Abstract W P308: A Four-Year Experience of Symptomatic Intracranial Hemorrhage Rate Following Intravenous Tissue Plasminogen Activator at a Comprehensive Stroke Center

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jeffrey C Wagner ◽  
Alessandro Orlando ◽  
Christopher V Fanale ◽  
Michelle Whaley ◽  
Kathryn L McCarthy ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
High Volume ◽  
Stroke Severity ◽  
Chi Square ◽  
Arrival Times ◽  
Intravenous Tissue Plasminogen Activator ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

OBJECTIVE: To describe the 4-year symptomatic intracranial hemorrhage (sICH) rate at a high-volume comprehensive stroke center. METHODS: This was a retrospective observational cohort study. All admitted adult (≥18 years) patients presenting with an ischemic stroke (IS) from 2010 to 2013 were included in this study. Chi-square, Wilcoxon rank-sum, Student’s t-tests and Cochran-Armitage trend tests were used to compare groups and analyze data. sICHs were defined by a 4-point increase in NIHSS within 36h with new ICH seen on CT; sICHs were included only if they were directly related to IV-tPA treatment. Favorable mRS outcome was defined as a score ≤2. In-patient stroke alerts were excluded from door-to-needle (DTN) times. RESULTS: 2673 patients were admitted with IS. Of these, 627 (23%) were treated with IV-tPA (90% <3h from symptom onset, 69% at an outside facility). There was a significant increase in the percentage of IS patients treated with IV-tPA over the four years (p-trend=0.02). Compared to patients not receiving IV/IA therapy, patients receiving IV-tPA had significantly higher NIHSS scores, higher prevalence of atrial fibrillation, hyperlipidemia, and cardioembolic etiology, and lower proportion of small vessel occlusive IS. The median (IQR) DTN was 41m (32-53). In the 627 IS patients treated with IV-tPA, 11 (1.8%) developed a sICH; in 2013, the sICH rate was 0.6% (1/158). IV-tPA patients who developed a sICH were similar to those who were sICH-free; however, sICH patients had a significantly higher proportion of coronary artery disease (p=0.04) and severe strokes (p=0.19), and higher median symptom to arrival times (237m vs 187m, p=0.19), but similar median DTN (40m vs 41m, p=0.84). The in-hospital mortality rate for the IV-tPA group was 11% (n=71), and 37% had favorable mRS discharge scores. CONCLUSIONS: These data show that expeditious care and careful selection of patients for IV-tPA treatment can lead to very low rates of sICHs. The few sICHs subsequent to IV-tPA are likely to be a consequence of long symptom-to-arrival times and stroke severity.

Abstract TMP69: Incidence of Intracranial Hemorrhage After Intravenous Thrombolysis in Telestroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nabeel A Herial ◽  
Evan M Fitchett ◽  
Maureen DePrince ◽  
Giuliana Labella ◽  
Kimon Bekelis ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Intravenous Thrombolysis ◽  
Study Data ◽  
Hemorrhagic Complication ◽  
Stroke Outcomes ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: Promoting intravenous tissue plasminogen activator (IV tPA) in treating eligible patients with acute ischemic stroke (AIS) is critical in reducing overall stroke burden. Effective telestroke networks are proven to facilitate higher rates of IV tPA use. Increasing data on stroke outcomes continues to emerge with expansion of telestroke services nationwide. Objective: To estimate the incidence of intracranial hemorrhage (ICH) in AIS patients treated with IV tPA via telestroke evaluation. Methods: In this study, data from a large telestroke network comprising 36 hospitals from 3 States and associated with a university-based health system and comprehensive stroke center was utilized. Data included total of 3198 acute telestroke evaluations performed within the network between January 2014 and June 2016. Distance of spoke hospitals from the hub ranged between 2.5 and 125 miles. All telestroke consultations were done using the remote presence robotic technology. 15% of all telestroke evaluations and 51% of post-IV tPA patients were transferred to the hub. CT imaging was used for identification and ICH as defined mainly in the NINDS trial was used for comparison. Results: Mean age of patients was 67 years (sd=16) and majority were women (n=1759, 55%). Average NIHSS score at presentation was 7. IV tPA was administered to 18% of all telestroke patients. Post IV tPA, any ICH (symptomatic or not) was noted in 8.7% of patients. Petechial hemorrhage was most frequently reported finding. Rate of any ICH in our telestroke population was relatively lower compared to the ECASS II (39%, p<0.001), ECASS III (27%, p<0.001), SITS-MOST (9.6%, p=0.63), ATLANTIS (11.4%, p=0.30), and higher than the NINDS (6.4%, p=0.29). Conclusions: Higher rate of IV tPA use and lower rate of hemorrhagic complication observed in this large study further supports and strengthens the role of telestroke technology and expertise in treatment of AIS.

