Abstract WP344: Vascular Unloading Technique for Continuous Non-invasive Blood Pressure Monitoring After Intravenous Thrombolysis in Acute Ischemic Stroke: Interim Analysis of a Prospective Method Comparison Study

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Timo Siepmann ◽  
Anne Koehler ◽  
Kristian Barlinn ◽  
Jessica Kepplinger ◽  
Alexandra Prakapenia ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Interim Analysis ◽  
Method Comparison ◽  
Comparison Study ◽  
Non Invasive ◽  
Method Comparison Study ◽  
Iv Tpa ◽  
Vascular Unloading Technique

Introduction: Elevated arterial blood pressure (BP) increases the risk of intracerebral hemorrhage after intravenous (IV) thrombolysis with tPA in acute ischemic stroke (AIS). While arterial BP is usually monitored using intermittent oscillometric measurements with an upper arm cuff, the vascular unloading technique (VUT) provides non-invasive continuous BP monitoring with a finger cuff. Hypothesis: We hypothesized that VUT monitoring is feasible in AIS patients receiving IV tPA, is comparable to the standard technique, and allows detection of BP peaks that might be missed in oscillometric BP monitoring. Methods: We performed an interim analysis of an ongoing prospective method comparison study. AIS patients were simultaneously monitored over 24 h following IV tPA bolus using VUT and contralateral oscillometric BP assessment every 30 min. Results: We present interim data from 15 out of 24 AIS (4 m, 11 f; aged 72.5±14.9 y, mean±SD) receiving IV tPA. Nominal significance level was set to 0.029 in accordance with Pocock’s rule. Missing data were less than 5% for both techniques. There was a positive correlation between VUT and oscillometric BP assessment (Pearson’s correlation coefficient r=0.91, p<0.001 for systolic BP; and r=0.88, p<0.001 for diastolic BP). Bland-Altman analysis confirmed this agreement (figure 1). The mean difference between VUT and oscillometric BP measurements was 9.4±6.1 mmHg for systolic, and 4.5±3.0 mmHg for diastolic BP (p=n.s.). Peaks (systolic BP>180 or diastolic BP>110 mmHg) were detected by VUT monitoring (at least one episode≥5 min) in 12 patients, and by oscillometric BP assessment (≥one time point of measurement) in 7 patients (p<0.01). Conclusions: Our interim data suggest that VUT-based BP monitoring is feasible in AIS patients receiving IV tPA, and might be more sensitive than intermittent oscillometric BP assessment in detecting potentially harmful blood pressure peaks. Figure 1: Bland Altman plot

scholarly journals Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients

2020 ◽  
Vol 11 ◽  
Author(s):  
Benjamin Maïer ◽  
Jean Philippe Desilles ◽  
Mikael Mazighi
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Tissue Type ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Early Reperfusion ◽  
Iv Tpa

Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.

Validity of non-invasive point-of-care hemoglobin estimation in healthy and sick children—a method comparison study

2015 ◽  
Vol 175 (2) ◽  
pp. 171-179 ◽  
Author(s):  
Aditya Bhat ◽  
Amit Upadhyay ◽  
Vijay Jaiswal ◽  
Deepak Chawla ◽  
Dharamveer Singh ◽  
...  
Keyword(s):  
Point Of Care ◽  
Method Comparison ◽  
Comparison Study ◽  
Non Invasive ◽  
Sick Children ◽  
Method Comparison Study

Abstract WMP87: Simulation Based Medical Education Improves Door to Needle Times in Acute Ischemic Stroke Management

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Tapan V Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Ilene Staff ◽  
Gilbert Fortunato ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Simulation Training ◽  
Linear Regression Analysis ◽  
Univariate Analysis ◽  
Multivariate Linear Regression Analysis ◽  
Simulation Based ◽  
Iv Tpa

