Abstract WP22: Reperfusion Therapy After Neurological Deterioration in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mooseok Park ◽  
Tai Hwan Park ◽  
Sang-Soon Park ◽  
Jong-Moo Park ◽  
Yong-Jin Cho ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Features ◽  
Statistical Significance ◽  
Multivariable Analysis ◽  
Reperfusion Therapy ◽  
Neurological Deterioration ◽  
Large Artery ◽  
Good Outcome ◽  
Intravenous Tissue Plasminogen Activator

Background: Guidelines do not recommend reperfusion therapy in acute ischemic stroke patients with mild symptoms considering low gain compared to the risk. However, some patients with mild first symptoms experience neurological deterioration (ND) after hospitalization. We aimed to analyze clinical features and outcomes of patient who received reperfusion therapy after ND occurred. Methods: We enrolled patients who were admitted within 7 days after acute ischemic stroke or TIA between January 2012 and July 2018 from a multicenter stroke registry database in Korea (CRCS-K). Patients who 1) admitted via emergency room, and 2) received reperfusion therapy including intravenous tissue plasminogen activator and/or endovascular treatment were included. Clinical features and outcomes such as modified Rankin Scale (mRS) score distribution at 3 months after stroke were compared between patients received reperfusion therapy after ND and those without ND before the treatment. Results: Among 51325 patients, 6577 (12.8%) received reperfusion therapy were identified. Reperfusion therapy was performed after ND in 136 patients (2.1%). Mean time of onset to needle is 342.1 and 167.2, and onset to perfusion is 1351.6 and 422.0 in patients treated after ND, and those without, respectively. TIA history was more frequent and atrial fibrillation history was less frequent in patients treated after ND. Initial median (IQR) National Institute of Health Stroke Scale (NIHSS) score was 8 (5 - 12), 10 (6 - 16) in patients treated after ND, and those without, respectively. Large artery atherosclerosis was more frequent in patients treated after ND (42.9 % vs. 26.7%). There was higher rate of good outcome at 90 days in patients treated after ND (84 [61.8%]) compared with those without ND before treatment (3359 [52.2%]; OR, 1.38 [95% CI, 1.02-1.87]). In multivariable analysis, good outcome at 90 days in patients treated after ND lacked statistical significance (OR, 1.06 [95% CI, 0.71-1.62]). There is no significant statistical difference of death at 90 days (13.2% vs. 10.4%, p = 0.364). Conclusion: Reperfusion therapy could apply patients with mild first symptoms experience ND after hospitalization and expect similar prognosis compared to those without ND before the treatment.

Abstract P401: Subocclusive and Occlusive Intracranial Thrombi in Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Lacy S Handshoe ◽  
Joshua Santucci ◽  
Takashi Shimoyama ◽  
Ken Uchino
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Course ◽  
Neurological Deterioration ◽  
High Rate ◽  
Control Group ◽  
Nihss Score ◽  
Good Outcome ◽  
Ct Angiogram ◽  
Group Sex

Background: Non-occlusive thrombus in an intracranial artery in acute ischemic stroke is an uncommon occurrence. We compared the clinical course and outcome of intracranial subocclusive to occlusive thrombi. Methods: We conducted a review of patients who presented with acute ischemic stroke and received CT angiogram at a single comprehensive stroke center from January 2018 to December 2019. Patients with intracranial subocclusive thrombus were compared to a control group with complete occlusion matched for occlusion location. Subocclusive thrombus was reviewed by two raters on CT angiography, disagreement resolved by consensus. Patient and stroke characteristics and the clinical course were analyzed. Neurological deterioration was defined as an increase in NIH Stroke Scale (NIHSS) score > 4 compared from baseline to 48 hours. Good outcome at discharge was defined as modified Rankin Score of ≤2. Results: Among 1151 acute ischemic strokes, there were 896 patients with CT angiograms. Sixteen out of 896 (1.8%) patients had intracranial subocclusive thrombus. Thirty-two with comparable intracranial occlusions were identified. In the subocclusive group, 3 of 16 (19%) of received acute endovascular intervention, compared to 13 of 32 (41%) in the occluded group. Sex, median age or time from last known well to hospital arrival did not differ between the two groups. The subocclusive thrombus group had less severe strokes, with median NIHSS score at arrival 3 compared to 8.5 in the occlusion group (p<0.01) and median NIHSS at discharge 1 compared to 5.5 in the occlusive group (p<0.01). Frequency of neurological deterioration in hospital did not differ between the subocclusive and occluded groups at 48 hours (15% vs 15% p=1.00). The subocclusive group was associated with a good outcome at discharge, OR 0.5.71, 95% confidence interval 1.41-23.1. Conclusion: Intracranial subocclusive thrombus in acute ischemic stroke has a more mild presentation compared to complete intracranial occlusion without a high rate of neurological deterioration.

