Abstract TMP12: Does Prehospital Magnesium Sulfate Differentially Improve Outcome in Hyperacute Stroke Patients With Higher Pretreatment Blood Pressure?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Phoebe H Johnson-Black ◽  
Sidney Starkman ◽  
Nerses Sanossian ◽  
David Liebeskind ◽  
Samuel Stratton ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cerebrovascular Disease ◽  
Acute Stroke ◽  
Magnesium Sulfate ◽  
Controlled Trial ◽  
Functional Independence ◽  
Forest Plot ◽  
Stroke Patients ◽  
Improve Outcome ◽  
Acute Cerebral Ischemia

Introduction: Magnesium sulfate (Mg) has blood pressure (BP) lowering, cerebral blood flow enhancing, and neuroprotective effects in preclinical and clinical studies. In the IMAGES phase 3 trial, Mg up to 12h after onset showed no benefit in acute stroke, but was associated with improved outcome in patients with higher blood pressure at entry. Hypothesis: We tested the hypothesis that ultra-early Mg improves functional outcome in acute stroke patients with higher baseline BP. Methods: FAST-MAG is a multicenter, double-blind, randomized, placebo-controlled trial of paramedic-initiated Mg, administered to patients with suspected stroke within 2h of symptom onset. The primary analysis showed neutral effect of Mg. This secondary analysis examines rates of functional independence (mRS 0-2) at 3m for Mg and placebo for different field BP groups. Results: Among 1622 patients with acute cerebrovascular disease, age was 69.6 (±13.4), 42% female, entry deficit severity in the field was LAMS 3.8 (±1.2), and first post-enrollment NIHSS in the ED was 11.5 (±9.9). Systolic blood pressure prior to enrollment was higher among patients with intracerebral hemorrhage (ICH) than acute cerebral ischemia (ACI), 175 (±25) vs 155 (±27), p < .001. The Figure shows the Forest plot for Mg vs placebo and functional independence among blood pressure groups. Heterogeneity of treatment effect was noted in the all-cerebrovascular patients population (p < .01), with fewer independent outcomes with Mg than placebo among patients with higher entry BPs. Analysis of Functional Independence (mRS 0-2) at 90 Days in Prespecified Subgroups Conclusion: This analysis did not confirm the prior finding of magnesium sulfate benefit among acute stroke patients with elevated blood pressure (and actually provided a signal in the opposing direction). Mg was not demonstrated to improve outcome when started in the first 2h of onset among patients with acute cerebrovascular disease and higher blood pressures.

Abstract TP261: Beyond the Golden Hour: Treating Acute Stroke in the Platinum 30 Minutes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Anantbir S Randhawa ◽  
Sidney Starkman ◽  
Nerses Sanossian ◽  
David S Liebeskind ◽  
Gilda Avila ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Study Drug ◽  
Functional Independence ◽  
Multicenter Trial ◽  
Stroke Patients ◽  
Golden Hour ◽  
Treatment Start ◽  
Acute Cerebral Ischemia ◽  
Trial Testing

Background: As hemorrhagic and ischemic strokes progress, acute stroke therapy is time dependent. To emphasize treatment speed for time-sensitive conditions, emergency medicine has developed not only the concept of the “golden hour,” but also the “platinum thirty”. Acute stroke patients treated within the first half-hour of onset have not been previously characterized. Methods: We analyzed all patients with acute stroke symptoms enrolled in the multicenter NIH-funded FAST-MAG trial, testing paramedic prehospital start of neuroprotective agent within 2h of onset. The frequency, demographic, clinical, and outcome features of patients with treatment start within the platinum 30m were compared with later treated patients. Results: Among the 1700 enrolled patients, 180 (10.6%) received study agent within 30 minutes of last known well (LKW). In these platinum-30 patients, final diagnoses were: acute cerebral ischemia in 70.0% (ischemic stroke 59.4%, TIA 10.6%); intracranial hemorrhage in 26.7%; and mimic in 2.8%, similar to the overall study population. Mean age was 68.3 (±13.2) years, 46.1% were women, initial deficit in the field on the Los Angeles Motor Scale was mean 4.1 (±1.2) and early-post-arrival NIHSS deficit was 11.3 (±10.5). Time from LKW to 911 call was median 4m (IQR 2-6); from LKW to paramedic evaluation 10m (IQR 7-12); from LKW to study drug start 27m (IQR 25-29); and from LKW to ED arrival 36m (IQR 31-41). Outcomes at 3 months included freedom from disability (mRS 0-1) in 35.0%, functional independence (mRS 0-2) in 53.3%, and mortality in 17.2%. Demographic, medical history, presenting deficit severity, and 3m outcomes among the platinum-30 patients were largely similar to the 1415 patients treated between 31-120m after onset. Conclusions: Paramedic prehospital initiation of neuroprotection study agent permits treatment start within the platinum first 30 minutes in a substantial proportion of acute ischemic and hemorrhagic stroke patients, accounting for more than 1 in 10 patients enrolled in a multicenter trial. Hyperacute, <30m patients activated the 911 system sooner after onset but were otherwise similar to later patients and are a treatable target in prehospital stroke trials.

