Abstract TP318: High White Blood Cell (WBC) Counts Are Predictive of tPA-related Hemorrhage

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Wenjun Deng ◽  
Bo Song ◽  
Lindsay Fisher ◽  
I-Ying Richard Chou ◽  
Maxwell Oyer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Immune System ◽  
Clinical Outcome ◽  
Blood Cell ◽  
White Blood Cell ◽  
Clinical Evidence ◽  
Stroke Onset ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Iv Tpa

Background: Infection is a major complication of ischemic stroke and contributes to the morbidity and mortality of stroke patients. Although growing evidence highlights the close relationship between inflammation and coagulation/fibrinolysis cascades, little has been reported regarding the influence of tPA on human immune system. Here, we explore changes in white blood cell (WBC) counts pre/post IV tPA and their association with tPA-related hemorrhagic transformation (HT). Method: 308 tPA-treated ischemic stroke patients were recruited with IRB approval, of which 16 developed HT within 24 hr post tPA. Routine WBC was analyzed at 1 month pre stroke, during stroke onset and during the first 48 hr post tPA. Result: We found that WBC was significantly increased within 12 hr post IV tPA and gradually reduced after 24 hr (Figure 1A). However, compared with patients without HT, HT patients had much higher levels of WBC throughout tPA treatment, and their WBC remained above normal even after 48 hr (Figure 1B). More importantly, we also found that HT patients had already developed elevated WBC as early as 1 month before their stroke onset (Figure 1B), which was predictive of tPA-related HT (Figure 1C, ROC AUC = 0.889, p = 0.001). Furthermore, the early elevation in WBC post-tPA was not associated with clinical evidence of infection. Conclusion: Our results provide early clinical evidence that in addition to activating fibrinolytic pathway, tPA may also modulate immune system during stroke treatment. In addition, elevated WBC pre-stroke maybe a predictive marker of tPA-related hemorrhage. While elevated WBC early in ischemic stroke was reported to correlate with poorer clinical outcome, the transient peak in WBC post tPA in this patient cohort ultimately had better clinical outcome, and is of interest. Further studies are needed and ongoing to evaluate differential WBC, stroke severity and long term clinical outcome, and to understand the molecular basis of tPA in immune cell modulation.

Abstract WP35: Penumbra Saved in Acute Stroke Patients Treated with IV Thrombolysis Predicts Minimal Infarct Growth Independent of Onset to Treatment

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Marie Luby ◽  
Zurab Nadareishvili ◽  
Kaylie Cullison ◽  
Richard T Benson ◽  
Amie W Hsia ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Independent Predictor ◽  
Lesion Volume ◽  
Stroke Patients ◽  
Volume Increase ◽  
Multimodal Mri ◽  
Favorable Clinical Outcome ◽  
Iv Tpa

Purpose and Hypothesis: The ability to measure the immediate tissue effects in patients treated with thrombolysis ultra-early relative to their known onset has increased. We hypothesized that shorter onset to treatment times (OTT) would lead to more penumbra saved, calculated using multimodal MRI. Methods: Patients were included in this study if they met the following criteria: (1) were admitted between January 2010 and June 1, 2014 at one of two regional stroke centers, (2) had known last seen normal, acute MRI and IV tPA start times, (3) received an admit diagnosis of ischemic stroke, and (4) were treated with standard IV tPA. Penumbral volumes were calculated using the baseline MRI-defined mismatch regions minus the infarcted regions defined by the co-registered DWI at 24 hours. Patients were categorized to the “early” IV tPA cohort if their OTT was ≤ 120 minutes. Infarct growth was quantitatively defined as lesion volume increase > 5 mL from baseline DWI to 5-day FLAIR. Favorable clinical outcome was defined as discharge or later mRS < 2. Results: Sixty-three patients, 23 early- and 40 late-treated, were included in the study with mean age 75 (±15) years, 48% female, median [IQR]: admit NIHSS 10 [5-19], OTT 139 [109-185] minutes, baseline DWI volume 11.2mL [3.5-39.6], baseline MTT volume 120.9mL [37.8-220.7], and baseline mismatch volume 119.3mL [34.6-200.7]. Aside from time-based variables, only the amount of penumbra infarcted at 24 hours (p=0.015) was significantly different between the early- (9mL [1.7-19.7] and late-treated (2.4mL [0.7-7]) cohorts. The patients with favorable outcome were younger (p=0.012) with less severe admit NIHSS (p=0.026), smaller baseline DWI volume (p=0.017), smaller 24 hour DWI volume (p=0.041), and greater percentage of penumbra saved at 24 hours (p=0.010) but no difference in OTT (p=0.267). Using binomial logistic regression, percentage of penumbra saved at 24 hours (95%CI:0.000-0.011, p=0.010) was the only independent predictor of no infarct growth. Conclusions: This study establishes that significantly larger penumbral tissue saved at 24 hours, not early OTT, is predictive of both favorable clinical outcome and no infarct growth.

