Making a Case for Acute Ischemic Stroke

2010 ◽  
Vol 23 (5) ◽  
pp. 387-397 ◽  
Author(s):  
Kathleen A. Baldwin ◽  
Stacey L. McCoy
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Treatment Options ◽  
Heart Association ◽  
Signs And Symptoms ◽  
The United States ◽  
Standards Of Care ◽  
Hospital Transport ◽  
Reperfusion Strategy

Stroke is the third leading cause of death in the United States and the number one cause of adult long-term disability. Disability in stroke survivors includes hemiparesis, aphasia, inability to walk without assistance, dependence on others for activities of daily living, depression, and institutionalization. Immediate recognition of acute ischemic stroke (AIS) signs and symptoms is required because many treatment options are time sensitive. Hospital transport via activation of 911 and emergency medical services (EMSs) removes delays to urgent diagnosis and intervention. Intravenous (IV) recombinant tissue plasminogen (rt-PA) is a time-sensitive reperfusion strategy. The American Heart Association (AHA) and American Stroke Association (ASA) recently revised recommendations that the time window for IV rt-PA be expanded from 3 hours to 4.5 hours after symptom onset in patients with mild to moderate stroke. Supportive therapies include crystalloid IV solutions, adequate oxygenation, and normothermia. Best rest is desired along with oxygen supplementation. Avoidance of fever is paramount since fever can contribute to negative outcomes. It is the purpose of this article to review risk factors, stroke symptoms, epidemiology, and current drug therapy of AIS. Standards of care will be reviewed.

EmboLess Mechanical Clot Removal Device: Possibility for Improving the Outcomes of Ischemic Stroke Patients

2010 ◽  
Author(s):  
Joseph Perosky ◽  
Adam Biddle ◽  
Kim DeGraaf ◽  
Whitney Hovan ◽  
Choi M. Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Options ◽  
The United States ◽  
Stroke Onset ◽  
Cerebral Vessel ◽  
Clot Removal ◽  
Mechanical Removal ◽  
The Brain

Ischemic stroke affects nearly 690,000 patients a year in the United States and is the leading cause of long-term disability and the third leading cause of death [1, 2]. Acute ischemic stroke occurs when a clot becomes lodged in a cerebral vessel, cutting off blood supply to areas of the brain. There are two treatment options for acute ischemic stroke: tissue plasminogen activator (beneficial within the first 4 hours of stroke onset), and mechanical removal (beneficial from 4 to 8 hours after stroke onset). The two FDA approved clot removal devices (MERCI and Penumbra) for ischemic stroke are capable of achieving revascularization rates between 48% and 80% [3, 4].

Intravenous Thrombolysis in Acute Ischemic Stroke

2018 ◽  
pp. 128-152
Author(s):  
Waldo R. Guerrero ◽  
Edgar A. Samaniego ◽  
Santiago Ortega
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
American Heart Association ◽  
American Heart ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Heart Association ◽  
Standard Of Care

The only proven therapy for patients with acute ischemic stroke is early recanalization. The use of intravenous thrombolytic alteplase is the standard of care for patients presenting with ischemic stroke within the first 4.5 hours from symptom onset. This chapter reviews the indications and contraindications to alteplase including the 2015 American Heart Association guidelines and their relevance to clinical practice. Furthermore, emerging research and ongoing trials on expanding the time window for intravenous thrombolysis are discussed.

Abstract WP382: Cardiac Troponin Assessment in Acute Ischemic Stroke Patients Presenting Within 4.5 Hours From Last Known Well

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Yuyao Sun ◽  
Malgorzata M Miller ◽  
Nils Henninger
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cardiac Troponin ◽  
Troponin I ◽  
Time Window ◽  
Diagnostic Yield ◽  
Heart Association ◽  
Coronary Syndrome ◽  
Cardiac Symptoms ◽  
History Of

