Abstract TP76: Symptomatic Intracranial Hemorrhage After IV tPA for Acute Ischemic Stroke in Patients with Relative Contraindications

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Kyle C Smith ◽  
Mohammed Alkuwaiti ◽  
Caitlin Bell ◽  
Donna Lindsay ◽  
Angela Heyer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Hemorrhagic Transformation ◽  
Exclusion Criteria ◽  
Exact Test ◽  
Medical Chart Review ◽  
Significant Difference ◽  
The Impact ◽  
Iv Tpa

Introduction: Contraindications to IV tPA in acute ischemic stroke (AIS) limits access to a proven medical therapy. A 2015 AHA review assigned Class 3 recommendations (harm) to IV tPA for AIS patients with prior intracranial hemorrhage (pICH), stroke within the last 3 months (SW3), or low platelets (LP) defined as platelets < 100,000. These recommendations, however, were based on sparse literature, notably only 4 AIS patients with pICH and 31 with LP, were reviewed. Our study further investigates the safety of IV tPA in these patient populations. Methods: We retrospectively reviewed all AIS cases treated with IV tPA at 2 academic centers from 1998-2015 and 2013-2015. Clinical data, including patient demographics, NIHSS, and relative exclusion criteria, was abstracted from each institution’s prospectively maintained stroke database. Neuroimaging and medical chart review was performed by two stroke neurologists. Results: 324 consecutive AIS patients treated with IV tPA were reviewed. We identified 12 patients who met current Class 3 exclusion criteria (eight pICH, two SW3, two LP). Two patients developed symptomatic hemorrhagic transformation and both had pICH (Table). For comparison, the symptomatic ICH rate in AIS patients receiving IV tPA without relative exclusion criteria was 2.37%, a statistically significant difference (p<0.02, using Fisher’s exact test). Conclusions: 12 AIS patients with Class 3 exclusion criteria were treated with IV tPA. Our eight reported cases of IV tPA in pICH patients adds substantially to the existing literature. In this study, 25% of patients with pICH developed symptomatic ICH after IV tPA. Although the low number of eligible patients limits interpretation of our findings, continued caution when considering IV tPA for AIS patients with pICH may be warranted. More data is needed to clarify the impact these relative contraindications have on the treatment of AIS.

Abstract 1122‐000199: Real‐World Bridging with Intra‐Arterial Therapy is Safe After Tenectplase in Patients with Acute Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Sindhu Sahito ◽  
Hemal Patel ◽  
Nasar Ali ◽  
Teye Umanah ◽  
Siddhart Mehta ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Real World ◽  
Subgroup Analysis ◽  
Hemorrhagic Transformation ◽  
Small Subset ◽  
Significant Difference ◽  
Ct Head ◽  
Ich Score

Introduction : The safety profile of IV tenecteplase (TNK) as a bridging therapy to Intra‐arterial therapy (IAT) is not well‐established in patients receiving acute ischemic stroke therapy. Our objective was to evaluate the incidence of hemorrhagic transformation in subjects who received TNK followed by IAT outside of clinical trial setting. Methods : Electronic medical records of subjects with stroke secondary to LVO who received TNK and IAT within 4.5 hours of last known normal were reviewed. CT head within 24 hours post‐TNK was evaluated for hemorrhagic transformation (HT). Severity was determined by ECASS III criteria Symptomatic intracranial hemorrhage was defined as an increase in NIHSS greater than or equal to 4. Clinical outcomes were assessed with NIHSS at admission, discharge and mRS scores at one month. Z score population proportions were used for subgroup analysis. Social Science Statistics was used for data analysis. Results : From October 2020 to April 2021, 20 subjects received IV tenecteplase. Four subjects did not have LVO or undergo IAT and were excluded from study. Four subjects (25%) developed hemorrhagic transformation. Of this subset, 2 subjects (12.5%) had asymptomatic HI‐1, 1 subject had symptomatic HI‐2, and 1 subject had asymptomatic PH‐1. One subject developed intracranial hemorrhage (ICH score 5) outside of stroke region (intraventricular, subarachnoid, infratentorial parenchymal) without evidence of hemorrhagic transformation of ischemic stroke. In subgroup analysis between subjects with HT and without HT, there was no statistically significant difference in intra‐arterial non‐thrombolytics (z = 0.1393, p = 0.44433); there was a trend towards significance in number of passes (z = 1.2534, p = .10565) and periprocedural IV heparin use for intracranial stenting and/or angioplasty (z = 0.9342, p = 0.17619). There was a statistically significant increase of HT when periprocedural IV integrilin (z = 1.6727, p = 0.04746) was used. Conclusions : Our small subset of early real‐world experience demonstrates a higher rate of symptomatic transformation in bridging with TNK when compared with alteplase. Larger prospective studies are needed to validate our findings.