Abstract WP39: Mechanical Embolectomy for Acute Ischemic Stroke Beyond Six Hours From Symptom Onset Using Advanced MR Imaging

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ryan McTaggart ◽  
Shadi Yaghi ◽  
Daniel C Sacchetti ◽  
Richard Haas ◽  
Shawna Cutting ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mr Imaging ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Lesion Volume ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome

Background: There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods: This is a single institution retrospective study between December 1st, 2015, and July 30 th , 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2. Results: In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusion: Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.

Topographic correlation of infarct area on CT perfusion with functional outcome in acute ischemic stroke

2020 ◽  
Vol 132 (1) ◽  
pp. 33-41 ◽  
Author(s):  
Neil Haranhalli ◽  
Nnenna Mbabuike ◽  
Sanjeet S. Grewal ◽  
Tasneem F. Hasan ◽  
Michael G. Heckman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Ct Perfusion ◽  
Multivariable Analysis ◽  
Reperfusion Therapy ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Logistic Regression Models ◽  
Confounding Variables

OBJECTIVEThe role of CT perfusion (CTP) in the management of patients with acute ischemic stroke (AIS) remains a matter of debate. The primary aim of this study was to evaluate the correlation between the areas of infarction and penumbra on CTP scans and functional outcome in patients with AIS.METHODSThis was a retrospective review of 100 consecutively treated patients with acute anterior circulation ischemic stroke who underwent CT angiography (CTA) and CTP at admission between February 2011 and October 2014. On CTP, the volume of ischemic core and penumbra was measured using the Alberta Stroke Program Early CT Score (ASPECTS). CTA findings were also noted, including the site of occlusion and regional leptomeningeal collateral (rLMC) score. Functional outcome was defined by modified Rankin Scale (mRS) score obtained at discharge. Associations of CTP and CTA parameters with mRS scores at discharge were assessed using multivariable proportional odds logistic regression models.RESULTSThe median age was 67 years (range 19–95 years), and the median NIH Stroke Scale score was 16 (range 2–35). In a multivariable analysis adjusting for potential confounding variables, having an infarct on CTP scans in the following regions was associated with a worse mRS score at discharge: insula ribbon (p = 0.043), perisylvian fissure (p < 0.001), motor strip (p = 0.007), M2 (p < 0.001), and M5 (p = 0.023). A worse mRS score at discharge was more common in patients with a greater volume of infarct core (p = 0.024) and less common in patients with a greater rLMC score (p = 0.004).CONCLUSIONSThe results of this study provide evidence that several CTP parameters are independent predictors of functional outcome in patients with AIS and have potential to identify those patients most likely to benefit from reperfusion therapy in the treatment of AIS.

scholarly journals Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 49-55
Author(s):  
Huong Bich Thi Nguyen ◽  
Thang Huy Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Large Artery ◽  
Limited Information ◽  
Anterior Circulation ◽  
Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

scholarly journals Noninvasive Ventilatory Correction as an Adjunct to an Experimental Systemic Reperfusion Therapy in Acute Ischemic Stroke

