Abstract T P203: Tissue Plasminogen Activator is Safe Via Telemedicine for Treatment of Mild Acute Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kasey Gildersleeve ◽  
Amanda L Jagolino ◽  
Hari Kishan Indupuru ◽  
Chunyan Cai ◽  
Mohammad H Rahbar ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Severe Stroke ◽  
Significant Difference ◽  
Tissue Plasminogen ◽  
Stroke Group ◽  
Baseline Characteristics ◽  
Mild Stroke ◽  
Iv Tpa

Objective: Telemedicine (TM) has increased the use of intravenous (IV) tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Administration of tPA via TM has been shown to be safe when given in the setting of established treatment guidelines. Debate exists regarding the use of tPA in patients deemed to have “mild” stroke. We report our study demonstrating the safety of tPA via TM for mild stroke. Methods: In this retrospective chart review from 4/12 to 4/13, we identified 137 patients who were given IV-tPA via TM in our 14 spoke network. Baseline characteristics and clinical variables were abstracted. We defined mild stroke by NIHSS of ≤4. Poor outcomes were defined as symptomatic intracranial hemorrhage (sICH), neurological worsening (an increase in NIHSS of ≥2 points regardless of cause of decline), angioedema, and death. Logistic regression analysis was performed between groups with NIHSS≤4 and NIHSS>4. Results: Table 1 depicts baseline characteristics. Of 137 patients, 27 presented with an NIHSS≤4 (20%) and 110 with an NIHSS>4 (80%). Although rates of sICH were higher in patients with NIHSS>4 compared to those with NIHSS≤4, there was no significant difference (1.8% vs 0%) (Table 2). There was no significant difference in the rates of neurologic worsening between mild (3.7%) and severe strokes (7.3%) (p<0.69). While rates of angioedema were higher in patients with severe stroke, this increment was not significant (0.9% vs 0%) (Table 2). Four deaths occurred in the severe stroke group compared to none in the mild stroke group, with no significant difference (Table 2). Conclusion: Our results suggest that IV tPA given via TM did not increase the risk of complications in patients with mild stroke. However, our sample size was small and we cannot rule out that some of the mild stroke patients had stroke mimics. Our results support using TM to enroll patients at community hospitals in the upcoming PRISM trial testing the efficacy of tPA in patients with mild stroke.

scholarly journals Imaging Evidence for Cerebral Hyperperfusion Syndrome after Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

2016 ◽  
Vol 2016 ◽  
pp. 1-5
Author(s):  
Yi Zhang ◽  
Abhay Kumar ◽  
John B. Tezel ◽  
Yihua Zhou
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Cerebral Hyperperfusion Syndrome ◽  
Hyperperfusion Syndrome ◽  
Cerebral Hyperperfusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background. Cerebral hyperperfusion syndrome (CHS), a rare complication after cerebral revascularization, is a well-described phenomenon after carotid endarterectomy or carotid artery stenting. However, the imaging evidence of CHS after intravenous tissue plasminogen activator (iv tPA) for acute ischemic stroke (AIS) has not been reported.Case Report. Four patients were determined to have manifestations of CHS with clinical deterioration after treatment with iv tPA, including one patient who developed seizure, one patient who had a deviation of the eyes toward lesion with worsened mental status, and two patients who developed worsened hemiparesis. In all four patients, postthrombolysis head CT examinations were negative for hemorrhage; CT angiogram showed patent cervical and intracranial arterial vasculature; CT perfusion imaging revealed hyperperfusion with increased relative cerebral blood flow and relative cerebral blood volume and decreased mean transit time along with decreased time to peak in the clinically related artery territory. Vascular dilation was also noted in three of these four cases.Conclusions. CHS should be considered in patients with clinical deterioration after iv tPA and imaging negative for hemorrhage. Cerebral angiogram and perfusion studies can be useful in diagnosing CHS thereby helping with further management.

Systemic Inflammation Indices in Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator: Clinical Yield and Utility

Angiology ◽  
2020 ◽  
pp. 000331972096999
Author(s):  
Mehmet Akif Topcuoglu ◽  
Mehmet Yasir Pektezel ◽  
Ezgi Yilmaz ◽  
Ethem Murat Arsava
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Clinical Utility ◽  
Lymphocyte Ratio ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Immune Inflammation ◽  
Iv Tpa

Inflammation indices derived from complete blood counts (CBCs) have been proposed to estimate benefit and risk of intravenous (IV) tissue plasminogen activator (tPA) in acute ischemic stroke. In 165 acute ischemic patients, the neutrophil-to-lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio, and systemic immune-inflammation index (SII) were calculated before and 24 hours after IV tPA. The area under receiver operating characteristic (AUC-ROC) curves, and positive and negative likelihood ratios (+LR,−LR) were produced to measure their diagnostic accuracy and clinical utility for tPA effectiveness, hemorrhage risk and third-month prognosis. None of the indices obtained “before” IV-tPA was found to be useful in determining acute and long-term functional efficacy and bleeding risk. Lymphocyte decrease, neutrophil increase, and parallel NLR and SII increase at the 24th-hour were associated with poor functional outcome. However, their clinical utility was not sufficient due to absence of effective thresholds. NLR threshold >5.65 provided ROC-AUC 0.86, sensitivity 71.3%, specificity 65.7%, −LR 0, +LR 3.76, and SII threshold >1781 had ROC-AUC 0.802, sensitivity 58.7%, specificity 72.7%, −LR 0.11, +LR 4.52, corresponding to an acceptable clinical yield. Systemic immune-inflammation index and NLR, but not other CBC-derived inflammatory parameters, have moderate utility as marker of tPA-related symptomatic hemorrhage occurrence.