scholarly journals How a CT-Direct Protocol at an American Comprehensive Stroke Center Led to Door-to-Needle Times Less Than 30 Minutes

2016 ◽  
Vol 7 (2) ◽  
pp. 70-73 ◽  
Author(s):  
Lisa M. Caputo ◽  
Judd Jensen ◽  
Michelle Whaley ◽  
Mark J. Kozlowski ◽  
Christopher V. Fanale ◽  
...  
Keyword(s):  
Implementation Process ◽  
Evaluation Process ◽  
Protocol Implementation ◽  
Time Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Before And After ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes ( P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

Abstract WMP65: A Dichotomized Cincinnati Prehospital Stroke Score is Correlated With Revascularization Therapy in Acute Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Christopher T Richards ◽  
Eddie Markul ◽  
Leslee Stein-Spencer ◽  
Shyam Prabhakaran
Keyword(s):  
Acute Stroke ◽  
Rank Correlation ◽  
High Volume ◽  
Large Vessel ◽  
Youden Index ◽  
Stroke Severity ◽  
Spearman’S Rank Correlation ◽  
Urban City ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stroke Center

Introduction: Early revascularization improves outcomes in patients with acute stroke, and prehospital identification of patients with large vessel occlusions can result in preferential transport to centers with endovascular capability. Several stroke severity scales have been developed to assist with prehospital triage, but emergency medical services (EMS) provider training on new assessment scales presents challenges. Hypothesis: A dichotomized Cincinnati Prehospital Stroke Scale (CPSS) with a cut-off of 2 correlates with acute stroke revascularization in a large US city. Methods: Patients with confirmed stroke arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large urban city with a single municipal EMS provider were identified. Demographics, prehospital CPSS, initial NIH stroke scale score (NIHSS) at hospital arrival, and type of revascularization (intravenous tissue plasminogen activator [IVtPA] or endovascular) were captured. Spearman’s rank correlation and Mann-Whitney U Test were performed after applying skewness/kurtosis tests. The Youden index was used to identify the optimal cut-off for the dichotomized CPSS. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for revascularization. Results: A total of 144 patients were included; 51% were male, 57% were white, and 33% were black. The mean age was 68.8 years (SD 16.1). A total of 31 patients (21.5%) underwent revascularization, most often with IVtPA alone (n=30). CPSS was ≥2 in 42% of patients, and the median NIHSS in patients with CPSS <2 vs CPSS ≥2 was 2 vs 8 (p<0.0001). CPSS and NIHSS in patients presenting within 4.5 hours were strongly correlated (Spearman's rho = 0.57, p<0.0001). The optimum CPSS cut-off that predicted revascularization was 2, with a sensitivity of 0.79, specificity of 0.81, and a Youden index of 0.61. CPSS ≥2 was strongly associated with revascularization (adjusted OR 14.5, 95% CI 5.0-42.4). Conclusions: Prehospital dichotomized CPSS with a cut-off of 2 is well correlated with acute stroke revascularization in a large US city. Further studies should investigate how the dichotomized CPSS performs in the prehospital identification of stroke patients with large vessel occlusions.

