Abstract 104: Golden Hour-Thrombolysis by Starting Treatment Before Hospital Arrival the Pre-Hospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S)

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Martin Ebinger ◽  
Matthias Wendt ◽  
Michal Rozanski ◽  
Benjamin Winter ◽  
Carolin Waldschmidt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Treatment Time ◽  
Point Of Care ◽  
Intravenous Thrombolysis ◽  
Conventional Care ◽  
Ct Scanner ◽  
Term Outcome ◽  
Golden Hour ◽  
Stroke Study ◽  
A Prospective Study

Objective: The effectiveness of intravenous thrombolysis in acute ischemic stroke is time dependent. The effects are likely to be highest if onset-to-treatment time (OTT) is < 60 minutes, the so called Golden-Hour. Starting thrombolysis in a specialized ambulance with a CT-scanner plus point-of-care laboratory reduced time from emergency call to treatment in the prospective controlled PHANTOM-S study. We evaluated the rate and effectiveness of Golden-Hour thrombolysis. Methods: The stroke emergency mobile (STEMO) is staffed with a neurologist trained in emergency medicine, a paramedic and a technician. The effects of the STEMO implementation were evaluated in a prospective study comparing weeks with and without STEMO-availability. STEMO was deployed when the dispatchers suspected an acute stroke during emergency calls. If STEMO was not available (in operation or maintenance), patients received conventional care. OTT-intervals were dichotomized in either ≤60 (Golden-Hour) or > 60 minutes as well as categorized in 10-minute intervals from 0 to 270 minutes for graphical description. Results: Overall, thrombolysis rates in ischemic stroke were 33% (200/614) when STEMO was deployed and 22% (330/1497) in conventional care (p<0.001). The proportion of Golden-Hour treatments (from all thrombolysis) was 6-fold higher after STEMO deployment (31.0%; n= 62 versus 4.9%; n=16; p<0.01). Compared to patients with longer OTT patients with Golden-Hour thrombolysis had no higher risks for 7- or 90-day mortality (adjusted ORs: 0.38, 95%-CI: 0.09-1.70 and 0.69, 95%-CI: 0.32-1.53) but were more likely to be discharged at home (adjusted OR: 1.93 95%CI: 1.09-3.41; p=0.024). Conclusion: STEMO increased the percentage of patients treated within the Golden-Hour. This entailed no risk to patients’ safety and was associated with better short-term outcome.

Abstract TMP25: Effects of Age and Ethnicity on the Benefits and Risks of Low- versus Standard-dose Alteplase in Acute Ischemic Stroke Patients: The Enchanted Trial

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Xia Wang ◽  
Thompson Robinson ◽  
Hisatomi. Arima ◽  
Joseph Broderick ◽  
Andrew Demchuk ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Effects ◽  
Low Dose ◽  
Standard Dose ◽  
Intravenous Thrombolysis ◽  
Open Label ◽  
Poor Outcome ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Study

Background and Purpose: As lower doses of alteplase reduce the risk of symptomatic intracerebral hemorrhage (sICH), older and Asian people may benefit more from low-dose alteplase than other patients with acute ischemic stroke (AIS). Methods: Data from the ENhanced Control of Hypertension ANd Thrombolysis strokE study (ENCHANTED), an international, multi-center, prospective, randomized, open-label, blinded-endpoint trial, were analyzed to assess effects of low- (0.6mg/kg body weight) vs. standard-dose (0.9mg/kg) alteplase in AIS patients, by age and ethnicity (Asian vs. non-Asian), pre-specified subgroup analyses, on key efficacy and safety outcomes. Results: 3297 patients (1248 female), mean age 67 years were included. After adjusting for baseline characteristics and management variables over the first seven days, increasing age was associated with poor outcome, defined by ordinal analysis of the modified Rankin score (mRS) (shift to a less favorable outcome, P trend <0.0001). In the comparison between low- and standard-dose alteplase, no significant differences were observed for 90-day poor outcome by age deciles and ethnicity. Less sICH was observed with low-dose alteplase, and this was consistent for age and ethnicity. There was no ethnic difference in the treatment effects by age, severity, and time to treatment. Conclusions: Increasing age predicts poor outcome in thrombolysis-treated AIS patients. There was no heterogeneity in the treatment effects of low- vs. standard-dose alteplase. Decisions about intravenous thrombolysis should be based on variables other than age and ethnicity.