Introduction: American Heart Association guidelines recommend obtaining baseline troponin in all acute ischemic stroke (AIS) patients to detect an acute coronary syndrome (ACS). Yet, data regarding the prevalence and diagnostic yield of troponin elevation in patients presenting within the time window for thrombolysis is limited. We sought to determine the diagnostic yield of cTnI in detecting ACS when assessed before or after 4.5h from last known well (LKW). Methods: We retrospectively analyzed 526 consecutive patients admitted for AIS or transient ischemic attack, who presented within 4.5h and had cardiac troponin I (cTnI) obtained within 48h from LKW. Results: The median time from LKW to cTnI measurement was 3.8h (IQR 1.5h-7.9h). 58% patients (n=306) had cTnI obtained ≤ 4.5h from LKW. After adjustment, factors independently relating to an elevated cTnI were the time to cTnI assessment (p<0.001), patient age (p=0.012), history of congestive heart failure (p<0.001), and a history of stroke/TIA (p=0.049). Patients who had a cTnI obtained within 4.5 hours from LKW, had significantly more often a normal (≤0.04 ng/mL) than elevated (>0.04 ng/mL) cTnI levels (61.9% vs. 44.7%; p=0.001). The sensitivity, specificity, and overall accuracy of an elevated cTnI assessed within 48h from LKW for ACS was 63.6%, 80.2%, and 79.5%, respectively. After stratification by the time to cTnI assessment within 4.5 h versus beyond 4.5h, the sensitivity of an elevated cTnI for ACS was markedly reduced to 42.9% whereas the specificity remained high at 84%. The optimal threshold to assess cTnI for detecting an ACS was 320 min in all included patients (sensitivity = 0.54, specificity = 0.67, Youden’s J = 0.203) and 340 minutes in patients with ACS (sensitivity 0.79, specificity 0.88, Youden’s J 0.661). Conclusions: Among patients presenting within the time window for rtPA treatment, the sensitivity of cTnI obtained within 4.5 hours from LKW to detect ACS is low. Our data suggests that cTnI routine assessment of cTnI in AIS subjects without cardiac symptoms should not be done within the first 6 hours from LKW.

Clinical Review and Implications of the Guideline for the Early Management of Patients With Acute Ischemic Stroke

2014 ◽  
Vol 25 (2) ◽  
pp. 130-141
Author(s):  
Sarah L. Livesay
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Healthcare Professionals ◽  
American Heart ◽  
Heart Association ◽  
The United States ◽  
Evidence Based ◽  
Early Management

Stroke is the fourth leading cause of death and the leading cause of significant, long-term disability in the United States. Clinicians’ knowledge and use of evidence to guide the care of patients with ischemic stroke are paramount to improving patient outcomes. The recently updated “Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” provides clinicians with evidence-based, expert consensus to guide the recognition and early management of patients with acute ischemic stroke. The guideline provides 115 recommendations for the management of patients with acute ischemic stroke, including 24 new recommendations and 51 revised recommendations divided into 14 major topic areas. This article reviews the recommendations and related literature and provides suggestions for use and implementation of the guideline within a stroke program of care.

scholarly journals Exploring the Unmet Need in Acute Ischemic Stroke Patients Not Treated With Intravenous Alteplase: The Get With The Guidelines‐Stroke Registry

2021 ◽  
Author(s):  
Brian Mac Grory ◽  
Ying Xian ◽  
Nicole C. Solomon ◽  
Roland A. Matsouaka ◽  
Marquita R. Decker‐Palmer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Population ◽  
Time Window ◽  
Unmet Need ◽  
The United States ◽  
Rapid Improvement ◽  
Stroke Registry ◽  
Intravenous Tissue Plasminogen Activator ◽  
Get With The Guidelines