Acute endovascular treatment delivery to ischemic stroke patients transferred within a telestroke network: a retrospective observational study

2016 ◽  
Vol 12 (5) ◽  
pp. 502-509 ◽  
Author(s):  
Jessica Barlinn ◽  
Johannes Gerber ◽  
Kristian Barlinn ◽  
Lars-Peder Pallesen ◽  
Timo Siepmann ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Intravenous Tissue Plasminogen Activator ◽  
Symptomatic Intracranial Hemorrhage ◽  
Stroke Center ◽  
Favorable Functional Outcome

Background Five randomized controlled trials recently demonstrated efficacy of endovascular treatment in acute ischemic stroke. Telestroke networks can improve stroke care in rural areas but their role in patients undergoing endovascular treatment is unknown. Aim We compared clinical outcomes of endovascular treatment between anterior circulation stroke patients transferred after teleconsultation and those directly admitted to a tertiary stroke center. Methods Data derived from consecutive patients with intracranial large vessel occlusion who underwent endovascular treatment from January 2010 to December 2014 at our tertiary stroke center. We compared baseline characteristics, onset-to-treatment times, symptomatic intracranial hemorrhage, in-hospital mortality, reperfusion (modified Treatment in Cerebral Infarction 2b/3), and favorable functional outcome (modified Rankin scale ≤ 2) at discharge between patients transferred from spoke hospitals and those directly admitted. Results We studied 151 patients who underwent emergent endovascular treatment for anterior circulation stroke: median age 70 years (interquartile range, 62–75); 55% men; median National Institutes of Health Stroke Scale score 15 (12–20). Of these, 48 (31.8%) patients were transferred after teleconsultation and 103 (68.2%) were primarily admitted to our emergency department. Transferred patients were younger (p = 0.020), received more frequently intravenous tissue plasminogen activator (p = 0.008), had prolonged time from stroke onset to endovascular treatment initiation (p < 0.0001) and tended to have lower rates of symptomatic intracranial hemorrhage (4.2% vs. 11.7%; p = 0.227) and mortality (8.3% vs. 22.6%; p = 0.041) than directly admitted patients. Similar rates of reperfusion (56.2% vs. 61.2%; p = 0.567) and favorable functional outcome (18.8% vs. 13.7%; p = 0.470) were observed in telestroke patients and those who were directly admitted. Conclusions Telestroke networks may enable delivery of endovascular treatment to selected ischemic stroke patients transferred from remote hospitals that is equitable to patients admitted directly to tertiary hospitals.

Abstract T P3: Safety of Eptifibatide after Full Dose IV tPA and Endovascular Treatment for Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jawad F Kirmani ◽  
Daniel Korya ◽  
Grace Choi ◽  
Jaskiran Brar ◽  
Harina Chahal ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Favorable Outcome ◽  
Stroke Severity ◽  
Categorical Data Analysis ◽  
Exact Test ◽  
Full Dose ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background and Objective: The safety of eptifibatide in combination with IV tPA for ischemic stroke has recently been demonstrated in the CLEAR-ER trial which used .6 mg/kg IV tPA plus eptifibatide (135 mcg/kg bolus and .75mcg/kg/min two-hour infusion) versus standard tPA (.9 mg/kg). Prior studies have also looked into the combination of intra-arterial (IA) tPA and eptifibatide at dosing and duration similar to cardiology literature. Our aim was to compare the safety and efficacy of eptifibatide after full dose IV tPA and endovascular treatment versus full dose IV tPA and endovascular treatment alone. Materials and Methods: We reviewed the records and procedure reports of patients who underwent endovascular treatment for ischemic stroke from 2010-2013 at a university affiliated comprehensive stroke center. Patients who received full dose IV tPA (.9 mg/kg) followed by endovascular treatment were compared with those who had the same treatment, but also received a bolus of 135 mcg/kg of eptifibatide followed by a .5 mcg/kg/min for 20 hours (based on IMPACT-II trial protocol). The initial and discharge NIH Stroke Scale as well as the discharge mRS (DCmRS) were evaluated. A DCmRS of 0 or 1 was considered a favorable outcome, and 2 or more was considered as a unfavorable. Initial stroke severity (NIHSS) was analyzed with logistic regression for baseline comparison and Fisher’s exact test were used for categorical data analysis. Results: We evaluated 2,016 patients with ischemic stroke, of which 230 received IV tPA and 91 (55% female) underwent endovascular treatment, 44 of them also received eptifibatide. Of the 44 patients who received eptifibatide (bolus and 20 hour infusion), 18% (n=8) had a favorable outcome, and in the group that did not receive eptifibatide , 9% (n=4) had a favorable outcome (OR=2.389, 95% CI 0.6645 to 8.589, p= 0.2217). Conclusion: Eptifibatide in combination with full dose IV tPA and endovascular treatment did not increase morbidity in our patient population, and may have improved outcome. Further, larger trials need to be conducted for more definitive results.