Abstract TMP14: Contemporary Use of IV Alteplase in Acute Ischemic Stroke Beyond 4.5 Hours of Stroke Onset in Clinical Practice is Rare

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Lee H Schwamm ◽  
Haolin Xu ◽  
Roland Matsouaka ◽  
Shreyansh Shah ◽  
Kevin Sheth ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Stroke Onset ◽  
Stroke Severity ◽  
Advanced Imaging ◽  
Clinical Registry ◽  
The Past ◽  
The Us ◽  
Significant Covariates ◽  
Iv Tpa

Introduction: Two RCTs conducted from 2010-2018 showed benefit in ischemic stroke (IS) of IV tPA >4.5 h from last known well (LKW) using advanced imaging selection. Many subjects were wakeup strokes treated < 4.5 h of symptom discovery (SxD). We assessed the frequency of IV tPA > 4.5 h in the national GWTG-Stroke clinical registry during the same period as the RCTs were performed. Methods: We analyzed all IS hospitalizations between 1/1/09 - 10/1/18 at fully participating GWTG-Stroke sites to identify 219,565 patients at 1919 sites who received IV tPA (no thrombectomy) and had valid LKW, SxD and treatment times recorded. Table shows significant covariates (standardized differences >10%) Results: Treatment beyond 4.5 h from LKW was rare, occurring in 2.19% (n=4798) of all tPA cases, and 50% of those treated were still within 4.5 h from SxD. The distribution of time to treatment in minutes was similar when stroke onset was defined by LKW compared to SxD (median (IQR) 134 (100-174) vs. 125 (94-163)) (Fig). The use of IV tPA at >4.5 h from LKW as a proportion of all tPA cases treated varied substantially across sites (median (IQR) 1.7% (0-3.1%)) but fewer than ~10% of sites had more than 5% of their tPA use occurring beyond 4.5 h. Compared to < 4.5 h, patients treated >4.5 h differed in age, AF, arrival mode/time, stroke severity and hospital region (Table). Conclusions: During the past decade and prior to published RCT evidence that extended window IV tPA was effective, US sites in GWTG-Stroke rarely treated patients beyond the guideline-approved window of 4.5 h. It will be important to monitor adoption of extended window thrombolysis in the US, and determine if additional RCT data are required to change practice.

Abstract WMP120: Pre-stroke Statin Enhancement of Collateralization in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mengmeng Ma ◽  
Jiaying Zhu ◽  
Li He
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Cerebral Artery ◽  
Collateral Circulation ◽  
Stroke Onset ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Statin Use

Background: Recent studies suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcome in case of stroke onset. It was speculated that pre-stroke statin may enhance collateral circulation and result in favorable functional outcome. This study aimed to investigate the association of pre-stroke statin use with leptomeningeal collaterals in acute ischemic stroke patients. Methods: We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 hours from May 2011 to April 2017. CTA imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; admission NIHSS was used to measure stroke severity; modified Rankin scale (mRS) at 90 day was used to measure outcome. Univariate and multivariate analyses were performed. Results: 239 patients met inclusion criteria. 54 patients use statin before stroke onset. Pre-stroke statin use was independently associated with good collateral circulations (rLMCS>10) (OR, 4.786; 95% CI, 1.195 - 19.171; P = 0.027). Pre-stroke statin use was not independently associated with lower stroke severity (NIHSS≤14) (OR, 1.955; 95%CI, 0.657- 5.816; P = 0.228), but pre-stroke statin use was independently associated with good outcome (mRS≤2) (OR, 3.868; 95%CI, 1.325 - 11.289; P = 0.013). Conclusion: Pre-stroke statin use seems enhance collateralization and improve clinical outcomes in patients with acute stroke. However, clinical controlled studies should be used to verify this claim.

Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients

2020 ◽  
Vol 13 (1) ◽  
pp. 14-18 ◽  
Author(s):  
Noel van Horn ◽  
Helge Kniep ◽  
Hannes Leischner ◽  
Rosalie McDonough ◽  
Milani Deb-Chatterji ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Logistic Regression Analysis ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Poor Clinical Outcome ◽  
Poor Outcome

BackgroundIn patients suffering from acute ischemic stroke from large vessel occlusion (LVO), mechanical thrombectomy (MT) often leads to successful reperfusion. Only approximately half of these patients have a favorable clinical outcome. Our aim was to determine the prognostic factors associated with poor clinical outcome following complete reperfusion.MethodsPatients treated with MT for LVO from a prospective single-center stroke registry between July 2015 and April 2019 were screened. Complete reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3–6 was defined as ‘poor outcome’. A logistic regression analysis was performed with poor outcome as a dependent variable, and baseline clinical data, comorbidities, stroke severity, collateral status, and treatment information as independent variables.Results123 patients with complete reperfusion (TICI 3) were included in this study. Poor clinical outcome was observed in 67 (54.5%) of these patients. Multivariable logistic regression analysis identified greater age (adjusted OR 1.10, 95% CI 1.04 to 1.17; p=0.001), higher admission National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI 1.02 to 1.28; p=0.024), and lower Alberta Stroke Program Early CT Score (ASPECTS) (OR 0.6, 95% CI 0.4 to 0.84; p=0.007) as independent predictors of poor outcome. Poor outcome was independent of collateral score.ConclusionPoor clinical outcome is observed in a large proportion of acute ischemic stroke patients treated with MT, despite complete reperfusion. In this study, futile recanalization was shown to occur independently of collateral status, but was associated with increasing age and stroke severity.