BACKGROUND Early administration of intravenous tissue plasminogen activator (IV alteplase) improves functional outcomes in patients with acute ischemic stroke, yet many patients are not treated with IV alteplase. There is a need to understand the reasons for nontreatment and the short‐ and long‐term outcomes in this patient population. METHODS We analyzed patients ≥65 years old with a primary diagnosis of acute ischemic stroke presenting within 24 hours of time last known well (LKW) but not treated with IV alteplase from 1630 Get With The Guidelines‐Stroke hospitals in the United States between January 2016 and December 2016. We report clinical characteristics, reasons for withholding treatment, in‐hospital mortality, and 90‐day and 1‐year outcomes including costs, stratified by time from LKW to presentation (≤4.5, >4.5–6, and >6–24 hours). RESULTS Of 39 760 patients (median age 80 [25th–75th quartiles: 73–87], 56.7% female), 19 391 (48.8%) presented within 4.5 hours of LKW. In those with documented reasons for withholding IV alteplase, the most common reasons were rapid improvement of symptoms (3985/14 782, 27.0%) and mild symptoms (3791/14 782, 25.6%). In 1100 out of 1174 (93.7%) patients presenting in the >3.0‐ to 4.5‐hour time window, the most common reason for not treating was a delay in patient arrival. The most common discharge location for those presenting ≤4.5 hours since LKW was home (8660/19 391, 44.7%). The 90‐day mortality and readmission rates were 18.9% and 23.0% in those presenting ≤4.5 hours since LKW, 19.0% and 22.2% in those presenting between 4.5 and 6 hours, and 19.1% and 23.2% in those presenting between 6 and 24 hours. Median 90‐day total in‐hospital costs remained relatively high at $9471 (Q25–Q75: $5622–$21 356) in patients presenting ≤4.5 hours since LKW. CONCLUSIONS Patients within the Get With The Guidelines‐Stroke registry not treated with IV alteplase have a high risk of readmission and mortality and have high total in‐hospital and postdischarge costs. This study may inform future efforts to address the unmet need to improve the scope of IV alteplase delivery along with other aspects of acute ischemic stroke care and, consequently, outcomes in this patient population.

Reperfusion strategy for simultaneous ST-segment elevation myocardial infarction and acute ischemic stroke within a time window

2014 ◽  
Vol 32 (9) ◽  
pp. 1157.e1-1157.e4 ◽  
Author(s):  
Héctor González-Pacheco ◽  
Aurelio Méndez-Domínguez ◽  
Gerardo Vieyra-Herrera ◽  
Francisco Azar-Manzur ◽  
Aloja Meave-González ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
Reperfusion Strategy

scholarly journals Acute ischemic stroke care in Germany – further progress from 2016 to 2019

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Daniel Richter ◽  
Ralph Weber ◽  
Jens Eyding ◽  
Dirk Bartig ◽  
Björn Misselwitz ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Unit ◽  
Time Window ◽  
Treatment Options ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Main Diagnosis ◽  
Regional Variability ◽  
Pronounced Increase

Abstract Background Stroke Unit Care (SUC), intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are evidence-based treatment options for acute ischemic stroke (AIS). Using nationwide comprehensive administrative data from Germany, we recently reported nationwide development of AIS admissions, SUC rates, IVT rates and MT rates in Germany between 2010 and 2016. In this update paper, we analyze data on the further development of these data to 2019 after publication of time window extensions for recanalization therapies. Methods We considered all hospitalized cases with the main diagnosis of the ICD-10-GM code I63 (AIS) for the year 2019. We identified stroke therapies by using the corresponding Operating and Procedure Keys for IVT, MT and SUC out of the DRG statistics. Regional analyses are based on data from the 412 German administrative districts and cities. We compared the results with those from 2016. Results Number of hospitalized AIS patients showed a mild decrease in 2019 (n = 225,531) compared with 2016 (n = 227,687), with significant more AIS patients treated on a stroke unit in 2019 (n = 167,799; 74.4% vs. n = 164,270; 72.1%, p < 0.001). The rate of IVT further increased from 14.9% (n = 33,916) in 2016 to 16.3% (n = 36,745) in 2019 (p < 0.001). Similarly, the MT rate increased from 4.3% (n = 9795) in 2016 to 7.2% (n = 16,135) in 2019 (p < 0.001). There was still a high regional variability for MT (1.4 to 15.2%) according to the place of residence of the AIS patients. Conclusions In Germany, the rates of recanalization therapies in patients with AIS continued to increase from 2016 to 2019. Compared to IVT-rates and numbers, the respective data for MT procedures showed an even more pronounced increase.