Introduction: Literature on the effectiveness of simulation based medical education programs used in acute ischemic stroke (AIS) care is scant. In an effort to improve coordination and door to needle time (DNT) for AIS care, a stroke simulation education training program for neurology nursing staff and neurology residents was implemented in a comprehensive stroke center. Methods: Hospital stroke registry was used for retrospective analysis. The study population was defined as all patients treated with IV-tPA for AIS in the emergency room from October 2008 to September 2014. Simulation training was implemented yearly, for a three month period starting from July 2011. All neurology residents and a group of nurses trained to respond to all AIS cases participated. Simulations were standardized, using deliberate practice with a trained live actor portraying stroke vignettes in the presence of a board certified vascular neurologist. During the period of study, there were no changes in Emergency Department stroke triage protocol, or changes in first provider response to AIS. The data was analyzed using IBM SPSS24 software. Results: We identified 448 patients admitted with AIS who were treated with IV-tPA. The average DNT on univariate analysis before and after intervention was 67.9 and 58.3 minutes [p <0.001]. A multivariate linear regression analysis was performed controlling for age, night/day shift, weekday/weekend, and blood pressure at presentation (>185/110). After controlling for confounders we found that simulation training independently reduced the DNT by 9.64 minutes [95% confidence interval (CI) 4.01 - 15.28, p=0.001]. Amongst other co-variates, only the systolic blood pressure >185 was associated with 14.27 minutes of delay in DNT [95% CI 3.36 - 25.191, p=0.011]. Conclusion: Time to thrombolysis from symptom onset is a critical factor in AIS management and evidence shows improving the DNT could improve patient outcomes. In our six year study, integration of simulation based medical education for AIS reduced the average DNT by 9.64 minutes in multivariate analysis. Simulation based medical education therefore should be considered as a standard process for providers involved in the care of AIS patients receiving thrombolytic treatment.

Abstract 2483: No Increased Risk of sICH in tPA Treated Stroke Patients With ECASS Exclusion Criteria

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Carolyn A Cronin ◽  
Nikeith Shah ◽  
Tanya Morovati ◽  
Lisa D Hermann ◽  
Kevin N Sheth
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Exclusion Criterion ◽  
Stroke Patients ◽  
Control Blood Pressure ◽  
Exclusion Criteria ◽  
Increased Risk ◽  
Iv Tpa

Introduction: Only about 2% of ischemic stroke patients are currently treated with IV tPA, with the most common reason for exclusion from treatment being time. The positive results of ECASS III expanded the time window for treatment to 4.5 hours, however it used more stringent exclusion criteria than are in use for <3 hrs in the USA. For patients who present 3-4.5 hours from symptom onset, the scientific advisory from the AHA/ASA recommends use of the more narrow ECASS III criteria. We evaluated the outcomes of patients who had been treated with IV tPA to test the hypothesis that thrombolysis is not safe in patients with one of the additional exclusion criteria (age >80, NIHSS >25, combination of previous stroke and diabetes, aggressive measures required to control blood pressure (IV infusion), or oral anticoagulant treatment). Methods: We performed a retrospective analysis of all acute ischemic stroke patients treated with IV tPA at our tertiary care academic medical center between June 2006 and June 2010. 191 patients were identified and stratified based on presence of each of the listed exclusion criteria. The primary outcomes are rate of symptomatic intracerebral hemorrhage (sICH) and in-hospital mortality. Additionally, patients with and without sICH were analyzed for differences in baseline characteristics. Results: There were 31 patients older than 80 years, 5 with NIHSS >25, 14 with the combination of prior stroke and diabetes, 19 required continuous IV infusions to control blood pressure below 185/110 mmHg, and 11 were taking oral anticoagulants. No exclusion criterion was associated with increased risk of sICH. There was higher in hospital mortality in patients >80 years (5 of 31 (16%) vs. 6 of 160 (4%), p=0.0186, RR = 3.15, 95% CI: 1.50 to 6.59), and those with NIHSS >25 (2 of 5 (40%) vs. 7 of 159 (4.4%), Relative risk = 11.48, 95% CI: 2.19 to 60.30). sICH was associated with atrial fibrillation (5 of 9 (55%), vs. 35 of 182 (19.2%), p=0.021; RR = 4.72, 95% CI: 1.33 to 16.77), larger final infarct volume (mean 173 ml 3 (SEM 43.3) vs. 42 ml 3 (SEM 6.3),p=0.0002), and elevated glucose (mean 166 mg/dL (SEM 23.1) vs. 127 mg/dL (SEM 4.1), p=0.038). Conclusions: In our cohort, none of the exclusion criteria from ECASS III, which were more stringent than those used in 0-3 hour US labeling, were associated with increased risk of sICH. tPA may be safe in these patients, who represent an important patient population of acute stroke patients. In agreement with prior studies, we have found that older patients and those with more severe deficits at presentation have higher mortality after acute ischemic stroke. Prospective studies are urgently needed to determine the safety and efficacy of tPA in this group of patients through all treatment time windows.

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