Abstract W P240: The Effect of Telestroke Network on Tissue Plasminogen Activator Utilization and Door to Needle Time on Rural Hospitals.

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Karina Castellon Larios ◽  
Katherine Rybka ◽  
Diana Greene-Chandos ◽  
Sergio Bergese ◽  
Michel Torbey
Keyword(s):  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Symptom Onset ◽  
Time Window ◽  
The United States ◽  
Rural Setting ◽  
Nihss Score ◽  
Number Of Patients ◽  
Tissue Plasminogen

Introduction: Stroke is the 4 th leading cause of death in the United States. Only 2-3% of ischemic stroke patients are receiving Tissue plasminogen activator (t-PA) despite an increase in time window to 4.5 hours. With less than 85% of the US population living within 30 minutes of primary stroke centers, it is important to review the effectiveness of telestroke network in delivering t-PA. The Ohio State University Wexner Medical Center (OSUWMC) Telestroke network was established in May 2011. Currently the network expands across 24 spokes located in rural central Ohio. Most of these centers have not given t-PA prior to joining the network. Objective: Evaluate the effectiveness of the OSUWMC telestroke in delivering t-PA for acute ischemic stroke in a rural setting and compare the stroke quality metrics to Ohio Coverdell registered Hospitals. Methods: We conducted a retrospective data review from the OSUWMC Telestroke Network database from May 22, 2011 to November 30, 2012. This included demographics, diagnostic impression, NIHSS score, average symptom onset to ED arrival, average door to CT time, average consult duration. t-PA administration and transfer status to OSUMWC were also collected. Summary statistics were generated using Microsoft Excel (version 2010, Microsoft Corporation) and SAS (version 9.3, SAS Institute). Results: In this study, a total of 422 Telestroke consultations were completed. 180 patients were diagnosed with ischemic stroke (57.5%). Average NIHSS score was 5 ±6, average symptom onset to ED arrival time was 4 hours 26 minutes (n=378), and the average door to CT time was 26 minutes (n=204). Forty-four percent (n=80) were approved to receive IV t-PA; 60% within one hour of ED arrival. From this number of patients thirty percent received t-PA within one hour compared to 38% in Ohio Coverdell hospitals. Conclusion: The implementation of telestroke network can deliver care that is equivalent to primary stroke centers. This approach may be an effective tool for rapid evaluation of patients in remote hospitals that require neurologic specialists.

Abstract T P53: Implementation and Outcome of Intravenous Recombinant Tissue Plasminogen Activator Administered 3-4.5 hour after Stroke in Korea

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Tai Hwan Park ◽  
Keun-Sik Hong ◽  
Sang-Soon Park ◽  
Youngchai Ko ◽  
Soo Joo Lee ◽  
...  
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Time Window ◽  
Recombinant Tissue Plasminogen Activator ◽  
Nihss Score ◽  
Excellent Outcome ◽  
Tissue Plasminogen ◽  
The Difference ◽  
Ischemic Attack ◽  
Iv Tpa