2010 ◽  
Vol 2010 ◽  
pp. 1-3
Author(s):  
Kristian Barlinn ◽  
Clotilde Balucani ◽  
Paola Palazzo ◽  
Limin Zhao ◽  
April Sisson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Option ◽  
Treatment Phase ◽  
Reperfusion Therapy ◽  
Complementary Treatment ◽  
Poor Functional Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Obstructive Sleep ◽  
Tissue Plasminogen

Background. Obstructive sleep apnea (OSA) is a common condition in patients with acute ischemic stroke and associated with early clinical deterioration and poor functional outcome. However, noninvasive ventilatory correction is hardly considered as a complementary treatment option during the treatment phase of acute ischemic stroke.Summary of Case. A 55-year-old woman with an acute middle cerebral artery (MCA) occlusion received intravenous tissue plasminogen activator (tPA) and enrolled into a thrombolytic research study. During tPA infusion, she became drowsy, developed apnea episodes, desaturated and neurologically deteriorated without recanalization, re-occlusion or intracerebral hemorrhage. Urgent noninvasive ventilatory correction with biphasic positive airway pressure (BiPAP) reversed neurological fluctuation. Her MCA completely recanalized 24 hours later.Conclusions. Noninvasive ventilatory correction should be considered more aggressively as a complementary treatment option in selected acute stroke patients. Early initiation of BiPAP can stabilize cerebral hemodynamics and may unmask the true potential of other therapies.

Abstract TP8: Safety And Outcome After Endovascular Reperfusion Therapy In Elderly Patients With Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Shyam Prabhakaran ◽  
Kevin N Sheth ◽  
John B Terry ◽  
Raul G Nogueira ◽  
Anat Horev ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Acute Ischemic Stroke ◽  
Neural Plasticity ◽  
Reperfusion Therapy ◽  
P Value ◽  
Nihss Score ◽  
Good Outcome ◽  
Initial Severity ◽  
Baseline Factors

Background: Age is a strong predictor of outcomes following acute ischemic stroke (AIS). Conflicting data exist on whether endovascular reperfusion therapy (ERT) should be offered to patients over 80 years of age. We compared the safety and efficacy of ERT in elderly (> 80 years) compared to non-elderly (< 80 years) patients with AIS. Methods: We collected data from a large multi-center prospective registry of AIS patients treated with ERT. Data were available on demographics, initial severity, angiographic results, hemorrhagic complications using the ECASS criteria, and 3-month functional outcomes using the modified Rankin Scale (mRS). The thrombolysis in myocardial infarction (TIMI) score was used to grade reperfusion. We compared baseline factors, procedural results, and clinical outcomes in those over > 80 years versus those < 80 years. P-value < 0.05 was considered significant. Results: Among 1077 patients with anterior circulation AIS, 223 (20.7%) were > 80 years. Elderly patients were more likely to have atrial fibrillation (54.3% vs. 31.4%, P < 0.001) but less likely to have diabetes (16.1% vs. 24.6%; P=0.046) or smoking (13.2% vs. 32.6%, P<0.001) history. Both groups were similar in other baseline factors, initial NIHSS score, location of occlusions, time from onset to groin puncture. TIMI 2 or 3 reperfusion was achieved in 64.5% of those > 80 vs. 70.7% in those < 80 (P=0.080). Rates of symptomatic hemorrhage and any intracranial hemorrhage were not different between groups. Good outcome at 3 months (mRS 0-2) was noted in 16.5% of elderly compared to 41.5% of non-elderly patients (P<0.001). Amongst elderly patients, the only independent predictor of good outcome was initial NIHSS score (adj. OR 0.882, 95% CI 0.821-0.948); good outcomes were achieved in 32.1% of those with NIHSS score < 10, 16.8% with NIHSS score 11-20, and only 5.9% with NIHSS score > 20. Conclusions: Patients > 80 years account for over one-fifth of those treated with ERT in this large registry and had worse outcomes compared with those < 80 years despite similar initial severity, time to treatment, and procedural results. Other factors such as increased baseline disability, more rapid time to completed infarction, and reduced neural plasticity may be contributing to these findings.