Abstract 3563: Ischemic Stroke with Early AM Onset is More Severe but Less Frequent

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
M. Carter Denny ◽  
Karen C Albright ◽  
Amelia K Boehme ◽  
T. Mark Beasley ◽  
Sheryl Martin-Schild
Keyword(s):  
Ischemic Stroke ◽  
Statistical Significance ◽  
Inpatient Rehabilitation ◽  
Stroke Onset ◽  
Time Interval ◽  
Stroke Severity ◽  
Large Artery ◽  
Clotting Factors ◽  
Discharge Disposition ◽  
Iv Tpa

Background: Diurnal fluctuations in clotting factors, occurrence of thrombosis, and stroke have been reported. We sought to evaluate the distribution of stroke occurrence and differences in stroke characteristics and outcomes in a biracial population. Methods: Patients presenting to our center with acute ischemic stroke of known symptom onset were identified by retrospective chart review. Patients were grouped into one of four onset periods: 00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-00:00. We compared demographics, baseline stroke severity, blood pressure and glucose levels, IV tPA treatment rates, stroke etiology, complications, and early clinical outcomes. Results: The 244 patients with a known time of onset were included in analyses; the distribution of stroke onset and comparison of other collected variables are demonstrated in the figure and table , respectively. Stroke onset 00:01-06:00 was less frequent, but associated with significantly higher median NIHSS score (p=0.005). Patients with stroke onset 00:01-06:00 were more often African-American, had atherothrombotic mechanisms (large artery or small artery infarctions), received IV tPA, and had reduced frequency of good mRS, though statistical significance was not achieved. Time interval of stroke onset was not an independent predictor of death, good outcome (mRS 0-2), or favorable discharge disposition (home or inpatient rehabilitation). Discussion: The most severe ischemic strokes occurred in early AM hours, but were less common than stroke onset during other time intervals. A larger sample is required to determine why ischemic stroke is more severe with early AM onset, if blacks are more susceptible to early AM stroke, and if early AM stroke is less responsive to tPA.

Abstract T P298: Impact of Accurate Weight Based Dosing of IV tPA in Acute Ischemic Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Vishal B Jani ◽  
Sopan Lahewala ◽  
Shilpkumar Arora ◽  
Erin Shell ◽  
Anmar Razak ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Statistical Significance ◽  
Categorical Variables ◽  
Stroke Severity ◽  
Fisher Exact Test ◽  
Weight Estimation ◽  
Stroke Patients ◽  
Significant Difference ◽  
Iv Tpa

Background: Accurate weight-based dosing is essential for efficacy and safety of thrombolysis in acute ischemic stroke (AIS). Stroke patients may be unable to communicate correct body weight (BW). Dosing may be estimated which can lead to error. Objective: To assess accuracy of weight estimation and the effect of weight and dosing discrepancy on outcome of patients with AIS Methods: 94 patients receiving IV tpa for AIS in a CSC registry between Feb, 2013 and Jul, 2014 were reviewed. All were given estimated weight based tPA- per patient input or agreement of 2 providers in ER. Accurate weights were obtained and recorded later. Actual weight was used to calculate the ideal TPA doses and compared to the weights and doses used. The cohort was separated into two groups based on weight discrepancy to those 10 kg (non forgiven) discrepancy. Rate of hemorrhage, NIHSS and hospice/mortality were assessed. Difference between categorical variables was tested using the chi-square and Fisher’ Exact Test. Differences between continuous variables were tested using Wilcoxon Rank Sum test and presented with median and IQ range. Results: 86.1% (forgiven cohort) were given the optimal tPA dose despite estimation. There was a significant difference in stroke severity based on admission NIHSS between the cohorts (33.3% in forgiven vs. 69.2% non-forgiven. P=0.04). Stroke severity based on discharge NIHSS did not reach statistical significance (mild: 71.8% vs 63.6%, moderate: 16.9% vs 9.1% and severe: 11.3% vs 27.3%, p = 0.32). 30 days modified Rankin Scale (mRS) was available for 52 pts without any significant difference (good outcome 44.4% vs 57.1%, poor outcome 35.6 % vs 28.6 %, p = 0.82). Statistically non significance toward higher rate of hemorrhagic conversion (6.4% vs 7.7%, p = 0.41), and higher mortality in non-forgiven group (7.41% vs 15.38%, p= 0.33). Conclusion: Accurate BW measurement prior tPA still remains challenging. In this study, weight estimation by 2 providers is fairly accurate. 14 % of the patients with discrepancy of > 10 kg had higher rate of mortality and hemorrhage although this was not statistically significant. Further studies with larger sample sizes are needed to examine the safety of weight estimation in AIS patients who receive IV tpa

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.

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