Abstract TP69: Administration of Tissue Plasminogen Activator: to Wait or not to Wait for Screening Coagulation Tests? Impact on Door to Needle Time and Symptomatic Intracerebral Hemorrhage

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Katie W Dahlberg ◽  
James Selph ◽  
Parth Thakker ◽  
Lauren C Dennis ◽  
Amanda Cotter ◽  
...  
Keyword(s):  
African American ◽  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Test Results ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Coagulation Tests ◽  
Tissue Plasminogen ◽  
Iv Tpa

Introduction and Hypothesis: Administration of intravenous tissue plasminogen activator (IV tPA) is currently the only FDA approved medical treatment for acute ischemic stroke. To improve outcomes the goal is to have reduced door to needle time (DTN) to IV tPA. Guidelines recommend obtaining coagulation tests prior to IV tPA, but new prescribing information suggest physicians may not need to wait for coagulation test results in patients not on anticoagulation therapy. We assessed the hypothesis if not waiting for these tests prior to IV tPA reduced the DTN time, without affecting the rate of symptomatic intracerebral hemorrhage (SICH). Methods: The study is a retrospective analysis of prospectively collected data on acute ischemic stroke patients treated at a Joint Commission Certified Stroke Center. Based on differing physician practices, patients received IV tPA prior to results of screening coagulation tests or they received IV tPA after tests returned. Measures obtained from chart review included initial NIH stroke scale (NIHSS), DTN time, lab return time, abnormal lab results, and development of post IV tPA SICH (defined as ICH associated with an NIHSS increase ≥4). Results: From January 2013 to May 2015, 136 patients received IV tPA. (Mean age ± SD = 65 ± 15 years, 53% male, 46% African American, 51% Caucasian, and 2% other, median NIHSS = 10, mean DTN ± SD = 65 ± 35 min). Group one, 102 patients, received IV tPA after test results were available (Mean age ± SD = 66 ± 15 years, 51% male, 50% African American, 48% Caucasian, and 2% other, median NIHSS = 10, mean DTN ± SD = 71 ± 34 min). Group two, 34 patients, received IV tPA prior to test results being available (Mean age ± SD = 64 ± 15 years, 59% male, 35% African American, 62% Caucasian, and 3% other, median NIHSS = 12, mean DTN ± SD = 46 ± 31 min). Group two had a significantly reduced DTN time (t test p<0.0002). No abnormal screening coagulation tests were found upon final review. There was no difference between in the rates of SICH (group one 4%, group two 6%, Fisher's exact test p>0.99). Conclusions: Selection of appropriate patients to receive IV tPA without waiting for screening coagulation tests to be returned, significantly improved DTN time. There was no significant difference between the rates of SICH in the two groups.

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.

scholarly journals Endovascular therapy in acute ischemic stroke: The way forward after results from the IMS 3, SYNTHESIS and MR Rescue trials

2013 ◽  
Vol 02 (02) ◽  
pp. 115-118 ◽  
Author(s):  
Bijoy Menon ◽  
Mayank Goyal
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Endovascular Therapy ◽  
Current Status ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

AbstractEndovascular therapy (EVT) has gained vogue in the management of patients with acute stroke. Newer stent-retriever devices have led to better recanalization rates. In many centers, EVT is slowly being used as an add on to or in some instances, even as an alternative to intravenous tissue plasminogen activator (IV tPA). The publication of the results of the SYNTHESIS expansion, Interventional Management of Stroke III and Mechanical Retrieval Recanalization of Stroke Clots Using Embolectomy trials in 2013 has questioned the enthusiastic use of EVT in acute stroke. They demonstrate that EVT (using a variety of devices) is no superior to IV tPA in the management of acute stroke. In the light of these controversial findings, we review the current status of EVT in the management of acute stroke.

scholarly journals Mechanical Thrombectomy With and Without Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Using Nested Knowledge

2021 ◽  
Vol 12 ◽  
Author(s):  
Gautam Adusumilli ◽  
John M. Pederson ◽  
Nicole Hardy ◽  
Kevin M. Kallmes ◽  
Kristen Hutchison ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: Mechanical thrombectomy (MT) is now the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation and may be performed irrespective of intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure. This study aims to understand better if tPA leads to higher rates of reperfusion and improves functional outcomes in AIS patients after MT and to simultaneously evaluate the functionality and efficiency of a novel semi-automated systematic review platform.Methods: The Nested Knowledge AutoLit semi-automated systematic review platform was utilized to identify randomized control trials published between 2010 and 2021 reporting the use of mechanical thrombectomy and IV-tPA (MT+tPA) vs. MT alone for AIS treatment. The primary outcome was the rate of successful recanalization, defined as thrombolysis in cerebral infarction (TICI) scores ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS) 0–2, 90-day mortality, distal embolization to new territory, and symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure.Results: We subjectively found Nested Knowledge to be highly streamlined and effective at sourcing the correct literature. Four studies with 1,633 patients, 816 in the MT+tPA arm and 817 in the MT arm, were included in the meta-analysis. In each study, patient populations consisted of only tPA-eligible patients and all imaging and clinical outcomes were adjudicated by an independent and blinded core laboratory. Compared to MT alone, patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10; 1.63]). However, there were no statistically significant differences in the rates of 90-day mRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67; 1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI: 0.80; 1.72]).Conclusions: Administering tPA prior to MT may improve the rates of recanalization compared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in this review. Further studies looking at the role of tPA before mechanical thrombectomy in different cohorts of patients could better clarify the role of tPA in the treatment protocol for AIS.

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