scholarly journals Safety and Outcomes of Intravenous tPA in Acute Ischemic Stroke Patients With Prior Stroke Within 3 Months

2020 ◽  
Vol 13 (1) ◽  
Author(s):  
Shreyansh Shah ◽  
Li Liang ◽  
Andrzej Kosinski ◽  
Adrian F. Hernandez ◽  
Lee H. Schwamm ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Tissue Type ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Symptomatic Intracranial Hemorrhage ◽  
Prior Stroke ◽  
Iv Tpa

Background Guidelines recommend against the use of intravenous tPA (tissue-type plasminogen activator; IV tPA) in acute ischemic stroke patients with prior ischemic stroke within 3 months. However, there are limited data on the safety of IV tPA in this population. Methods and Results A retrospective observational study of patients ≥66 years of age linked to Medicare claims and treated with IV tPA at Get With The Guidelines–Stroke hospitals (February 2009 to December 2015). We identified 293 patients treated with IV tPA who had a prior ischemic stroke within 3 months and 30 655 with no history of stroke. Patients with prior stroke had a higher stroke severity (median National Institutes of Health Stroke Scale, 11 [6–19] versus 11 [6–18]; absolute standardized difference, 11.2%) and a higher prevalence of cardiovascular comorbidities. Patients with prior stroke had a higher unadjusted risk for symptomatic intracranial hemorrhage (7.7% versus 4.8%) and in-hospital mortality (12.6% versus 8.9%), but these differences were not statistically significant after adjustment. When stratified by prespecified time epochs, the elevated risk for symptomatic intracranial hemorrhage was seen only within the first 14 days (16.3% versus 4.8%; adjusted odds ratio [aOR], 3.7 [95% CI, 1.62–8.43]) but not in other epochs (2.1% versus 4.8%; aOR, 0.38 [95% CI, 0.05–2.79] for 15–30 days and 7.4% versus 4.8%; aOR, 1.36 [95% CI, 0.77–2.40] for 31–90 days). In addition, patients with prior stroke were significantly more likely to have a combined outcome of in-hospital mortality or discharge to hospice (25.9% versus 17.0%; aOR, 1.70 [95% CI, 1.21–2.38]), less likely to be discharged to home (28.3% versus 32.3%; aOR, 0.72 [95% CI, 0.54–0.98]), or to have good functional outcomes at discharge (modified Rankin Scale, 0–1; 11.3% versus 20.0%; aOR, 0.46 [95% CI, 0.24–0.89]). Conclusions Stroke providers need to continue to be vigilant about the safety of IV tPA in patients with prior stroke, particularly those with an event in the previous 14 days.

Abstract TP22: Outcomes After Endovascular Therapy in a Population With Mild Acute Ischemic Stroke: A 6.5 Year Observational Cohort Study at a High Volume Comprehensive Stroke Center

