Abstract WP198: Is There a "Smoker's Paradox" in Acute Reperfusion Therapies?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Reza Bavarsad Shahripour ◽  
John P Donnelly ◽  
Harn Shiue ◽  
Alissa Gadpaille ◽  
Kanika Arora ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Ischemic Stroke ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Nihss Score ◽  
Paradoxical Finding ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background & Purpose: Recent studies have suggested a “smoker’s paradox,” referring to higher recanalization rates and better outcomes after IV thrombolytic therapy for ischemic stroke in smokers compared to nonsmokers. Our goal was to evaluate whether this paradox exists for both IV and endovascular therapies (ET) in our population. Methods: We retrospectively evaluated consecutive AIS patients (March 2014-April 2015) admitted to our comprehensive stroke center. Patients were stratified by treatment: IV tPA, ET, or neither. The primary endpoint was the modified Rankin scale (mRS) at discharge (“favorable outcome” score 0- 2) analyzed by logistic regression adjusted for demographic factors and admission NIHSS score. Successful reperfusion after ET was classified as Thrombolysis in Cerebral Infarction (TICI) scores of 2b or greater on immediate angiographic imaging. Results: Of 765 patients, 29 % were smokers (n= 222) including 63 % white (Table). Among smokers, 15% received tPA and 3% of patients received ET. Among nonsmokers 14% received tPA and 6% received ET. There was no difference in favorable outcome between smokers and nonsmokers in patients treated with tPA (60.6% vs. 52.6%; P= 0.43) or ET (26% vs. 40.0%; P= 0.325). There was no difference between smokers and nonsmokers in re-canalization after ET (70.6 % vs. 70.0%; P= 0.62). In patients without tPA or ET treatment, favorable outcome was more frequent in smokers compared to nonsmokers (66.5% vs. 47.8 %; P< 0.001). In a regression model adjusted for admission NIHSS, age, gender, and race, the prevalence of good outcome in smokers was 18% more than nonsmokers. (PR 1.177; 95% CI: 1.021 - 1.409). Conclusions: Our study did not support presence of the “Smoker’s Paradox” in AIS patients who receive IV or ET therapy. A rigorous adjustment for risk factors is likely to eliminate the paradoxical finding of more frequent favorable outcome in smokers who have not received tPA or ET.

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.

Abstract NS7: Presenting Symptoms and Response to Dysphagia Screen Predict Unfavorable Outcome in Acute Ischemic Stroke Patients Who Do Not Receive IV tPA Due to Mild and Rapidly Improving Stroke Symptoms

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Deborah Camp ◽  
Katja Bryant ◽  
Susan Zimmermann ◽  
Cynthia. Brasher ◽  
Kerrin M Connelly ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Unfavorable Outcome ◽  
Favorable Outcome ◽  
Nihss Score ◽  
Factors Associated ◽  
Presenting Symptoms ◽  
Lower Likelihood ◽  
Iv Tpa

Background & Purpose: Studies have shown that patients who do not receive IV t-PA due to mild and rapidly improving stroke symptoms (MaRISS) are often not discharged home. The purpose of this study was to identify whether presenting symptoms and response to initial dysphagia screen can predict which patients not treated with IV tPA due to MaRISS have an unfavorable outcome. Methods: Acute ischemic stroke (AIS) patients presenting to hospitals participating in the Georgia Coverdell Acute Stroke Registry and not treated with IV t-PA due to MaRISS alone from January 1, 2009 through December 31, 2013 were included in this analysis. Patients who were unable to ambulate or needed assistance to ambulate prior to admission were excluded. Presenting symptoms and response to dysphagia screen were collected from retrospective chart review at participating hospitals. Multivariable regression analysis was used to identify factors associated with a lower likelihood of favorable outcome, defined as discharge to home. During the study period, < 1% of patients presenting to participating hospitals with MaRISS within the 3 hour time window received IV t-PA. Results: Of 841 AIS patients who did not receive IV-tPA due to MaRISS [median NIHSS 1 (Q1-Q3: 0-3)], 160 (19%) did not have a favorable outcome. Factors associated with lower likelihood of a favorable outcome included increasing NIHSS score (per unit OR 0.89, 95% CI 0.84 to 0.93), weakness as the presenting symptom (OR 0.50, 95% CI 0.30 to 0.84), and a failed dysphagia screen (OR 0.43, 95% CI 0.23 to 0.80). Conclusion: Nearly 1 in 5 AIS patients presenting with MaRISS were not discharged to home. Among AIS patients who present with MaRISS and do not receive IV thrombolytic therapy, baseline characteristics including increasing NIHSS score and weakness as a presenting symptom, and a failed dysphagia screen were all associated with a lower likelihood of discharge to home. Given the low rate of patients presenting during the study period, a prospective randomized trial to evaluate IV t-PA treatment focusing on this subgroup of patients is warranted.