Abstract 184: Intravenous Thrombolysis for Acute Ischemic Stroke in the “Golden Hour”: a Propensity-matched Analysis of SITS-EAST Registry

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Georgios Tsivgoulis ◽  
Aristeidis H Katsanos ◽  
Pavla Kadlecova ◽  
Anna Czlonkowska ◽  
Adam Kobayashi ◽  
...  
Keyword(s):  
Treatment Time ◽  
Intravenous Thrombolysis ◽  
Serum Glucose ◽  
Relative Reduction ◽  
Regression Analyses ◽  
Stroke Units ◽  
Nihss Score ◽  
Golden Hour ◽  
Clinical Recovery ◽  
Scarce Data

Background & Purpose: There are scarce data regarding outcomes of AIS patients treated with IVT within 60 min from symptom onset (“golden hour”). We sought to compare outcomes between AIS patients treated within (OTT≤60 min) and outside (OTT: 61-270min) the “golden hour” [GH(+) & GH (-)] using a propensity score matching approach. Methods: Patients were evaluated during a 12-year period in a large, international, prospective registry of IVT (SITS-EAST). They underwent serial NIHSS-score assessments at baseline, 2 hrs and 24 hrs following tPA-bolus. Clinical recovery (CR) at 2 and 24 hrs was defined as a reduction of ≥10 points in NIHSS-score compared with baseline, or a NIHSS-score of ≤3 at 2 and 24 hrs respectively. A relative reduction in NIHSS-score of ≥40% at 2 hrs was predictive of complete recanalization (CREC). sICH was defined using SITS-MOST criteria; 3-month favourable functional outcome (FFO) was defined as a mRS-score of 0-1. The two groups were matched for demographics, risk factors, baseline NIHSS, admission blood pressure and serum glucose. Results: Out of 19.077 tPA-treated AIS patients, 71 patients in GH(+) group [mean age 67±13 years; median NIHSS-score 12 points (IQR 10); median onset to treatment time (OTT) 55min, (IQR 10)] were matched to 6882 patients in GH(-) group (mean age 67±12 years; median NIHSS-score 11 points (IQR 9); median OTT 155min (IQR 55)]. The two groups did not differ in any of the matched characteristics (p>0.1). GH(+) had significantly (p<0.05) higher rates of 2hr (31% vs. 12%) and 24hr (41% vs. 27%) CR, CREC (39% vs. 21%) and 3-month FFO (47% vs. 34%). The rates of sICH (0% vs. 2%) and 3-month mortality (9% vs. 13%) were similar (p>0.2) in the two groups. GH(+) was independently (p<0.05) associated with 2hr CR (OR:5.5; 95%CI: 2.6-12.0), 24hr CR (OR:2.0; 95%CI: 1.1-3.6), CREC (OR:2.4; 95%CI: 1.4-4.3), and 3-month FFO (OR:2.3; 95%CI: 1.3-4.1) in multivariable logistic regression analyses adjusting for potential confounders. Conclusions: AIS patients treated with IVT within the GH have substantially higher odds of early CR and FFO. These findings highlight the potential of mobile stroke units to further improve AIS outcomes by increasing the rates of tPA delivery within the GH.

Abstract 3274: Early Symptom Onset to Arterial Puncture Time in the Endovascular Management of Acute Ischemic Stroke Predicts Successful Revascularization

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Richard S Jung ◽  
Jitendra Sharma ◽  
Tanzila Shams ◽  
Numthip Chitravas ◽  
Kristine A Blackham
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Treatment Time ◽  
Intravenous Thrombolysis ◽  
Endovascular Management ◽  
Intravenous Tissue Plasminogen Activator ◽  
Flow Improvement ◽  
Relationship Of