scholarly journals Impacts of treatments on recurrence and 28-year survival of ischemic stroke patients

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Ting-Ann Wang ◽  
Tzy-Haw Wu ◽  
Shin-Liang Pan ◽  
Hsiu-Hsi Chen ◽  
Sherry Yueh-Hsia Chiu
Keyword(s):  
Ischemic Stroke ◽  
Cerebrovascular Disease ◽  
Cox Regression ◽  
Controlled Trial ◽  
Stroke Recurrence ◽  
Long Term Effects ◽  
Stroke Patients ◽  
Double Blind ◽  
Term Survival

AbstractAspirin and nicametate are well-established therapies for preventing recurrence and mortality from stroke in patients diagnosed as ischemic stroke. However, their respective effects on the recurrence, making allowance for the duration of recurrence and death without the occurrence of recurrence, and long-term survival have not been well elucidated. We aimed to evaluate long-term effect of two kinds of treatment on cerebrovascular death among ischemic stroke patients with or without the recurrence of stroke. Data used in this study were derived from the cohort based on a multicenter randomized double-blind controlled trial during 1992 to 1995 with the enrollment of a total of 466 patients with first-time non-cardioembolic ischemic stroke who were randomly allocated to receive aspirin (n = 222) or nicametate (n = 244). The trial cohort was followed up over time to ascertain the date of recurrence within trial period and death until Sep of 2019. The time-dependent Cox regression model was used to estimate the long-term effects of two treatments on death from cerebrovascular disease with and without recurrence. A total of 49 patients experienced stroke recurrence and 89 cerebrovascular deaths was confirmed. Patients treated with nicametate were more likely, but non statistically significantly, to have recurrence (aHR: 1.73, 95% CI 0.96–3.13) as compared with those treated by aspirin. Nicametate reduced the risk of cerebrovascular death about 37% (aHR: 0.63, 95% CI 0.41–0.97) compared with aspirin. The aspirin group had a lower recurrence rate than the nicametate group even with recurrence after 1–2 years of follow-up of first stroke but the latter had significantly reduced death from cerebrovascular disease for nicametate group, which requires more research to verify.

Abstract WP471: Significant Factors for Early Independent Toilet Activities in Acute Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Yuki Sawada ◽  
Takahisa Mori ◽  
Yuna Hosaka
Keyword(s):  
Cognitive Function ◽  
Acute Stroke ◽  
Mmse Score ◽  
Multiple Logistic Regression Analysis ◽  
Early Discharge ◽  
Functional Independence ◽  
Lower Limbs ◽  
Stroke Patients ◽  
Trunk Control ◽  
Significant Factors