Abstract 1122‐000091: Predictors of Symptomatic Hemorrhagic Transformation After Mechanical Thrombectomy in Acute Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Anqi Luo ◽  
Agnelio Cardenas ◽  
Lee A Birnbaum
Keyword(s):  
Risk Factors ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Hemorrhagic Transformation ◽  
Current Standard ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Introduction : Mechanical thrombectomy (MT) has become the current standard of care for large vessel occlusion stroke but is associated with an increased risk of intracranial hemorrhage (ICH). Although several studies have investigated the risk factors, there is still limited, not well‐established data. This study aims to evaluate the risk factors of HT after MT. Methods : We retrospectively reviewed all MT patients who were treated at a single comprehensive stroke center from 12/2016 to 7/2019. Variables included initial NIHSS, blood glucose, initial systolic blood pressure, age, gender, IV tPA, time from door to recanalization, and TICI score. Outcome measures were HT on post‐procedure or 24‐hour post‐tPA head CT/MRI as well as modified Rankin scale (mRS) upon discharge. Results : Among 74 patients (68.8 ± 14 years, men 47.3%), 9 (12.2%) experienced hemorrhagic transformation after thrombectomy. Average admitting NIHSS was significantly higher in the HT group (22 vs 16.8, p = 0.041). TICI 3 after MT was protective for HT (OR 0.078, 95% CI 0.009‐0.663). IV tPA (OR 3.86, 95% CI 1.448‐10.326) was associated with good neurological outcome at discharge (mRS < = 2), but HT was not (OR 0.114, 95% CI 0.013‐0.964). Patients with mRS < = 2 upon discharge were younger (65.2±12 vs 71.9±15, p = 0.04) and had lower initial BG (124±45.8 vs 157±69.6, P = 0.02). Conclusions : TICI 3 score, decreased NIHSS, and lower BG were associated with less HT and better outcomes in our MT cohort. Admitting NIHSS > = 20 may be a reasonable threshold to predict HT after MT. Our findings are consistent with the TICI‐ASPECTS‐glucose (TAG) score to predict sICH; however, we used initial NIHSS as a surrogate for ASPECTS. Further studies may utilize additional quantitative measures such as CTP data to predict HT.

Predictors of Outcome, Complications, and Recanalization of the Solitaire Device

Neurosurgery ◽  
2015 ◽  
Vol 77 (3) ◽  
pp. 355-361 ◽  
Author(s):  
Badih Daou ◽  
Nohra Chalouhi ◽  
Robert M. Starke ◽  
Richard Dalyai ◽  
Kate Hentschel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Univariate Analysis ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Nihss Score ◽  
Flow Restoration ◽  
The Mean

Abstract BACKGROUND: The use of mechanical thrombectomy in the management of acute ischemic stroke is becoming increasingly popular. OBJECTIVE: To identify notable factors that affect outcome, revascularization, and complications in patients with acute ischemic stroke treated with the Solitaire Flow Restoration Revascularization device. METHODS: Eighty-nine patients treated with the Solitaire Flow Restoration Revascularization device (ev3/Covidien Vascular Therapies, Irvine, California) were retrospectively analyzed. Three endpoints were considered: revascularization (Thrombolysis In Cerebral Infarction), outcome (modified Rankin Scale score), and complications. Univariate analysis and multivariate logistic regression were conducted to determine significant predictors. RESULTS: The mean time from onset of symptoms to the start of intervention was 6.7 hours. The average procedure length was 58 minutes. The mean NIH Stroke Scale (NIHSS) score was 16 on arrival and 8 at discharge. Of the patients, 6.7% had a symptomatic intracerebral hemorrhage, 16.8% had fatal outcomes within 3 months post-intervention, and 81.4% had a successful recanalization. Thrombus location in the M1 segment of the middle cerebral artery was associated with successful recanalization (thrombolysis in cerebral infarction 2b/3) (P = .003). Of the patients, 56.6% had a favorable outcome (modified Rankin Scale score at 3 months: 0–2). In patients younger than 80 years of age, 66.7% had favorable outcome. Increasing age (P = .01) and NIHSS score (P = .002) were significant predictors of a poor outcome. On multivariate analysis, NIHSS score on admission (P = .05) was a predictor of complications. On univariate analysis, increasing NIHSS score from admission to 24 hours after the procedure (P = .05) and then to discharge (P = .04) was a predictor of complications. Thrombus location in the posterior circulation (P = .04) and increasing NIHSS score (P = .04) predicted mortality. CONCLUSION: The Solitaire device is safe and effective in achieving successful recanalization after acute ischemic stroke. Important factors to consider include age, NIHSS score, and location.