Abstract TP56: The Impact of Early Ischemic Changes on Head CT on Hemorrhagic Conversion and Outcomes in Patients With Acute Ischemic Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ayaz Khawaja ◽  
Karen Albright ◽  
Angela Hays Shapshak ◽  
Harn Shiue ◽  
April Sisson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Hemorrhagic Transformation ◽  
Poor Functional Outcome ◽  
Head Ct ◽  
Increased Risk ◽  
The Impact ◽  
Iv Tpa

Background: Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA. Methods: We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed. Results: A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p<0.0001). For patients treated with IV TPA, EIC was seen more frequently in patients with pre-stroke anticoagulant use (26.3% vs. 6.7%, p=0.010) and less frequently in patients with pre-stroke statin use (15.8% vs. 43.3%, p=0.025). A higher proportion of HT was observed in patients with EIC (12.8% vs. 6.8%, p=0.016 untreated, 36.8% vs. 14.6%, p=0.024 IV TPA) and with hyperdense artery sign (8.2% vs. 3.7%, p=0.022 untreated, 36.8% vs. 15.7%, p=0.035 IV TPA). For untreated patients, EIC was observed in a larger proportion of patients with an NIHSS>14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013). Conclusions: In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.

Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

Abstract P201: Octogenarian and Nonagenarian Outcomes Among Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
RAJAN R GADHIA ◽  
Farhaan S Vahidy ◽  
Tariq Nisar ◽  
Destiny Hooper ◽  
David Chiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Combined Treatment ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Acute Stroke Treatment ◽  
Iv Tpa

Objective: Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80. Methods: We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation. Results: A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively). Conclusion: Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.

Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam H De Havenon ◽  
Christopher Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

Abstract WMP17: Computerized Tomography Perfusion to Characterize Lack of Clinical Improvement After Recanalization in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Alvaro Garcia-Tornel ◽  
Marta Olive-Gadea ◽  
Marc Ribo ◽  
David Rodriguez-Luna ◽  
Jorge Pagola ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Significant Proportion ◽  
Hemorrhagic Transformation ◽  
Vessel Occlusion ◽  
Clinical Recovery ◽  
Good Functional Outcome ◽  
Significant Difference

A significant proportion of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) present poor functional outcome despite recanalization. We aim to investigate computed tomography perfusion (CTP) patterns after EVT and their association with outcome Methods: Prospective study of anterior large vessel occlusion AIS patients who achieved complete recanalization (defined as modified Thrombolysis in Cerebral Ischemia (TICI) 2b - 3) after EVT. CTP was performed within 30 minutes post-EVT recanalization (POST-CTP): hypoperfusion was defined as volume of time to maximal arrival of contrast (Tmax) delay ≥6 seconds in the affected territory. Hyperperfusion was defined as visual increase in cerebral blood flow (CBF) and volume (CBV) with advanced Tmax compared with the unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as a decrease of ≥8 points in NIHSS score at 24h or NIHSS≤2 and good functional outcome by mRS ≤2 at 3 months. Results: One-hundred and forty-one patients were included. 49 (34.7%) patients did not have any perfusion abnormality on POST-CTP, 60 (42.5%) showed hypoperfusion (median volume Tmax≥6s 17.5cc, IQR 6-45cc) and 32 (22.8%) hyperperfusion. DCR appeared in 56% of patients and good functional outcome in 55.3%. Post-EVT hypoperfusion was related with worse final TICI, and associated worse early clinical evolution, larger final infarct volume (p<0.01 for all) and was an independent predictor of functional outcome (OR 0.98, CI 0.97-0.99, p=0.01). Furthermore, POST-CTP identified patients with delayed improvement: in patients without DCR (n=62, 44%), there was a significant difference in post-EVT hypoperfusion volume according to functional outcome (hypoperfusion volume of 2cc in good outcome vs 11cc in poor outcome, OR 0.97 CI 0.93-0.99, p=0.04), adjusted by confounding factors. Hyperperfusion was not associated with worse outcome (p=0.45) nor symptomatic hemorrhagic transformation (p=0.55). Conclusion: Hypoperfusion volume after EVT is an accurate predictor of functional outcome. In patients without dramatic clinical recovery, hypoperfusion predicts good functional outcome and defines a “stunned-brain” pattern. POST-CTP may help to select EVT patients for additional therapies.

Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Nancy Edwards ◽  
Hooman Kamel ◽  
S. Andrew Josephson
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Aneurysms ◽  
Intravenous Thrombolysis ◽  
Aneurysm Rupture ◽  
Exact Test ◽  
Intravenous Tissue Plasminogen Activator ◽  
Unruptured Cerebral Aneurysms ◽  
Risk Of Hemorrhage ◽  
Iv Tpa

Background and Purpose: Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms. Methods: We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms. Results: We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%). Conclusion: Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.

Abstract WP88: Volumetric Measures of Hemorrhagic Transformation After Acute Ischemic Stroke Predicts Neurological Deterioration Better Than Radiologic Classification

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ali Hamzehloo ◽  
Atul Kumar ◽  
Laura Heitsch ◽  
Daniel Strbian ◽  
Agnieszka Slowik ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Neurological Status ◽  
Hemorrhagic Transformation ◽  
Neurological Deterioration ◽  
Receiver Operating Curve ◽  
Early Neurological Deterioration ◽  
Hemorrhage Volume ◽  
The Difference ◽  
The Impact

Introduction: Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) may contribute to neurologic deterioration. The current radiologic classification of HT is qualitative and distinguishes petechial hemorrhagic infarction from parenchymal hematoma (PH-1 and PH-2). However, this grading scheme is subjective and may not accurately reflect the impact of HT on neurological status and outcome. We sought to evaluate whether the volume of hemorrhage was a better marker of deterioration. Methods: We evaluated AIS patients with follow-up CT imaging from a prospective stroke genetics study. HT seen within 36 hours of AI was classified using ECASS criteria. In addition, we outlined all confluent areas of hemorrhage to derive hemorrhage volume (HV). We calculated ΔNIHSS as the difference between baseline and 24-hour NIHSS. Early neurological deterioration (END) was defined as ΔNIHSS of -4 points or more. Association of radiologic HT grade and HV with ΔNIHSS and END were analyzed using linear regression and receiver-operating-curve testing. Results: We analyzed 948 stroke patients with median NIHSS 7 (IQR 4-14), 64% receiving tPA and ΔNIHSS +2 (IQR 0-5). 294 (31%) had HT (146 HI1, 63 HI2, 42 PH1 and 43 PH2). HT was associated with higher baseline NIHSS but not with tPA treatment or ΔNIHSS. END occurred in 113 (12%) including 46 with HT (16%) vs. 67 (10%) without HT (p=0.02). Amongst those with HT, the radiologic grade was not associated with ΔNIHSS or END (20% of PH2, 20% of PH1 vs. 15% of HI1/HI2, p=0.40). However, greater HV was associated with ΔNIHSS (adjusting for baseline NIHSS and tPA, estimate -1.5 point per 10-ml, p=0.0001) and with END (those with END had median HV 7 vs. 3-ml, p=0.001). A cut-off of 12-ml had 45% sensitivity and 90% specificity for END (AUC of 0.72). Conclusion: We demonstrated that while HT was associated with a higher risk of END, the ECASS classification alone did not distinguish those who worsened. It appears that hemorrhage volume may better predict worsening NIHSS and END with moderate sensitivity.