Background: Although the benefit of intravenous recombinant tissue plasminogen activator (IV-TPA) has been proved in patients with 3-4.5 hour after stroke from a randomized trial and observational studies, in which most subjects were Western population. We aimed to determined the safety and efficacy of IV-TPA within the 3- to 4.5-hour window in Korean population. Methods: Using a prospective, web-based registry of consecutive patients with acute stroke or transient ischemic attack (TIA) admitted to 12 academic hospitals in Korea, we enrolled 616 patients receiving IV-TPA therapy within 3 hours and 107 within 3-4.5 hours after stroke onset for this study. Functional outcome measured by modified Rankin scale (mRS) at 3 months after stroke was compared between the two time window cohorts. Symptomatic intracranial hemorrhage (SICH) defined as any apparently extravascular blood in the brain or within the cranium associated with 4 points or more increase in the National Institutes of Health Stroke Scale (NIHSS) score or leading to death was evaluated for safety. Odds ratios (OR) and 95% confidence intervals (CI) was calculated to present the probability of achieving each outcome for patients treated within 3-4.5 hours compared to those treated within 3 hours. Results: The excellent outcome (mRS 0-1) was less often achieved in the 3-4.5 hours cohort than in the within 3 hours cohort (39.3% vs 42.9%), but the difference was not statistically significant after adjusting for age, sex, baseline NIHSS score, weight, glucose, center (adjusted OR [95% CI], 1.26 [0.60-2.65]). The proportion of mRS 0-2 at 3 months (48.6% vs55.7%) was not also different between two groups (adjusted OR [95% CI], 0.80 [0.41-1.54]). The rate of SICH was higher in the 3-4.5 hours cohort than in the within 3 hours cohort (4.7% vs 3.1%), but the difference was not statistically significant (adjusted OR [95% CI], 0.81 [0.20-3.35]). Conclusion: This study shows that IV-TPA therapy within the 3- to 4.5-hour window after ischemic stroke is safe and effective in Korean patients.

scholarly journals Thromboembolic complications following tissue plasminogen activator therapy in patients of acute ischemic stroke - Case report and possibility for detection of cardiac thrombi

Open Medicine ◽  
2018 ◽  
Vol 13 (1) ◽  
pp. 551-555 ◽  
Author(s):  
Junko Yamaguchi ◽  
Kosaku Kinoshita ◽  
Marina Hirabayashi ◽  
Satoshi Hori ◽  
Makoto Furukawa ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Case Report ◽  
Transesophageal Echocardiography ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Time Window ◽  
Ulnar Artery ◽  
Diagnostic Methods ◽  
Thromboembolic Complications ◽  
Tissue Plasminogen

AbstractMany reports focus on the probability of intracranial hemorrhage as a complication after recombinant tissue plasminogen activator (rt-PA) therapy. However, thromboembolic complications are not well discussed. We experienced a case in which severe thromboembolic complications occurred in the right radial and right ulnar artery. Arterial fibrillation was observed in this case. If multiple thrombi exist in the atrium or ventricle, multiple small embolic particles may appear following thrombolytic therapy, and that may be a potential risk of secondary thromboembolic complications due to incomplete dissolution of thrombi. Transesophageal echocardiography is a standard method to detect intracardiac sources of emboli in the case of arterial fibrillation. Transesophageal echocardiography is, however, an invasive method for patients with ischemic stroke during rt-PA therapy. High resolution enhanced CT could be a useful tool and may be a reliable alternative to transthoracic echocardiography. Careful assessment of thromboembolic complications following rt-PA therapy in patients with arterial fibrillation is needed. In this case report and mini review, we would like to discuss about the accurate diagnostic methods to detect cardiac or undetermined embolic sources and provide expedited stroke care. These embolic sources may be more readily discovered during rt-PA therapy within the limited therapeutic time window.

Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network?

2019 ◽  
Vol 26 (6) ◽  
pp. 317-321 ◽  
Author(s):  
Krishna Nalleballe ◽  
Rohan Sharma ◽  
Sukanthi Kovvuru ◽  
Aliza Brown ◽  
Sen Sheng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Time Window ◽  
Traditional Practices ◽  
Next Of Kin ◽  
Support Programme ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen

Objective The purpose of this study was to determine reasons for not giving intravenous tissue plasminogen activator to eligible patients with acute ischemic stroke in a telestroke network. Methods We performed a retrospective analysis of prospectively collected data of patients who were seen as a telestroke consultation during 2015 and 2016 with the Arkansas Stroke Assistance through Virtual Emergency Support programme for possible acute ischemic stroke. Results Total consultations seen were 809 in 2015 and 744 in 2016, out of which 238 patients in 2015 and 247 patients in 2016 received intravenous tissue plasminogen activator. In 2015 and 2016, out of the remaining 571 and 497 patients, 294 and 200 patients respectively were thought to be cases of acute stroke based on clinical evaluation. The most common reasons for not being treated in 2015 and 2016, respectively, were; (a) minimal deficits in 42.17% and 49.5% cases, (b) falling out of the 4.5-hour time window in 22.44% and 22% cases, (c) patient/next of kin refusal in 18.02% and 16.5% cases. Less common reasons included limited functional status, abnormal labs (thrombocytopenia, elevated international normalised ratio (INR)/prothrombin time (PT)/partial thromboplastin time (PTT), hypo or hyperglycemia etc), recent surgery and symptoms being too severe etc. Conclusion ‘Minimal deficits’ and ‘out of time window’ continue to be the major causes for not receiving thrombolysis during acute ischemic stroke in both traditional and telestroke systems. Patient/next of kin refusal was high in our telestroke system when compared to traditional practices. Considering the increasing utility of telestroke this needs to be further looked into, along with the ways to address it.

The multiarm optimization of stroke thrombolysis phase 3 acute stroke randomized clinical trial: Rationale and methods

2020 ◽  
pp. 174749302097834
Author(s):  
S Iris Deeds ◽  
Andrew Barreto ◽  
Jordan Elm ◽  
Colin P Derdeyn ◽  
Scott Berry ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Symptom Onset ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Patients ◽  
Phase 3 ◽  
Tissue Plasminogen ◽  
Stroke Thrombolysis

Background Intravenous recombinant tissue plasminogen activator is the only proven effective medication for the treatment of acute ischemic stroke. Two approaches that may augment recombinant tissue plasminogen activator thrombolysis and prevent arterial reocclusion are direct thrombin inhibition with argatroban and inhibition of the glycoprotein 2b/3a receptor with eptifibatide. Aim The multi-arm optimization of stroke thrombolysis trial aims to determine the safety and efficacy of intravenous therapy with argatroban or eptifibatide as compared with placebo in acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 3 h of symptom onset. Sample size estimate A maximum of 1200 randomized subjects to test the superiority of argatroban or eptifibatide to placebo in improving 90-day modified Rankin scores. Methods and design Multiarm optimization of stroke thrombolysis is a multicenter, multiarm, adaptive, single blind, randomized controlled phase 3 clinical trial conducted within the National Institutes of Health StrokeNet clinical trial network. Patients treated with 0.9 mg/kg intravenous recombinant tissue plasminogen activator within 3 h of stroke symptom onset are randomized to receive intravenous argatroban (100 µg/kg bolus followed by 3 µg/kg/min for 12 h), intravenous eptifibatide (135 µg/kg bolus followed by 0.75 µg/kg/min infusion for 2 h) or IV placebo. Patients may receive endovascular thrombectomy per usual care. Study outcomes The primary efficacy outcome is improved modified Rankin score assessed at 90 days post-randomization. Discussion Multiarm optimization of stroke thrombolysis is an innovative and collaborative project that is the culmination of many years of dedicated efforts to improve outcomes for stroke patients.

Abstract WP242: A Drill Down Analysis of Door-to-Needle Time of Acute Ischemic Stroke Patients Treated with Intravenous Tissue Plasminogen Activator

