scholarly journals Influence of the COVID-19 Pandemic on Treatment Times for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 40-47
Author(s):  
James E. Siegler ◽  
Alicia M. Zha ◽  
Alexandra L. Czap ◽  
Santiago Ortega-Gutierrez ◽  
Mudassir Farooqui ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Interquartile Range ◽  
Continuous Variables ◽  
Significant Delay ◽  
Lower Odds ◽  
Collateral Effect ◽  
Novel Coronavirus

Background and Purpose: The pandemic caused by the novel coronavirus disease 2019 (COVID-19) has led to an unprecedented paradigm shift in medical care. We sought to evaluate whether the COVID-19 pandemic may have contributed to delays in acute stroke management at comprehensive stroke centers. Methods: Pooled clinical data of consecutive adult stroke patients from 14 US comprehensive stroke centers (January 1, 2019, to July 31, 2020) were queried. The rate of thrombolysis for nontransferred patients within the Target: Stroke goal of 60 minutes was compared between patients admitted from March 1, 2019, and July 31, 2019 (pre–COVID-19), and March 1, 2020, to July 31, 2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. Results: Of the 2955 patients who met inclusion criteria, 1491 were admitted during the pre–COVID-19 period and 1464 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. Patients treated during COVID-19 were at lower odds of receiving thrombolysis within 60 minutes of arrival (odds ratio, 0.61 [95% CI, 0.38–0.98]; P =0.04), with a median delay in door-to-needle time of 4 minutes ( P =0.03). The lower odds of achieving treatment in the Target: Stroke goal persisted after adjustment for all variables associated with earlier treatment (adjusted odds ratio, 0.55 [95% CI, 0.35–0.85]; P <0.01). The delay in thrombolysis appeared driven by the longer delay from imaging to bolus (median, 29 [interquartile range, 18–41] versus 22 [interquartile range, 13–37] minutes; P =0.02). There was no significant delay in door-to-groin puncture for patients who underwent thrombectomy (median, 83 [interquartile range, 63–133] versus 90 [interquartile range, 73–129] minutes; P =0.30). Delays in thrombolysis were observed in the months of June and July. Conclusions: Evaluation for acute ischemic stroke during the COVID-19 period was associated with a small but significant delay in intravenous thrombolysis but no significant delay in thrombectomy time metrics. Taking steps to reduce delays from imaging to bolus time has the potential to attenuate this collateral effect of the pandemic.

scholarly journals Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States

Stroke ◽  
2020 ◽  
Vol 51 (11) ◽  
pp. 3241-3249 ◽  
Author(s):  
Hamidreza Saber ◽  
Kasra Khatibi ◽  
Viktor Szeder ◽  
Satoshi Tateshima ◽  
Geoffrey P. Colby ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Mechanical Thrombectomy ◽  
Reperfusion Therapy ◽  
Interquartile Range ◽  
Nihss Score ◽  
Discharge Disposition ◽  
Younger Age

Background and Purpose: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0–5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Results: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59–79] years; median NIHSS score of 2 [interquartile range, 1–4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71–2.13], P <0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09–1.83], P <0.001). Conclusions: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

scholarly journals Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1616-1619 ◽  
Author(s):  
James Beharry ◽  
Michael J. Waters ◽  
Roy Drew ◽  
John N. Fink ◽  
Duncan Wilson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Scale Score ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

scholarly journals Early NT-ProBNP (N-Terminal Probrain Natriuretic Peptide) Elevation Predicts Malignant Edema and Death After Reperfusion Therapy in Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Author(s):  
Xuting Zhang ◽  
Shenqiang Yan ◽  
Wansi Zhong ◽  
Yannan Yu ◽  
Min Lou
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Natriuretic Peptide ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
Median Serum ◽  
The Relationship

Background and Purpose: We aimed to investigate the relationship between early NT-proBNP (N-terminal probrain natriuretic peptide) and all-cause death in patients receiving reperfusion therapy, including intravenous thrombolysis and endovascular thrombectomy (EVT). Methods: This study included 1039 acute ischemic stroke patients with early NT-proBNP data at 2 hours after the beginning of alteplase infusion for those with intravenous thrombolysis only or immediately at the end of EVT for those with EVT. We performed natural log transformation for NT-proBNP (Ln(NT-proBNP)). Malignant brain edema was ascertained by using the SITS-MOST (Safe Implementation of Thrombolysis in Stroke-Monitoring Study) criteria. Results: Median serum NT-proBNP level was 349 pg/mL (interquartile range, 89–1250 pg/mL). One hundred twenty-one (11.6%) patients died. Malignant edema was observed in 78 (7.5%) patients. Ln(NT-proBNP) was independently associated with 3-month mortality in patients with intravenous thrombolysis only (odds ratio, 1.465 [95% CI, 1.169–1.836]; P =0.001) and in those receiving EVT (odds ratio, 1.563 [95% CI, 1.139–2.145]; P =0.006). The elevation of Ln(NT-proBNP) was also independently associated with malignant edema in patients with intravenous thrombolysis only (odds ratio, 1.334 [95% CI, 1.020–1.745]; P =0.036), and in those with EVT (odds ratio, 1.455 [95% CI, 1.057–2.003]; P =0.022). Conclusions: An early increase in NT-proBNP levels was related to malignant edema and stroke mortality after reperfusion therapy.

