States. Results: Of the 3,780,955 patients admitted with ischemic stroke, 244,092 (6.46%) received intravenous thrombolytic treatment, and 48,409 (1.28%) underwent endovascular treatment. There was a fourfold increase in patients who underwent endovascular treatment (0.55% of ischemic strokes in 2009 vs. 2.03% in 2016, trend p < 0.001). In multivariate logistic regression analysis, adjusted for age, gender, thrombolytic therapy, in hospital complications including secondary intracranial hemorrhages, the rate of none to minimal disability improved between the two study intervals (2009-2011 versus 2013-2016), odds ratio (OR) 1.82, 95% confidence interval (CI) 1.47-2.67, p=<0.0001) and moderate to severe disability decreased (OR 0.56, 95% CI 0.45- 0.70, p= <0.0001). There was significant decrease inpatient mortality for patients treated during 2013-2016; OR 0.67, 95% CI 0.56- 0.79, p= <0.0001). Conclusion: There has been a significant increase in the proportion of acute ischemic stroke patients receiving endovascular treatment with improvement of outcomes. Our analysis support generalizability of the successful results observed in clinical trials of endovascular treatment in the post-stent retriever approval era in United States.

Abstract WP13: The Rate of Hemicraniectomy Utilization for Acute Ischemic Stroke Patients Undergoing Endovascular Treatment is Decreasing in the United States

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Saqib A Chaudhry ◽  
Ameer E Hassan ◽  
Mohammad R Afzal ◽  
Riaz Riaz ◽  
Haseeb Rahman ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Multivariate Logistic Regression Analysis ◽  
The United States ◽  
Severe Disability ◽  
National Database ◽  
Stroke Patients

Background and Purpose: Hemicraniectomy is carefully selected for patients with acute ischemic stroke in whom endovascular treatment has failed to prevent adverse outcomes of large hemispheric stroke. We evaluated trends in the utilization of hemicraniectomy in patients who underwent endovascular therapy according to the availability of three generations of thrombectomy devices and analyzed the associated rates of death and disability among them over a nine year period. Methods: We obtained data for patients admitted to hospitals in the United States from 2004 to 2012 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate and pattern of hemicraniectomy utilization, and associated in-hospital outcomes of endovascular treatment among ischemic stroke patients. Outcomes were compared between three time periods: 2004-2006 (post MERCI), 2007-2009 (post Penumbra) and 2010-2012 (post Solitaire stent retriever) approvals. Results: Of the 6,021,636 patients admitted with ischemic stroke, 28,956 (0.48%) underwent endovascular treatment. Of the patients who underwent endovascular therapy, 2,219 (7.6%) required subsequent hemicraniectomy. There was a 7 fold decrease in the utilization of hemicraniectomy in these patients between 2004 and 2009 (25.6% in 2004 vs. 3.5% in 2009, p < 0.001) with a yearly trend towards decreased utilization of hemicraniectomy [OR 0.7, 95% CI 0.6- 0.8, p <.0001]. In multivariate logistic regression analysis there was a reduction in the rate of in hospital mortality of the 2007-2009 and the 2010-2012 groups when compared to the 2004-2006 interval group (2007-2009, odds ratio (OR) 0.9, 95% confidence interval (CI) (0.7- 1.2) and 2010-2012, [OR 0.9, 95%CI 0.7- 1.1]). The rate of moderate to severe disability increased for patients treated during 2007-2009 and 2010-2012. Conclusion: In the last 9 years there has been a significant decrease in the utilization of hemicraniectomy in acute ischemic stroke patients who underwent endovascular treatment. Despite reduction in use of hemicraniectomy, the mortality rate in endovascularly treated patients have shown a reduction, but there was an increase in rate of moderate to severe disability.

scholarly journals Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel

2020 ◽  
Vol 15 (5) ◽  
pp. 540-554 ◽  
Author(s):  
Adnan I Qureshi ◽  
Foad Abd-Allah ◽  
Fahmi Al-Senani ◽  
Emrah Aytac ◽  
Afshin Borhani-Haghighi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Current Knowledge ◽  
Intravenous Thrombolysis ◽  
Adult Patients ◽  
World Health ◽  
Stroke Patients ◽  
International Panel ◽  
Health Organization ◽  
Tract Infections

Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.

scholarly journals Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

2021 ◽  
Vol 14 ◽  
pp. 175628642110211
Author(s):  
Georgios Magoufis ◽  
Apostolos Safouris ◽  
Guy Raphaeli ◽  
Odysseas Kargiotis ◽  
Klearchos Psychogios ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Inclusion Criteria ◽  
Stroke Patients ◽  
Treatment Algorithms ◽  
Late Presenters

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

scholarly journals Incorporation of α2-Plasmin Inhibitor into Fibrin Clots and Its Association with the Clinical Outcome of Acute Ischemic Stroke Patients

Biomolecules ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. 347
Author(s):  
Zsuzsa Bagoly ◽  
Barbara Baráth ◽  
Rita Orbán-Kálmándi ◽  
István Szegedi ◽  
Réka Bogáti ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Intravenous Thrombolysis ◽  
Fibrin Clot ◽  
Clot Lysis ◽  
Stroke Patients ◽  
Plasmin Inhibitor ◽  
Fibrin Clots

Cross-linking of α2-plasmin inhibitor (α2-PI) to fibrin by activated factor XIII (FXIIIa) is essential for the inhibition of fibrinolysis. Little is known about the factors modifying α2-PI incorporation into the fibrin clot and whether the extent of incorporation has clinical consequences. Herein we calculated the extent of α2-PI incorporation by measuring α2-PI antigen levels from plasma and serum obtained after clotting the plasma by thrombin and Ca2+. The modifying effect of FXIII was studied by spiking of FXIII-A-deficient plasma with purified plasma FXIII. Fibrinogen, FXIII, α2-PI incorporation, in vitro clot-lysis, soluble fibroblast activation protein and α2-PI p.Arg6Trp polymorphism were measured from samples of 57 acute ischemic stroke patients obtained before thrombolysis and of 26 healthy controls. Increasing FXIII levels even at levels above the upper limit of normal increased α2-PI incorporation into the fibrin clot. α2-PI incorporation of controls and patients with good outcomes did not differ significantly (49.4 ± 4.6% vs. 47.4 ± 6.7%, p = 1.000), however it was significantly lower in patients suffering post-lysis intracranial hemorrhage (37.3 ± 14.0%, p = 0.004). In conclusion, increased FXIII levels resulted in elevated incorporation of α2-PI into fibrin clots. In stroke patients undergoing intravenous thrombolysis treatment, α2-PI incorporation shows an association with the outcome of therapy, particularly with thrombolysis-associated intracranial hemorrhage.

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