Abstract 164: Outcome Prediction After Endovascular Reperfusion Therapy For Acute Ischemic Stroke: The SNARL Score

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Shyam Prabhakaran ◽  
Kevin N Sheth ◽  
John B Terry ◽  
Raul G Nogueira ◽  
Anat Horev ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Outcome Prediction ◽  
Validation Cohort ◽  
Reperfusion Therapy ◽  
Anterior Circulation ◽  
Derivation Cohort ◽  
Good Outcome ◽  
C Statistic ◽  
Pre Treatment

Background: Tools to predict outcome after endovascular reperfusion therapy (ERT) for acute ischemic stroke (AIS) have previously included only pre-treatment variables. We sought to derive and validate an outcome prediction score based on readily available pre-treatment and treatment factors. Methods: The derivation cohort consisted of 516 patients with anterior circulation AIS from 9 centers from September 2009-July 2011. The validation cohort consisted of 110 patients with anterior circulation AIS from the Penumbra Pivotal Trial. Multivariable logistic regression identified predictors of good outcome, defined as a modified Rankin Score (mRS) of < 2, in the derivation sample; model beta coefficients were used to assign point scores. Discrimination was tested using C-statistics. We then validated the score in the Penumbra cohort and performed calibration (predicted versus observed good outcome) in both cohorts. Results: Good outcome at 3 months was noted in 189 (36.8%) patients in the derivation cohort. The independent predictors of good outcome were A ge (2 pts: <60; 1 pt: 60-79; 0 pts: >79), N IHSS score (4 pts: 0-10; 2 pts: 11-20; 0 pts: > 20), L ocation of clot (2 pts: M2; 1 pt: M1; 0 pts: ICA), R ecanalization (5 pts: TICI 2 or 3), and S ymptomatic hemorrhage (2 pts: none, HT1-2, or PH1; 0 pts: PH2). The outcome (SNARL) score demonstrated good discrimination in the derivation cohort (C-statistic 0.78, 95% CI 0.72-0.78) and validation cohort (C-statistic 0.74, 95% CI 0.64-0.84). There was excellent calibration in each cohort (Figure). Conclusions: The SNARL score is a validated tool to determine the probability of functional recovery among AIS treated with endovascular reperfusion strategies. Unlike previous scores that did not include treatment factors such as successful recanalization or hemorrhagic complications, our score can be applied to patients after treatment and may provide guidance to physicians, patients, and families about expected functional outcome.

scholarly journals Association of Prestroke Glycemic Control With Vascular Events During 1-Year Follow-up

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012729
Author(s):  
Jun Young Chang ◽  
Wook-Joo Kim ◽  
Jee Hyun Kwon ◽  
Ji Sung Lee ◽  
Beom Joon Kim ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Multivariable Analysis ◽  
Large Artery ◽  
Stroke Subtype ◽  
Vascular Events ◽  
Vascular Death ◽  
Ischemic Stroke Subtype

ObjectiveWe evaluated the association between admission HbA1c and subsequent risk of composite vascular events, including stroke, myocardial infarction, and vascular death, in patients with acute ischemic stroke and diabetes.MethodsPatients who had a transient ischemic attack or an acute ischemic stroke within 7 days of symptom onset, and diabetes were included in a retrospective cohort design using the stroke registry of the Clinical Research Center for Stroke in Korea. The association between admission HbA1c and composite vascular events, including stroke, myocardial infarction (MI), and vascular death, during one-year follow-up was estimated using the Fine-Gray model. The risk of composite vascular events according to the ischemic stroke subtype was explored using fractional polynomial and linear-quadratic models.ResultsOf the 18567 patients, 1437 developed composite vascular events during follow-up. In multivariable analysis using HbA1c as a categorical variable, the risk significantly increased at a threshold of 6.8%–7.0%. The influence of admission HbA1c level on the risk of composite vascular events was pronounced particularly among those in whom fasting glucose at admission was ≤130 mg/dL. The optimal ranges of the HbA1c associated with minimal risks for composite vascular events was the lowest for the small vessel occlusion subtype (6.6, [95% confidence internal [CI], 6.3–6.9]), compared to the large artery atherosclerosis (7.3 [95% CI, 6.8–7.9]) or the cardioembolic subtype (7.4[95% CI, 6.3–8.5]).ConclusionIn patients with ischemic stroke and diabetes, the risks of composite vascular events were significantly associated with admission HbA1c. The optimal range of the admission HbA1c was below 6.8%–7.0%, and were different according to the ischemic stroke subtype.

Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusions: Large Multicenter Series and Systematic Review

2016 ◽  
Vol 41 (5-6) ◽  
pp. 306-312 ◽  
Author(s):  
Mikayel Grigoryan ◽  
Diogo C. Haussen ◽  
Ameer E. Hassan ◽  
Andrey Lima ◽  
Jonathan Grossberg ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Anterior Circulation ◽  
Medical Interventions ◽  
Good Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Lower Baseline ◽  
Poor Outcomes

Background: Ischemic strokes due to tandem occlusions (TOs) have poor outcomes if they have been treated with only medical interventions. Recent trials demonstrated the effectiveness of endovascular treatment of acute ischemic stroke due to intracranial occlusions; however, most studies excluded patients with TOs. Methods: Retrospective review of prospectively collected thrombectomy databases from 3 stroke centers between 2011 and 2015. Consecutive patients with tandem extracranial steno-occlusive carotid disease and intracranial occlusions who underwent emergent thrombectomy were selected. Angiographic and clinical outcomes were analyzed; baseline and procedural variables were included in univariate and multivariate analyses to define the independent predictors of good outcomes (90-day modified Rankin Scale ≤2). Results: A total of 100 patients met the study inclusion criteria. The mean age was 64.4 ± 12.5, baseline National Institutes of Health Stroke Scale (NIHSS) 17.6 ± 5.0, time from last known well to puncture 7.3 ± 5.8 h, and Alberta Stroke Program Early CT Score (ASPECTS) 7.5 ± 1.6. Forty percent received intravenous tissue plasminogen activator. Intracranial occlusion sites included: internal carotid artery thrombus, 31%; middle cerebral artery (MCA)-M1, 53%; MCA-M2, 10%; and anterior cerebral artery, 6%. Good outcome was achieved in 42% and successful reperfusion modified thrombolysis in cerebral infarction (mTICI ≥2B) in 88% of the cases, including complete (mTICI 3) reperfusion in 40%. Severe parenchymal hematoma (PH)-2 occurred in 6% of the patients and 90-day mortality was 20%. In the multivariate analysis, younger age (OR 0.93; 95% CI 0.88-0.98; p = 0.004), lower baseline NIHSS (OR 0.84; 95% CI 0.74-0.94; p = 0.003), higher ASPECTS (OR 1.50; 95% CI 1.02-2.19; p = 0.038), and mTICI 3 reperfusion (OR 3.56; 95% CI 1.18-10.76; p = 0.024) were independent predictors of good outcome at 90 days. Conclusions: Acute endovascular treatment of tandem anterior circulation occlusions yields good outcomes and has similar outcome predictors to isolated intracranial occlusions. Given their comparable clinical behavior, these patients should be included in future trials.

Acute Ischemic Stroke Associated with Myocardial Infarction: Challenges and Management

2021 ◽  
Author(s):  
Anusha Boyanpally ◽  
Shawna Cutting ◽  
Karen Furie
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Reperfusion Therapy ◽  
Anterior Wall ◽  
Intravenous Tissue Plasminogen Activator ◽  
Clinical Scenarios ◽  
Increased Risk ◽  
Temporal Succession ◽  
Myocardial Involvement

AbstractAcute ischemic stroke (AIS) and acute myocardial infarction (AMI) may co-occur simultaneously or in close temporal succession, with occurrence of one ischemic vascular event increasing a patient's risk for the other. Both employ time-sensitive treatments, and both benefit from expert consultation. Patients are at increased risk of stroke for up to 3 months following AMI, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, provided anterior wall myocardial involvement has been carefully evaluated. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality.

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