Introduction: Acute stroke patients have problems with toilet activities. Independent toilet activity in hospitalized patients is important for dischargee to home. Hypothesis: Lower limbs function, trunk control and cognitive function are important factors of early independent toilet activities and discharge to home within 7 days. Methods: We included acute ischemic stroke patients who 1) were admitted from June 2017 to May 2018 and 2) received early rehabilitation treatment. Patients with disturbed level of consciousness were excluded. Functional independence measure (FIM) scale of 6 or 7 was defined as independence and FIM scale of 5 or less as dependence. We evaluated Brunnstrom Recovery Stage (BRS) of arms, fingers and lower limbs, trunk control test (TCT), Mini-Mental State Examination (MMSE) and investigated significant factors of early independent toilet activities and discharge to home within 7 days. Results: One-hundred twenty-four patients met our inclusive criteria. Their average age was 75.8 years, male gender of 63.7%, median BRS of arms, fingers and lower limbs was 5, 5 and 5, median TCT score and MMSE score were 94 and 24.7, respectively. Fifty-three patients were independent in toilet activity and 73 patients were dependent. All patients with independent toilet activity discharged to home within 7 days. In independent and dependent toilet activity patients, an average age was 73.6 and 77.4 (p<0.05), median BRS of arms was 5 and 5 (p<0.01), median BRS of fingers was 6and 5 (p<0.01), median BRS of lower limbs was 5 and 5 (p<0.01), median TCT score was 100 and 61 (p<0.01), and median MMSE score was 27.8 and 22.5 (p<0.01), respectively. Multiple logistic regression analysis showed that MMSE score (p<0.01), TCT score (p<0.01), and BRS of lower limbs (p<0.05) were independent factors for independent toilet activity and discharge to home. Receiver operating characteristic (ROC) curve for early discharge to home demonstrated that cut-off values of MMSE score, TCT score and MRS of lower limbs were 27 or more, 87 or more and 5 or more, respectively. Conclusion: BRS as lower limbs function, TCT as trunk control and MMSE as cognitive function were important factors of early independent toilet activities and early discharge to home.

scholarly journals Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial

2018 ◽  
Vol 14 (3) ◽  
pp. 298-305 ◽  
Author(s):  
Philip M Bath ◽  
Polly Scutt ◽  
Jason P Appleton ◽  
Mark Dixon ◽  
Lisa J Woodhouse ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Glyceryl Trinitrate ◽  
Acute Stroke ◽  
Controlled Trial ◽  
Nitric Oxide Donor ◽  
Main Trial ◽  
Randomized Controlled ◽  
Baseline Characteristics ◽  
The Uk ◽  
Stroke Trial

Background High blood pressure is common in acute stroke and associated with a worse functional outcome. Glyceryl trinitrate, a nitric oxide donor, lowers blood pressure in acute stroke and may improve outcome. Aims Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) tested the feasibility of performing a UK multicenter ambulance-based stroke trial, and the safety and efficacy of glyceryl trinitrate when administered by paramedics before hospital admission. Methods Paramedic-led ambulance-based multicenter prospective randomized single-blind blinded-endpoint parallel-group controlled trial of transdermal glyceryl trinitrate (given for four days) versus sham in patients with ultra-acute (<4 h) presumed stroke. Data are number (%), median (interquartile range) or mean (standard deviation). Results Recruitment ran from October 2015 to 31 May 2018. A total 1149 patients were recruited from eight UK ambulance services and taken to 54 acute hospitals. Baseline characteristics include: mean age 73 (15) years; female 555 (48%); median time from stroke to randomization 70 (45, 115) min; face-arm-speech scale score 2.6 (0.5); and blood pressure 162 (25)/92 (18) mmHg. The final diagnosis was ischemic stroke 52%, hemorrhagic stroke 13%, Transient Ischemic Attack (TIA) 9%, and mimic 25%. The main trial results will be presented in quarter 4 2018. The results will also be included in updated Cochrane systematic reviews, and individual patient data meta-analyses of all relevant randomized controlled trials. Conclusion It was feasible to perform a multicenter ambulance-based ultra-acute stroke trial in the UK and to treat with glyceryl trinitrate versus sham. The relatively unselected cohort of stroke patients is broadly representative of those admitted to hospital in the UK. Trial registration ISRCTN26986053.

scholarly journals Adherence to Post-Acute Rehabilitation Guidelines Improves Functional Recovery in Stroke

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 333-333
Author(s):  
Pamela W Duncan ◽  
Ronnie D Horner ◽  
Dean M Reker ◽  
VA Medical Ctr ◽  
Kansas City ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Acute Stroke ◽  
Functional Recovery ◽  
Stroke Rehabilitation ◽  
Functional Independence ◽  
Case Mix ◽  
Stroke Patients ◽  
Sf 36 ◽  
Acute Rehabilitation

97 Purpose & Methods: To assess if compliance with post-stroke rehabilitation guidelines improves functional recovery. The design of the study was an inception cohort of stroke patients followed prospectively for 6 months. The setting was eleven Department of Veteran Affairs Medical Centers providing care to stroke patients. The subjects included 288 selected patients with stroke admitted between January 1998 - March 1999. Data were abstracted from medical records and telephone interviews. Primary outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and post-acute rehabilitation composite compliance scores (range 0–100) were derived from an algorithm. All outcomes were adjusted for case mix. Results: Average compliance scores in acute and post acute care settings were 68.2% (+ 14) and 69.5% (+ 14.4), respectively. After case-mix adjustment, level of compliance with post-acute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function scores and mortality were not affected by compliance with post-acute rehabilitation guidelines. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. Conclusion: Process of care in post-acute stroke rehabilitation affects 6-month functional recovery. Our findings support the use of guidelines as means of assessing quality of care and improving outcomes. These quality indicators are needed to ensure that quality of care is not comprised with new organizational and funding changes involving post-acute stroke care.