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Marija Lum ◽  
Jon Schrock
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Symptom Onset ◽  
Demographic Data ◽  
Head Ct ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: Target stroke guidelines recommend a door-to-needle time (DNT) ≤60 minutes for acute ischemic stroke (AIS) patients treated with tissue plasminogen activator (tPA). Research has shown that <30% of patients achieve this goal. It is unclear how the timing of chest radiography (CXR) and electrocardiography (EKG) affect DNT. We studied all steps involved in the evaluation and treatment of AIS with IV tPA to look for causes of delay. Methods: A retrospective review of all AIS patients treated in the ED with IV tPA over a four year period was performed. Transferred patients were excluded. Times comparing intervals from door to head CT, CT result, EKG, CXR, and IV tPA treatment, were evaluated. Demographic data and length of symptom onset were recorded. Non-modifiable delays in treatment were recorded. Data are presented in minutes (min) as medians with interquartile range and χ 2 testing was used as appropriate. Results: A total of 79 AIS patients met inclusion criteria, with 22 (28%) receiving IV tPA ≤60 minutes. Treatment with tPA in ≤60 minutes was significantly greater if symptom onset was >90 minutes (p<0.05) and if the EKG was done after the head CT (p<0.05). There was a change in median CT times with those who received EKG before CT and those who did not, 23 min (15-36 min) and 17 min (10-24min), respectively. Patients who received a CXR before CT had a median CT time of 32 min (21-38min) compared to 19 min (13-27min) for patients who did not. Unavoidable delays related to trauma, intubation, or delayed familial consent occurred in 7 (9%) patients. Post-tPA hemorrhage occurred in 13 (16%) patients. Eight (10%) patients expired. Conclusion: Non-critical studies performed prior to head CT increase DNT. An EKG performed before the head CT is completed increased CT time by 6 minutes and a CXR obtained before the head CT increased CT time by 13 minutes. Physician urgency is also a critical factor in DNT and is diminished in patients who arrive soon after symptom onset. DNT ≤60 minutes for AIS patients are affected by the level of urgency and order of diagnostic studies. Current primary stroke center recommendations of an EKG and CXR within 45 minutes may result in delayed treatment if these studies are performed before the head CT.

Abstract 159: Treatment with Intravenous Tissue Plasminogen Activator in the “Golden Hour” in the National US Get With The Guidelines-Stroke Population

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jeffrey L Saver ◽  
Gregg C Fonarow ◽  
Eric E Smith ◽  
Mathew J Reeves ◽  
Digvijaya Navalkele ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Time Window ◽  
Systems Of Care ◽  
Stroke Treatment ◽  
Golden Hour ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Independent Ambulation

Background: Innovations in prehospital and Emergency Department systems of care increasingly enable IV tissue plasminogen activator (tPA) delivery in the first 60 minutes after onset, a time window not tested in placebo-controlled clinical trials. We sought to characterize efficacy and safety outcomes when tPA is delivered in the “golden hour.” Methods: We analyzed 65,384 acute ischemic stroke patients treated with tPA within 4.5 hours of symptom onset in 1456 hospitals participating in GWTG-Stroke from Jan 2009 to Sept 2013. Multivariable logistic regression modeling was employed to evaluate the independent impact of treatment within 60 minutes of onset on outcome. Results: 878 patients (1.3%) received lytic therapy within 60 minutes of onset, versus 6490 (9.9%) in 61-90m, 46,457 (71.1%) in 91-180m, and 11,559 (17.7%) in 181-270m. Independent patient-level factors associated with treatment in the golden hour were older age (aOR 1.15 per 5 years over age 65), higher NIHSS (aOR, 1.04 per scale point), non-EMS arrival (aOR 1.59), and arrival during on hours (aOR 1.61). Hospital level predictors were higher tPA volume (aOR 1.08 per 5 cases), non-PSC (aOR 1.27), and Western region (aOR 1.38 vs Northeast). Compared with the 61-270m window, treatment within 0-60m was associated with increased independent ambulation at d/c, aOR 1.22 (95% CI 1.03-1.45); discharge to home, aOR 1.25 (1.07-1.45); and being disability-free at d/c, aOR 1.72 (95% CI 1.21-2.46, mRS 0-1). No differences were noted in in-hospital mortality or SICH. Considering all discharge mRS transitions, golden hour treatment showed greatest impact at mRS 0-1 vs 2-6 (Figure). Conclusions: Ischemic stroke treatment with IV tPA in the golden hour is associated with more frequent independent ambulation at discharge, discharge to home, and, especially, being disability free at discharge. These findings support intensive efforts, including Target: Stroke and prehospital thrombolysis, to speed treatment initiation.

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