scholarly journals Body mass index is a risk factor for hemorrhagic transformation in older ischemic stroke patients after intravenous thrombolysis: a single center retrospective study

2019 ◽  
Author(s):  
Changqing Miao ◽  
Xiaoyan Yin ◽  
Chunying Mu ◽  
Yan Qu ◽  
Guogang Luo ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Ischemic Stroke ◽  
Confidence Interval ◽  
Acute Ischemic Stroke ◽  
Body Mass ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Tomography Scan

Abstract Background: The aim of our study was to determine whether body mass index is a predictor of hemorrhagic transformation in acute ischemic stroke patients after intravenous thrombolysis. Methods: A retrospective observational study was conducted to recruit 261 participants from a single center in China (67.0% males, median age 65 years). A head computed tomography scan was performed after 24 hours to evaluate hemorrhagic transformation occurrence, and a computed tomography scan was performed immediately in cases of clinical worsening. Multivariate logistic regression was used to estimate the association between risk factors and hemorrhagic transformation in acute ischemic stroke patients after intravenous administration of recombinant tissue plasminogen activator. Results: Of 261 patients, 40 (15.3%) developed hemorrhagic transformation (55% males, median age 70 years). Body mass index was higher in patients with hemorrhagic transformation than in patients without hemorrhagic transformation (25.7 vs 23.7; P value, 0.013). The multivariate logistic regression model showed that body mass index was an independent predictor of hemorrhagic transformation in patients aged ≥ 73 years (odds ratio, 1.74; 95% confidence interval, 1.22-2.49) but not in patients aged < 73 years (odds ratio, 1.01; 95% confidence interval, 0.87-1.18). In addition, the odds ratio was 5.16 (95% confidence interval, 2.21-12.04) when the body mass index was ≥ 25 kg/m2 compared to a body mass index < 25 kg/m2. Conclusions: The present study demonstrated that body mass index was an independent predictor of hemorrhagic transformation in older acute ischemic stroke patients after intravenous thrombolysis. Keywords: Body mass index, Hemorrhagic transformation, Intravenous thrombolysis, Ischemic stroke, Older patients.

scholarly journals Low-dose versus standard-dose alteplase for intravenous thrombolysis in patients with acute ischemic stroke in Iran: Results from the safe implementation of treatments in stroke registry

2022 ◽  
Author(s):  
Elyar Sadeghi-Hokmabadi ◽  
Abdoreza Ghoreishi ◽  
Reza Rikhtegar ◽  
Payam Sariaslani ◽  
Shahram Rafie ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Dose Group ◽  
Low Dose ◽  
Standard Dose ◽  
Intravenous Thrombolysis ◽  
Standard Group ◽  
Eastern Region ◽  
Significant Difference

Background: Rates of intracranial hemorrhage (ICH) after intravenous thrombolysis (IVT) differ depending regard are scarce in the Middle Eastern region. Methods: The present retrospective study was performed on data extracted from the Safe Implementation of Treatments in Stroke (SITS) registry. Computed tomography (CT) image analysis was based on the SITS-Monitoring Study (SITS-MOST) definition for symptomatic ICH (SICH). Functional outcome at 3 months was assessed using the modified Rankin Scale (mRS). Multivariate logistic regression including adjusted analysis was used for comparison between groups. Results: Of 6615 patients, 1055 were enrolled. A total of 86% (n = 906) received a standard dose and 14% (n = 149) received a low dose of alteplase. Favorable 3-month outcome was achieved in 481 (53%) patients in the standard group and 71 (48%) patients in the low-dose group [adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI): 0.87-1.75, P = 0.218]. SICH occurred in 14 (1.5%) patients in the standard group and 3 (2%) patients in the low-dose group [odds ratio (OR) = 2.77, 95% CI: 0.36-21.04, P = 0.120]. At 3 months, mortality occurred in 145 (16.0%) patients in the standard group and 29 (19.4%) patients in the low-dose group (OR = 1.22, 95% CI: 0.78-1.91, P = 0.346). Conclusion: Low-dose compared to standard-dose alteplase for patients with acute ischemic stroke (AIS) was not associated with fewer hemorrhagic events and there was no significant difference in the favorable 3-month outcome (mRS: 0-2) or mortality rate.