Abstract WP148: Functional Independence Score of Acute Stroke Patients Can Predict Favorable Clinical Outcome at 3 Months After Stroke Onset

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Takashi Johno ◽  
Hiroyuki Kawano ◽  
Masataka Torii ◽  
Hiroshi Kamiyama ◽  
Tatsuo Amano ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Functional Independence ◽  
Stroke Onset ◽  
Stroke Patients ◽  
Favorable Clinical Outcome

Abstract WP140: Functional Independence Scores of Acute Stroke Patients is Associated With Discharge Directly to Home

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Hiroyuki Kawano ◽  
Takashi Johno ◽  
Masataka Torii ◽  
Hiroshi Kamiyama ◽  
Tatsuo Amano ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Independence ◽  
Stroke Patients

scholarly journals The Effect of Early Treatment with Intravenous Magnesium Sulfate on the Incidence of Cardiac Comorbidities in Hospitalized Stroke Patients

2020 ◽  
Vol 2020 ◽  
pp. 1-8
Author(s):  
Kameron Bechler ◽  
Kristina Shkirkova ◽  
Jeffrey L. Saver ◽  
Sidney Starkman ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Adverse Events ◽  
Acute Stroke ◽  
Magnesium Sulfate ◽  
Serum Magnesium ◽  
High Dose ◽  
Stroke Patients ◽  
Serious Adverse Events ◽  
Intravenous Magnesium ◽  
Prophylactic Measures ◽  
Cardiac Adverse Events

Background. Cardiac adverse events are common among patients presenting with acute stroke and contribute to overall morbidity and mortality. Prophylactic measures for the reduction of cardiac adverse events in hospitalized stroke patients have not been well understood. We sought to investigate the effect of early initiation of high-dose intravenous magnesium sulfate on cardiac adverse events in stroke patients. Methods. This is a secondary analysis of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized phase-3 clinical trial, conducted from 2005-2013. Consecutive patients with suspected acute stroke and a serum magnesium level within 72 hours of enrollment were selected. Twenty grams of magnesium sulfate or placebo was administered in the ambulance starting with a 15-minute loading dose intravenous infusion followed by a 24-hour maintenance infusion in the hospital. Results. Among 1126 patients included in the analysis of this study, 809 (71.8%) patients had ischemic stroke, 277 (24.6%) had hemorrhagic stroke, and 39 (3.5%) with stroke mimics. The mean age was 69.5 (SD13.4) and 42% were female. 565 (50.2%) received magnesium treatment, and 561 (49.8%) received placebo. 254 (22.6%) patients achieved the target, and 872 (77.4%) did not achieve the target, regardless of their treatment group. Among 1126 patients, 159 (14.1%) had at least one CAE. Treatment with magnesium was not associated with fewer cardiac adverse events. A multivariate binary logistic regression for predictors of CAEs showed a positive association of older age and frequency of CAEs (R=1.04, 95% CI 1.03-1.06, p<0.0001). Measures of early and 90-day outcomes did not differ significantly between the magnesium and placebo groups among patients who had CAEs. Conclusion. Treatment of acute stroke patients with magnesium did not result in a reduction in the number or severity of cardiac serious adverse events.

CONTROLLED TRIAL OF A HOME-CARE SERVICE FOR ACUTE STROKE PATIENTS

The Lancet ◽  
1985 ◽  
Vol 325 (8424) ◽  
pp. 323-326 ◽  
Author(s):  
DerickT. Wade ◽  
CliveE. Skilbeck ◽  
Richard Langton-Hewer ◽  
David Bainton ◽  
Christopher Burns-Cox
Keyword(s):  
Home Care ◽  
Acute Stroke ◽  
Care Service ◽  
Controlled Trial ◽  
Home Care Service ◽  
Stroke Patients
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