Background: As is seen in the early door-to-needle times of intravenous thrombolysis in the treatment of acute ischemic stroke (AIS), prior endovascular management trials have demonstrated early revascularization can lead to improved outcomes. We aimed to study the relationship of the time from acute stroke onset to the time of arterial groin puncture (OTP) as a possible predictor of successful revascularization. Methods: We retrospectively analyzed 149 patients who presented to our hospital with AIS and underwent emergent endovascular treatment from January 1, 2008 to March 31, 2011. Charts were reviewed for baseline characteristics, OTP times, and endovascular therapies employed. Primary outcomes included successful revascularization (TIMI 2 to 3 flow), improvement of baseline NIHSS ≥ 4, symptomatic ICH (increase of NIHSS ≥ 4), in-hospital mortality, and mRS two or less at discharge. We excluded patients with OTP times greater than eight hours to ensure consistency with approved usage of mechanical thrombectomy devices. Independent samples T-tests were performed to determine relationships of OTP with our primary outcomes. Results: Of the 149 patients who underwent endovascular therapy, 120 had OTP times less than eight hours. Of these 120, 44% were male, median age was 73 years (range 17, 93), median baseline NIHSS was 18 (range 5, 28), 53% received intravenous tissue plasminogen activator (tPA), 69% received intra-arterial tPA, and mechanical thrombectomy was performed in 69%. Internal carotid artery occlusions were seen in 32% of patients, 50% had M1 segment occlusions, and only five patients had posterior circulation occlusions. Successful revascularization was achieved in 70% of interventions, 10% of patients had mRS ≤ 2 at discharge, symptomatic hemorrhage was 18%, and in-hospital mortality was 24%. Patients with TIMI 2 to 3 flow had significantly shorter mean OTP times (3.9 vs 4.5 hours; p=0.024). No significant associations of mean OTP times were found with symptomatic hemorrhage rate (4.4 vs 4.0; p=0.628), in-hospital mortality (4.0 vs 4.0; p=0.677), improvement in NIHSS (3.9 vs 4.2; p=0.283), or a mRS ≤ 2 at discharge (3.7 vs 4.1; p=0.185). Conclusions: The recanalization rate in our study is comparable to prior endovascular trials. Patients with OTP times less than 3.9 hours were more likely to result in successful revascularization. Onset to groin puncture did not predict in-hospital mortality, symptomatic hemorrhage, or condition at discharge in our study. Further study is needed to determine if advanced perfusion imaging prior to intervention may impact treatment time and ultimately clinical outcome.

Management of acute ischemic stroke

BMJ ◽  
2020 ◽  
pp. l6983 ◽  
Author(s):  
Michael S Phipps ◽  
Carolyn A Cronin
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Time ◽  
Recurrent Stroke ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Developed Countries ◽  
Future Research ◽  
The Impact

ABSTRACT Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

scholarly journals A new nomogram for individualized prediction of the probability of hemorrhagic transformation after intravenous thrombolysis for ischemic stroke patients

BMC Neurology ◽  
2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Yaya Wu ◽  
Hui Chen ◽  
Xueyun Liu ◽  
Xiuying Cai ◽  
Yan Kong ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Validation Cohort ◽  
Treatment Time ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Calibration Plot ◽  
Global Burden ◽  
Nihss Score ◽  
Individualized Prediction

Abstract Background A reliable scoring tool to detect the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis for ischemic stroke is warranted. The present study was designed to develop and validate a new nomogram for individualized prediction of the probability of hemorrhagic transformation (HT) in patients treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA). Methods We enrolled patients who suffered from acute ischemic stroke (AIS) with IV rt-PA treatment in our emergency green channel between August 2016 and July 2018. The main outcome was defined as any type of intracerebral hemorrhage according to the European Cooperative Acute Stroke Study II (ECASS II). All patients were randomly divided into two cohorts: the primary cohort and the validation cohort. On the basis of multivariate logistic model, the predictive nomogram was generated. The performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration plot. Results A total of 194 patients with complete data were enrolled, of whom 131 comprised the primary cohort and 63 comprised the validation cohort, with HT rate 12.2, 9.5% respectively. The score of chronic disease scale (CDS), the global burden of cerebral small vascular disease (CSVD), National Institutes of Health Stroke Scale (NIHSS) score ≥ 13, and onset-to-treatment time (OTT) ≥ 180 were detected important determinants of ICH and included to construct the nomogram. The nomogram derived from the primary cohort for HT had C- Statistics of 0.9562 and the calibration plot revealed generally fit in predicting the risk of HT. Furthermore, we made a comparison between our new nomogram and several other risk-assessed scales for HT with receiver operating characteristic (ROC) curve analysis, and the results showed the nomogram model gave an area under curve of 0.9562 (95%CI, 0.9221–0.9904, P < 0.01) greater than HAT (Hemorrhage After Thrombolysis), SEDAN (blood Sugar, Early infarct and hyper Dense cerebral artery sign on non-contrast computed tomography, Age, and NIHSS) and SPAN-100 (Stroke Prognostication using Age and NIHSS) scores. Conclusions This proposed nomogram based on the score of CDS, the global burden of CSVD, NIHSS score ≥ 13, and OTT ≥ 180 gives rise to a more accurate and more comprehensive prediction for HT in patients with ischemic stroke receiving IV rt-PA treatment.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of intravenous thrombolysis treatment in the region. Results from the SITS-MENA Registry

2019 ◽  
Vol 15 (9) ◽  
pp. 980-987 ◽  
Author(s):  
S Al-Rukn ◽  
M Mazya ◽  
N Akhtar ◽  
H Hashim ◽  
B Mansouri ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle East ◽  
Observational Study ◽  
Prospective Observational Study ◽  
Treatment Time ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Stroke Severity ◽  
University Hospitals ◽  
Mena Region