Safety and early outcomes after intravenous thrombolysis in acute ischemic stroke patients with prestroke disability

2020 ◽  
pp. 174749302095460
Author(s):  
Charith Cooray ◽  
Michal Karlinski ◽  
Adam Kobayashi ◽  
Peter Ringleb ◽  
Janika Kõrv ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Outcome Measures ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Absolute Difference ◽  
Stroke Patients ◽  
Symptomatic Intracerebral Hemorrhage

Background There are limited data on intravenous thrombolysis treatment in ischemic stroke patients with prestroke disability. Aim We aimed to evaluate safety and outcomes of intravenous thrombolysis treatment in stroke patients with prestroke disability. Methods We analyzed 88,094 patients treated with intravenous thrombolysis, recorded in the Safe Implementation of Treatments in Stroke (SITS) International Thrombolysis Register between January 2003 and December 2017, with available NIHSS data at stroke-onset and after 24 h. Of them, 4566 patients (5.2%) had prestroke disability, defined as a modified Rankin Scale score of 3–5. Safety outcome measures included Symptomatic Intracerebral Hemorrhage, any type of parenchymal hematoma on 24 h imaging scans irrespective of clinical symptoms, and death within seven days. Early outcome measures were 24-h NIHSS improvement (≥4 from baseline to 24 h). Results Patients with prestroke disability were older, had more severe strokes, and more comorbidities than patients without prestroke disability. When comparing patients with prestroke disability with patients without prestroke disability, there was however no significant increase in adjusted odds for symptomatic intracerebral hemorrhage (adjusted odds ratio 0.83 (95% CI 0.60–1.15) (absolute difference in proportion 1.17% vs. 1.27%)) or for parenchymal hemorrhage (adjusted odds ratio 0.96 (0.83–1.11) (7.51% vs. 6.34%)). The prestroke disability group had a significantly lower-adjusted odds ratio for a 24-h NIHSS improvement (adjusted odds ratio 0.79 (0.73–0.85) (45.95% vs. 48.45%)) and a higher adjusted odds ratio for seven-day mortality (aOR 1.40 (1.21–1.61) (10.40% vs. 4.93%)). Conclusions Intravenous thrombolysis in acute ischemic stroke patients with prestroke disability was not associated with an increased risk of symptomatic intracerebral hemorrhage or parenchymal hemorrhage. Prestroke disability was however associated with a higher risk of early mortality compared to patients without prestroke disability.

scholarly journals Disentangling Sex Differences in Use of Reperfusion Therapy in Patients With Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (8) ◽  
pp. 2332-2338
Author(s):  
Jeppe Mainz ◽  
Grethe Andersen ◽  
Jan Brink Valentin ◽  
Martin Faurholdt Gude ◽  
Søren Paaske Johnsen
Keyword(s):  
Sex Differences ◽  
Ischemic Stroke ◽  
Time Delay ◽  
Acute Ischemic Stroke ◽  
Emergency Medical Services ◽  
Symptom Onset ◽  
Odds Ratio ◽  
Stroke Unit ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy

Background and Purpose: Previous studies from local settings have reported that women with acute ischemic stroke have a lower chance of receiving reperfusion therapy treatment, including intravenous thrombolysis and thrombectomy, than men, but the underlying mechanisms of this disparity have not been identified. We aimed to examine sex differences in the utilization of reperfusion therapy focusing on all the phases of pre- and in-hospital time delay in a nationwide population-based cohort. Methods: This study was based on data from nationwide public registries. The study population included patients aged at least 18 years admitted with acute ischemic stroke using emergency medical services in Denmark dispatched after an emergency call in the period 2016 to 2017. Study outcomes included time delays from symptom onset to start of reperfusion therapy and use of reperfusion therapy. Data were analyzed using multivariable quantile regression and logistic regression. Results: A total of 5356 stroke events fulfilled the inclusion criteria. Women (26.6%) were less likely to receive intravenous thrombolysis than men (30.2 %), corresponding to an unadjusted odds ratio of 0.84 (95% CI, 0.74–0.95). In addition, women experienced a 20 minutes longer median time delay from stroke symptom onset to stroke unit arrival than men. Adjusting for onset-to-door time only appeared to have a limited effect on the sex differences in use of intravenous thrombolysis, whereas the odds ratio was 1.06 (95% CI, 0.93–1.21) when adjusting for age at stroke, stroke severity, and cohabitation status. No sex difference was observed for the use of thrombectomy. Conclusions: Women received less reperfusion therapy than men and had a longer time delay from symptom onset to stroke unit arrival, primarily due to a longer delay from symptom onset to emergency medical services call. These differences appeared to be due to the higher age and the higher proportion of women living alone at the time of the stroke.