Abstract W P46: Permeability Surface Product as a Predictor of Hemorrhagic Transformation in Acute Ischemic Stroke Intervention

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Matt Parker ◽  
Andrew Matthews ◽  
Neal Rutledge ◽  
Kirk Conrad ◽  
Jeff Luci
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Ct Perfusion ◽  
Hemorrhagic Transformation ◽  
Permeability Change ◽  
Permeability Changes ◽  
Permeability Surface ◽  
Surface Product ◽  
Iv Tpa

Introduction/purpose: A significant complication in the intervention of acute ischemic stroke is hemorrhagic transformation (HT). It has been postulated that perfusion permeability imaging showing increased blood brain barrier permeability can be used to predict hemorrhagic transformation and possibly alter therapies. Materials and Methods: We retrospectively reviewed 1040 sequential CT perfusion scans with permeability surface area product maps calculated using the Patlak model for all patients that exhibited stroke like symptoms between October 2011 and November 2012. The size of the permeability surface product was ranked on a qualitative three-part scale of small, moderate and large permeability changes. A change smaller than 25% of the image was considered a small result. A moderate result is a permeability change that is approximately 25% of the image. A large permeability change exceeds 25% of the image. Follow up non-contrast CT images (>24 hours but <15 days after initial perfusion imaging) were used to determine if HT had occurred in the cases where an increase in permeability surface product was observed. Results: There was a positive increase in permeability maps in 142 of the 1040 cases. The size of the permeability change was moderate to large in 101 of the positive cases (71%). Hemorrhagic transformation was observed in 12 patients that showed an increase in permeability surface product (8.4%). Of the cases that resulted in HT, nine (75%) resulted in an HI1 and HI2 subtypes. There were three (25%) of the more severe parenchymal hemorrhages (PH1, PH2) observed. Out of the 12 positive hemorrhagic transformations four (33%) were treated with iv-TPA and two (17%) received endovascular thrombectomies, while six (50%) did not receive TPA or endovascular intervention. Of the major parenchymal hemorrhages (PH1/2) two occurred after iv-TPA treatment of the stroke, with the other arising after endovascular thrombectomy. No difference was found in the size or degree of the permeability changes and the incidence of HT. Conclusions: Elevated permeability on CT perfusion imaging had no relevant predictive value for hemorrhagic transformation in acute ischemic stroke at our institution.

Abstract 202: The NIH Stroke Scale Can Miss Improvement After IV tPA For Acute Ischemic Stroke

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Elisabeth B Marsh ◽  
Erin Lawrence ◽  
Rafael H Llinas
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Post Treatment ◽  
Functional Improvement ◽  
Stroke Severity ◽  
Post Discharge ◽  
Significant Difference ◽  
The Mean ◽  
Iv Tpa

Background and Objective: The National Institute of Health Stroke Scale (NIHSS) is the most commonly used metric to evaluate stroke severity and improvement following intervention. Despite its advantages as a rapid, reproducible screening tool, it may be too insensitive to adequately capture functional improvement following treatment. We evaluated the difference in rate of improvement by previously accepted criteria (change of ≥4 NIHSS points) versus physician documentation in patients receiving IV tissue plasminogen activator (tPA) for acute ischemic stroke. Methods: Prospectively collected data on all patients receiving IV tPA over a 15 month period were retrospectively reviewed. NIHSS 24 hours post-treatment and on discharge were extrapolated based on examination and compared to NIHSS on presentation. NIHSS scores at post-discharge follow-up were also recorded. Two reviewers evaluated the medical record and determined improvement based on physician documentation. Using tests of proportion, ‘significant improvement’ by NIHSS was compared to physician documentation at each time point. Results: Forty-one patients were treated with IV tPA. The mean admission NIHSS was 8.6 and improved to 6.4 24 hours post-tPA. Twenty-nine of 41 patients (79%) were “better” by documentation; however only 11/41 (27%) met NIHSS criteria for improvement (p compared to documentation <0.001). On discharge, 20/41 patients (49%) met NIHSS criteria for improvement; however a significant difference between physician documentation remained (p=0.04). The mean post-discharge follow-up NIHSS score was 2.0. 20/21 patients (95%) were “better” compared to 16/21 (76%) meeting NIHSS criteria (p=0.08). Conclusion: The NIHSS may inadequately capture functional improvement post-treatment, especially in the days immediately following intervention.

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