Abstract 32: Intravenous Tpa Delays Door-to-puncture Time in Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Shashvat Desai ◽  
Jay Dolia ◽  
Kavit Shah ◽  
Merritt Brown ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Empirical Studies ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Negative Effect ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: The current 2018 AHA/ASA Guidelines for early stroke management recommend use of IV tPA in all eligible acute ischemic stroke patients within 4.5 hours of onset while being considered for mechanical thrombectomy (MT). Whether or not tPA administration is beneficial prior to thrombectomy is still an ongoing debate. Potential delay of MT initiation due to tPA start is a major concern but has not been well-delineated in empirical studies. Methods: In a prospective large volume comprehensive stroke center registry, we analyzed all patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with thrombectomy between 2012-2017, who arrived directly from field to ED within 4.5h of last known well. Patients without contraindication to IV-tPA are given bolus dose in the scanner suite and the remainder of the 1h infusion en route to and in the angio-suite to prevent delay. Results: Among 777 thrombectomy patients identified in the database, 237 arrived directly within 4.5 hours from onset, including 65.8% (156) not treated with IV-tPA and 34.2% (81) receiving IV-tPA, both well-matched in age and NIHSS. Overall, the door-to-needle (DTN) time was 40m (IQR31-56), surpassing the Target Stroke national targets (60m and 45m) active during the study period. However, median door-to-puncture (DTP) time was 22m longer in the IV-tPA group, 74 vs 52m (p<0.001). IV-tPA was not independently associated with better recanalization rate (TICI 2B-3 95.9% vs 92.9%) or functional independent outcome (modified Rankin score 0-2) at 90 days, 37.3% vs 39.4%. Conclusion: IV-tPA administration in AIS-LVO was associated with delayed door-to-puncture times in a comprehensive stroke center with efficient DTN times surpassing advanced national targets, without change in recanalization rate or outcomes. Randomized trials are needed to determine the net positive, neutral, or negative effect of IV-tPA in this population.

scholarly journals Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina

2020 ◽  
Vol 78 (1) ◽  
pp. 39-43
Author(s):  
Matías ALET ◽  
Federico Rodríguez LUCCI ◽  
Sebastián AMERISO
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Demographic Data ◽  
Reperfusion Therapy ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Abstract Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Objective: Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke. Methods: Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed. Results: We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%. Conclusions: With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.

Abstract TMP10: Impact on Mechanical Thrombectomy Time Efficiencies Following Hospital Bypass Protocol Implementation: Northwest Ohio Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sharjeel Panjwani ◽  
Julie Shawver ◽  
Rami Abdelaziz ◽  
Gretchen Tietjen ◽  
Mouhammad Jumaa ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prospective Studies ◽  
Mechanical Thrombectomy ◽  
Arterial Occlusion ◽  
Before And After ◽  
Lucas County ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
Early Stroke

Background: Early stroke identification and treatment with mechanical thrombectomy (MT) increases likelihood of favorable outcome. We compared our MT time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: Our RA protocol mandates emergent comprehensive stroke center transfer for patients with RACE score ≥ 5. We compared MT cases for RA patients (N=37) from Jul 2015-Jun 2016 with procedures performed on Stroke Alerts [(SA) N=56] from preceding 2 years. Transfers from outside LC, private transport and inhospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 call to treatment, and outcomes were compared. Results: Treatment times including 911 call to IV tPA treatment, groin puncture, and recanalization were all significantly faster in the RA cohort (see graphic). Overall RA patients achieved recanalization and favorable outcomes at higher rate, although the latter was not statistically significant. Conclusion: Our experience indicates that RA protocol is highly effective in enhancing overall time efficiency for MT and may contribute to improved clinical outcomes. Further prospective studies are warranted.