Background and methods Intravenous thrombolysis for acute ischemic stroke in the Middle-East and North African (MENA) countries is still confined to the main urban and university hospitals. This was a prospective observational study to examine outcomes of intravenous thrombolysis-treated stroke patients in the MENA region compared to the non-MENA stroke cohort in the SITS International Registry. Results Of 32,160 patients with ischemic stroke registered using the SITS intravenous thrombolysis protocol between June 2014 and May 2016, 500 (1.6%) were recruited in MENA. Compared to non-MENA (all p < 0.001), median age in MENA was 55 versus 73 years, NIH Stroke Scale score 12 versus 9, onset-to-treatment time 138 versus 155 min and door-to-needle time 54 min versus 64 min. Hypertension was the most reported risk factor, but lower in MENA (51.7 vs. 69.7%). Diabetes was more frequent in MENA (28.5 vs. 20.8%) as well as smoking (20.8 vs. 15.9%). Hyperlipidemia was less observed in MENA (17.6 vs. 29.3%). Functional independence (mRS 0–2) at seven days or discharge was similar (53% vs. 52% in non-MENA), with mortality slightly lower in MENA (2.3% vs. 4.8%). SICH rates by SITS-MOST definition were low (<1.4%) in both groups. Conclusions Intravenous thrombolysis patients in MENA were younger, had more severe strokes and more often diabetes. Although stroke severity was higher in MENA, short-term functional independency and mortality were not worse compared to non-MENA, which could partly be explained by younger age and shorter OTT in MENA. Decreasing the burden of stroke in this young population should be prioritized.

Collateral Circulation Predicts the Size of the Infarct Core and the Proportion of Salvageable Penumbra in Hyperacute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

2015 ◽  
Vol 40 (3-4) ◽  
pp. 182-190 ◽  
Author(s):  
Harri Rusanen ◽  
Jukka T. Saarinen ◽  
Niko Sillanpää
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Collateral Circulation ◽  
Cerebral Blood Volume ◽  
Treatment Time ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
The Impact

Background: We studied the impact of collateral circulation on CT perfusion (CTP) parametric maps and the amount of salvaged brain tissue, the imaging and clinical outcome at 24 h and at 3 months in a retrospective acute (<3 h) stroke cohort (105 patients) with anterior circulation thrombus treated with intravenous thrombolysis. Methods: Baseline clinical and imaging information were collected and groups with different collateral scores (CS) were compared. Binary logistic regression analyses using good CS (CS ≥2) as the dependent variable were calculated. Results: CTP Alberta Stroke Program Early CT Score (ASPECTS) was successfully assessed in 58 cases. Thirty patients displayed good CS. Poor CS were associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (15 vs. 7, p = 0.005) and at 24 h (10 vs. 3, p = 0.003) after intravenous thrombolysis. Good CS were associated with a longer mean onset-to-treatment time (141 vs. 121 min, p = 0.009) and time to CTP (102 vs. 87 min, p = 0.047), better cerebral blood volume (CBV) ASPECTS (9 vs. 6, p < 0.001), better mean transit time (MTT) ASPECTS (6 vs. 3, p < 0.001), better noncontrast CT (NCCT) ASPECTS (10 vs. 8, p < 0.001) at arrival and with favorable clinical outcome at 3 months (modified Rankin Scale ≤2, p = 0.002). The fraction of penumbra that was salvageable at arrival and salvaged at 24 h was higher with better CS (p < 0.001 and p = 0.035, respectively). In multivariate analysis, time from the onset of symptoms to imaging (p = 0.037, OR 1.04 per minute, 95% CI 1.00-1.08) and CBV ASPECTS (p = 0.001, OR 2.11 per ASPECTS point, 95% CI 1.33-3.34) predicted good CS. In similar multivariable models, MTT ASPECTS (p = 0.04, OR 1.46 per ASPECTS point, 95% CI 1.02-2.10) and NCCT ASPECTS predicted good CS (p = 0.003, OR 4.38 per CT ASPECTS point, 95% CI 1.66-11.55) along with longer time from the onset of symptoms to imaging (p = 0.045, OR 1.03 per minute, 95% CI 1.00-1.06 and p = 0.02, OR 1.05 per minute, 95% CI 1.00-1.09, respectively). CBV ASPECTS had a larger area under the receiver operating characteristic curve for good CS (0.837) than NCCT ASPECTS (0.802) or MTT ASPECTS (0.752) at arrival. Conclusions: Favorable CBV ASPECTS, NCCT ASPECTS and MTT ASPECTS are associated with good CS along with more salvageable tissue and longer time from the onset of symptoms to imaging in ischemic stroke patients treated with intravenous thrombolysis.

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