scholarly journals Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 308-312
Author(s):  
Aristeidis H. Katsanos ◽  
Apostolos Safouris ◽  
Amrou Sarraj ◽  
Georgios Magoufis ◽  
Ronen R. Leker ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Controlled Clinical Trials ◽  
Randomized Controlled Clinical Trials ◽  
Randomized Controlled ◽  
Intravenous Alteplase

Background and Purpose: Accumulating evidence from randomized controlled clinical trials suggests that tenecteplase may represent an effective treatment alternative to alteplase for acute ischemic stroke. In the present systematic review and meta-analysis, we sought to compare the efficacy and safety outcomes of intravenous tenecteplase to intravenous alteplase administration for acute ischemic stroke patients with large vessel occlusions (LVOs). Methods: We searched MEDLINE (Medical Literature Analysis and Retrieval System Online) and Scopus for published randomized controlled clinical trials providing outcomes of acute ischemic stroke with confirmed LVO receiving intravenous thrombolysis with either tenecteplase at different doses or alteplase at a standard dose of 0.9 mg/kg. The primary outcome was the odds of modified Rankin Scale score of 0 to 2 at 3 months. Results: We included 4 randomized controlled clinical trials including a total of 433 patients. Patients with confirmed LVO receiving tenecteplase had higher odds of modified Rankin Scale scores of 0 to 2 (odds ratio, 2.06 [95% CI, 1.15–3.69]), successful recanalization (odds ratio, 3.05 [95% CI, 1.73–5.40]), and functional improvement defined as 1-point decrease across all modified Rankin Scale grades (common odds ratio, 1.84 [95% CI, 1.18–2.87]) at 3 months compared with patients with confirmed LVO receiving alteplase. There was little or no heterogeneity between the results provided from included studies regarding the aforementioned outcomes (I 2 ≤20%). No difference in the outcomes of early neurological improvement, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and the rates of modified Rankin Scale score 0 to 1 or all-cause mortality at 3 months was detected between patients with LVO receiving intravenous thrombolysis with either tenecteplase or alteplase. Conclusions: Acute ischemic stroke patients with LVO receiving intravenous thrombolysis with tenecteplase have significantly better recanalization and clinical outcomes compared with patients receiving intravenous alteplase.

Abstract WMP4: Thrombectomy-only versus Combined Intravenous Alteplase and Thrombectomy: Meta-analysis

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Michelle P Lin ◽  
Geoffrey P Colby ◽  
Rafael H Llinas
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Intravenous Alteplase ◽  
Iv Tpa

Introduction: Contraindications for intravenous thrombolysis are not infrequent (eg. anticoagulation, recent surgery, unclear last known well). With overwhelming recent evidence supporting the use of endovascular thrombectomy for large-vessel occlusive stroke, we conducted a metaanalysis to compare long-term functional outcome between thrombectomy-alone versus combined IV-tPA and thrombectomy. Hypothesis: Patients with acute ischemic stroke ineligible for IV-tPA treated with thrombectomy-alone have equally favorable long-term functional outcomes to patients treated with combined IV-tPA and thrombectomy Methods: Searched PubMed from 2014-2016 using pre-specified terms for studies that report odds ratio of improvement in mRS score at 90 days comparing thrombectomy vs IV-tPA stratified by whether patients had received IV-tPA. Multivariate adjusted odds ratios were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates were compared between thrombectomy-alone and combined IV-tPA and thrombectomy. Forest plots constructed. Results: Of the 920 studies, 3 studies reported subgroup analysis with 822 participants, 19.5% (N=160) received thrombectomy-alone, 80.5% (N=662) received combined IV-tPA and thrombectomy. Among patients who received thrombectomy-alone, the pooled odds ratio of good functional outcome at 3 months was 2.48 (1.43-4.30), in the combined IV-tPA and thrombectomy group the pooled odds ratio was 1.85 (1.37-2.49). Conclusions: Endovascular therapy was an effective therapy for patients ineligible for IV-tPA presenting with acute ischemic stroke caused by large vessel occlusive disease. While IV-tPA should not be withheld before thrombectomy in IV-tPA eligible patients, prospective studies are needed to select those who may benefit more from thrombectomy-only treatment.

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