Abstract TP253: Ongoing Quality Improvement for Acute Ischemic Stroke at Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Shimeng Liu ◽  
Zhu Zhu ◽  
Mohammad Shafie ◽  
Hermelinda Abcede ◽  
Jay Shah ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Discharge ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference ◽  
Time Periods ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: Ongoing quality improvement is essential for better outcomes and healthcare cost control. The aim of this study is to examine the progressive quality benchmarks for acute ischemic stroke (AIS) at an academic comprehensive stroke center (CSC). Methods: We retrospectively analyzed consecutive patients with AIS at University of California Irvine Medical Center from Jan 1 st , 2013 to Dec 31 th , 2018.Demographics and clinical data were collected from the Get-With-The-Guideline (GWTG) -Stroke registry and electronic medical records. Patients were stratified into 3 time periods according to their admission dates: 2013 to 2014; 2015 to 2016; and 2017 to 2018. Quality benchmarks for AIS, including door-to-needle (DTN) times, rates of receiving IV tPA and/or endovascular thrombectomy (EVT), rate of symptomatic intracerebral hemorrhage (sICH), and outcomes at hospital discharge were analyzed to identify trends of quality improvement in the last 6 years. Results: A total of 1369 patients were included in the study; 398 (29%) patients received acute reperfusion therapy, with 231 (17%) receiving IV tPA, 97 (7%) receiving both IV tPA and EVT, 70 (5%) receiving EVT only. There was no significant difference in baseline characteristics of the patients during the 3 time periods. IV tPA rates were 20% in 2013-2014, 30% in 2015-2016, and 22% in 2017-2018 ( p =0.0005). The EVT rates in 2017-2018 (15% vs. 9%; OR: 1.77; 95% CI: 1.16 - 2.68; p = 0.008) and 2015-2016 (14% vs. 9%; OR: 1.70; 95% CI: 1.11 - 2.59; p = 0.01) were significantly higher than in 2013-2014. There were significant ongoing improvements in median DTN times, with 57 minutes in 2013-2014, 45 minutes in 2015-2016, and 39 minutes in 2017-2018. Among patients receiving IV tPA, significantly more patients had favorable outcomes (mRS score 0-3) at hospital discharge in 2015-2016 (67% vs. 42%; OR: 2.80; 95% CI: 1.46 - 5.40; p =0.002) than in 2013-2014. Conclusions: We demonstrate ongoing improvement in rates of IV tPA and EVT as well as DTN times for IV tPA in patients with AIS.

scholarly journals Determinants of extended door-to-needle time in acute ischemic stroke and its influence on in-hospital mortality: results of a nationwide Dutch clinical audit

BMC Neurology ◽  
2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Laurien S. Kuhrij ◽  
◽  
Perla J. Marang-van de Mheen ◽  
Renske M. van den Berg-Vos ◽  
Frank-Erik de Leeuw ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Quality Improvement ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Clinical Audit ◽  
Intravenous Thrombolysis ◽  
Natural Spline ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Abstract Background Intravenous thrombolysis (IVT) plays a prominent role in the treatment of acute ischemic stroke (AIS). The sooner IVT is administered, the higher the odds of a good outcome. Therefore, registering the in-hospital time to treatment with IVT, i.e. the door-to-needle time (DNT), is a powerful way to measure quality improvement. The aim of this study was to identify determinants that are associated with extended DNT. Methods Patients receiving IVT in 2015 and 2016 registered in the Dutch Acute Stroke Audit were included. DNT and onset-to-door time (ODT) were dichotomized using the median (i.e. extended DNT) and the 90th percentile (i.e. severely extended DNT). Logistic regression was performed to identify determinants associated with (severely) extended DNT/ODT and its effect on in-hospital mortality. A linear model with natural spline was used to investigate the association between ODT and DNT. Results Included were 9518 IVT treated patients from 75 hospitals. Median DNT was 26 min (IQR 20–37). Determinants associated with a higher likelihood of extended DNT were female sex (OR 1.17, 95% CI 1.05–1.31) and admission during off-hours (OR 1.12, 95% CI 1.01–1.25). Short ODT correlated with longer DNT, whereas longer ODT correlated with shorter DNT. Young age (OR 1.38, 95% CI 1.07–1.76) and admission to a comprehensive stroke center (OR 1.26, 1.10–1.45) were associated with severely extended DNT, which was associated with in-hospital mortality (OR 1.54, 95%CI 1.19–1.98). Conclusions Even though DNT in the Netherlands is short compared to other countries, lowering the DNT may be achievable by focusing on specific subgroups.

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