Abstract T P10: Therapeutic Time Window for Endovascular Therapy of Acute Ischemic Stroke Depends on THRIVE Score: A Retrospective Single-center Study

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kenichi Todo ◽  
Nobuyuki Sakai ◽  
Tomoyuki Kono ◽  
Taku Hoshi ◽  
Hirotoshi Imamura ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Time Window ◽  
Medical Center ◽  
Multivariate Logistic Regression Analysis ◽  
Symptom Duration ◽  
Vascular Events ◽  
Good Outcome ◽  
Therapeutic Time Window

Background and purpose: The outcome after endovascular therapy in acute ischemic stroke is associated with onset-to-reperfusion time (ORT). The Totaled Health Risks in Vascular Events (THRIVE) score is also an important pre-thrapeutic predictor of outcome. We hypothesized that the therapeutic time window is narrower in patients with the higher THRIVE score. Methods: We retrospectively studied consecutive 109 ischemic stroke patients with successful reperfusion after endovascular therapy between October 2005 and March 2014 at a single institute (Kobe City Medical Center General Hospital). Inclusion criteria was as follows: National Institutes of Health Stroke Scale (NIHSS) score ≥8, stroke symptom duration ≤8 h, premorbid modified Rankin Scale (mRS) score ≤2, and thrombolysis myocardial infarction score 2-3. We analyzed the relationships of ORT, THRIVE score, and THRIVE+ORT score with good outcome (mRS ≤2 at 3 months). The THRIVE+ORT score was defined as the sum of the THRIVE score and ORT (h). Results: Median ORT was 5.5 h (IQR; 4.4-7.1 h), median THRIVE score was 5 (IQR; 4-6), and median THRIVE+ORT score was 10.8 (IQR; 9.2-12.5). Good outcome rates for patients with ORT ≤4 h, >4 and ≤6 h, >6 and ≤8 h, and >8h were 50.0%, 45.8%, 37.0%, and 21.4%, respectively (p=0.3), those with THRIVE score ≤3, >3 and ≤5, >5 and ≤7, and >7 were 57.1%, 51.4%, 28.3%, and 20.0%, respectively (p9 and ≤11, >11 and ≤13, and >13 were 64.0%, 44.1%, 34.4%, and 16.7%, respectively (p<0.05). Multivariate logistic regression analysis revealed that THRIVE+ORT score was an independent predictor of good outcome after adjusted for THRIVE score (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.082-1.728) or after adjusted for ORT (OR, 1.517: 95% CI, 1.160-1.983). Conclusion: Our study showed that THRIVE+ORT score was associated with outcome that was independent from THRIVE score or ORT. This is the first report to suggest that patients with the higher THRIVE score require the shorter ORT for good outcome.

Abstract WP178: Acute Stroke Ischemic Symptom Onset-to-Arrival Time in Michigan Hospitals

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Muhammad U Farooq ◽  
Kathie Thomas
Keyword(s):  
African American ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Outcomes ◽  
Symptom Onset ◽  
Arrival Time ◽  
Heart Association ◽  
The United States ◽  
Stroke Patients ◽  
White Patients

Objectives: Stroke is the fifth-leading cause of death and the leading cause of disability in the United States. One of the primary goals of the American Heart Association/American Stroke Association is to increase the number of acute stroke patients arriving at emergency departments (EDs) within 1-hour of symptom onset. Earlier treatment with thrombolysis in patients with acute ischemic stroke translates into improved patient outcomes. The objective of this abstract is to examine the association between the use of emergency medical services (EMS) and symptom onset-to-arrival time in patients with ischemic stroke. Methods: A retrospective review of ischemic stroke patients (n = 8873) from 25 Michigan hospitals from January 2012-December 2014 using Get With the Guidelines databases was conducted. Symptom onset-to-ED arrival time and arrival mode were examined. Results: It was found that 17.4% of ischemic stroke patients arrived at the hospitals within 1-hour of symptom onset. EMS transported 69.1% of patients who arrived within 1-hour of symptom onset. During this 1-hour period African American patients (22%) were less likely to use EMS transportation as compared to White patients (72%). The majority of patients, 41.8%, arrived after 6-hours of symptom onset. EMS transported only 40% of patients who arrived after 6-hours of symptom onset. As before, during this 6-hour period African American patients (20%) were also less likely to use EMS transportation as compared to White patients (75%). Symptom onset-to-ED arrival time was shorter for those patients who used EMS. The median pre-hospital delay time was 2.6 hours for those who used EMS versus 6.2 hours for those who did not use EMS. Conclusions: The use of EMS is associated with a decreased pre-hospital delay, early treatment with thrombolysis and improved patient outcomes in ischemic stroke patients. Community interventions should focus on creating awareness especially in minority populations about stroke as a neurological emergency and encourage EMS use amongst stroke patients.

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