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Donald Frei ◽  
Alessandro Orlando ◽  
Richard Bellon ◽  
Jeffrey Wagner ◽  
Christopher V Fanale ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Randomized Clinical Trials ◽  
High Volume ◽  
Vessel Occlusion ◽  
Meaningful Improvement ◽  
Early Symptom ◽  
Observational Cohort ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Introduction: Despite suffering mild acute ischemic strokes (AIS, NIHSS≤7), patients have a non-zero risk of significant morbidity and mortality. Intra-arterial therapy (IAT) is clearly effective in non-mild AIS, but mild AISs have been excluded from IAT trials, limiting our understanding of their outcomes after IAT. The objective of this study was to report on patient outcomes in a mild AIS population who received IAT. Methods: We included all adults (≥18) with a mild AIS admitted over 6.5 years to a high-volume comprehensive stroke center and who received IAT. Patients were excluded for any contraindication to IAT (n=240). Outcomes were symptomatic ICH (sICH), in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (>2 vs ≤2). Results: There were 55 patients included in the study (Table 1). Overall, patients were predominately aged 55-79 years, admitted with an NIHSS 4-7, or had hypertension. 72% of patients either had a cardioembolic or large vessel occlusion (LVO), and 73% arrived either 0h to 4.5h, or >6h to <12h from symptom onset. 15 patients also received IV-tPA. There were no sICHs. Mortality was 9%; a majority of deaths were in males, patients with ages 55-79, LVOs, or an early symptom to arrival time. 42% of patients showed a 3-point improvement in NIHSS at discharge; a majority of these patients were white, aged 55-79, or had hyperlipidemia. Ultimately, 45% were discharged with an mRS ≥2. There were no cerebral artery perforations or groin complications. Conclusions: These data highlight the safety of IAT in patients with mild AIS, mirroring the results seen in recent large randomized clinical trials showing efficacy of IAT in the non-mild AIS population. Patients in our study had a non-existent risk of sICH, and a mortality rate similar to literature examining IV-tPA administration in patients with mild AIS. Furthermore, a large proportion of patients showed a clinically meaningful improvement in NIHSS, or were discharged with a favorable mRS.

Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis

2018 ◽  
Vol 11 (1) ◽  
pp. 14-19 ◽  
Author(s):  
Mohammad Ismail ◽  
Xavier Armoiry ◽  
Noam Tau ◽  
François Zhu ◽  
Udi Sadeh-Gonik ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Relative Risk ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Meta Analysis ◽  
Functional Independence ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

BackgroundThe effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke due to large vessel occlusion is time-dependent. While only stroke centers with endovascular capabilities perform MT, many patients who had a stroke initially present to the closest primary stroke centers capable of administering earlier intravenous thrombolysis, and then require to be transferred to a comprehensive stroke center for MT.PurposeTo compare the outcomes of this care pathway (drip and ship (DS)) with that whereby patients are directly transferred to a comprehensive stroke center (mothership (MS)).MethodsWe performed a systematic review and meta-analysis of published studies using several electronic databases to determine whether successful reperfusion (modified Thrombolysis In Cerebral Infarction ≥2b), functional independence at 90 days (modified Rankin Scale score ≤2), symptomatic intracranial hemorrhage, and 90-day mortality differed between those who underwent MT with the DS or the MS treatment pathway. Outcomes were meta-analyzed and the results expressed as adjusted relative risk (aRR) for the primary analysis and unadjusted relative risk (uRR) for secondary analysis.ResultsEight studies including 2068 patients were selected, including one study reporting results fully adjusted for baseline characteristics. Patients undergoing MS had better functional independence than those undergoing DS (uRR=0.87, 95% CI 0.81 to 0.93; aRR=0.87, 95% CI 0.77 to 0.98). No difference was found between the treatment pathways in successful reperfusion (uRR=1.05, 95% CI 0.95 to 1.15; aRR=1.00, 95% CI 0.92 to 1.10), symptomatic intracranial hemorrhage (uRR=1.37, 95% CI 0.91 to 2.06; aRR, 1.53, 95% CI 0.79 to 2.98), and 90-day mortality (uRR=1.00, 95% CI 0.84 to 1.19; aRR=1.21, 95% CI 0.89 to 1.64).ConclusionsPatients who had an acute ischemic stroke admitted directly to a comprehensive stroke center (MS patients) with endovascular capacities may have better 90-day outcomes than those receiving DS treatment. However, major limitations of current evidence (ie, retrospective studies and selection bias) suggest a need for adequately powered studies. Multicenter randomized controlled trials are expected to answer this question.

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