Thrombolysis in young adults with stroke

Neurology ◽  
2019 ◽  
Vol 92 (24) ◽  
pp. e2784-e2792 ◽  
Author(s):  
Jodi A. Dodds ◽  
Ying Xian ◽  
Shubin Sheng ◽  
Gregg C. Fonarow ◽  
Deepak L. Bhatt ◽  
...  
Keyword(s):  
Young Adults ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Brain Imaging ◽  
Older Patients ◽  
Younger Patients ◽  
Stroke Registry ◽  
Symptomatic Intracranial Hemorrhage ◽  
Get With The Guidelines ◽  
To Receive

ObjectiveTo determine whether young adults (≤40 years old) with acute ischemic stroke are less likely to receive IV tissue plasminogen activator (tPA) and more likely to have longer times to brain imaging and treatment.MethodsWe analyzed data from the Get With The Guidelines–Stroke registry for patients with acute ischemic stroke hospitalized between January 2009 and September 2015. We used multivariable models with generalized estimating equations to evaluate tPA treatment and outcomes between younger (age 18–40 years) and older (age >40 years) patients with acute ischemic stroke.ResultsOf 1,320,965 patients with acute ischemic stroke admitted to 1,983 hospitals, 2.3% (30,448) were 18 to 40 years of age. Among these patients, 12.5% received tPA vs 8.8% of those >40 years of age (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.56–1.71). However, younger patients were less likely to receive brain imaging within 25 minutes (62.5% vs 71.5%, aOR 0.78, 95% CI 0.73–0.84) and to be treated with tPA within 60 minutes of hospital arrival (37.0% vs 42.8%, aOR 0.74, 95% CI 0.68–0.79). Compared to older patients, younger patients treated with tPA had a lower symptomatic intracranial hemorrhage rate (1.7% vs 4.5%, aOR 0.55, 95% CI 0.42–0.72) and lower in-hospital mortality (2.0% vs 4.3%, aOR 0.65, 95% CI 0.52–0.81).ConclusionsIn contrast to our hypothesis, younger patients with acute ischemic stroke were more likely to be treated with tPA than older patients, but they were more likely to experience delay in evaluation and treatment. Compared with older patients, younger patients had better outcomes, including fewer intracranial hemorrhages.

Abstract 203: Use of Endovascular Therapy and Trends in Clinical Outcomes within the Nationwide Get With The Guidelines-Stroke Registry

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Bijoy K Menon ◽  
Jeffrey L Saver ◽  
Mayank Goyal ◽  
Raul Noguiera ◽  
Shyam Prabhakaran ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcomes ◽  
Endovascular Therapy ◽  
Patient Characteristics ◽  
National Registry ◽  
Stroke Registry ◽  
Large Size ◽  
Symptomatic Intracranial Hemorrhage ◽  
Independent Ambulation ◽  
Get With The Guidelines

Purpose: To determine hospital and patient level characteristics associated with use of endovascular therapy for acute ischemic stroke and to analyze trends in clinical outcome. Methods: Data were from Get With The Guidelines-Stroke hospitals from 4/1/2003 to 6/30/2013. We looked at secular trends in number of hospitals providing endovascular therapy, use of endovascular therapy in these hospitals, and clinical outcomes. We also analyzed hospital and patient characteristics associated with endovascular therapy utilization. Results: Of 1087 hospitals, 454 provided endovascular therapy to at least one patient in the study period. From 2003 to 2012, the proportion of hospitals providing endovascular therapy increased by 1.6%/year (from 12.9% to 28.9%), with a modest drop in 2013 to 23.4%. Use in these hospitals increased from 0.7% to 2% of all ischemic stroke patients (p<0.001) with a modest drop in 2013 to 1.9%. In multivariable analyses, patient outcomes after endovascular therapy improved over time, with reductions in in-hospital mortality (29.6% in 2004 to 16.2% in 2013; p=0.002); and from late 2010, reduction in symptomatic intracranial hemorrhage (ICH) (11% in 2010 to 5% in 2013; p<0.0001) and increased independent ambulation at discharge (24.5% in 2010 to 33% in 2013; p<0.0001) and discharge home (17.7% in 2010 to 26.1% in 2013; p<0.0001) (Attached figure). Hospital characteristics associated with endovascular therapy use included large size, teaching status and urban location while patient characteristics included younger age, EMS transport, absence of prior stroke and white race. Conclusion: Use of endovascular therapy increased modestly in this national registry from 2003 to 2012 and decreased in 2013. Clinical outcomes improved notably from 2010 to 2013, coincident with the introduction of newer thrombectomy devices.

Abstract TMP19: Intravenous Recombinant Tissue-type Plasminogen Activator Use in Young Adults With Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jodi A Dodds ◽  
Ying Xian ◽  
Shubin Sheng ◽  
Gregg Fonarow ◽  
Ronald A Matsouaka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Older Patients ◽  
Young Patients ◽  
Tissue Type ◽  
Stroke Patients ◽  
Younger Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator

Background: Intravenous recombinant tissue-type plasminogen activator (rt-PA) administration improves outcomes in acute ischemic stroke. However, young patients (<40 years old) presenting with stroke symptoms may experience delays in treatment due to misdiagnosis or a reluctance to treat since they do not fit the profile of a typical stroke patient. Methods: We analyzed data from the large national Get With The Guidelines–Stroke registry for acute ischemic stroke patients hospitalized between January 2009 and September 2015. Multivariable models with generalized estimating equations (GEE) were used to test for differences between younger (age 18-40) and older (age > 40) acute ischemic stroke patients, controlling for patient and hospital characteristics including stroke severity. Results: Of 1,320,965 AIS patients admitted to participating hospitals, 2.3% (30,448) were aged 18-40. Among these patients, 12.5% received rt-PA versus 8.8% of those aged >40 (p<0.001). Of patients arriving within 3.5 hours of symptom onset without contraindications, 68.7% of younger patients received IV rt-PA versus 63.3% of older patients (adjusted OR [aOR] 1.30, 95% CI 1.21 to 1.40), without evidence that age-related differences varied by sex (interaction p-value 0.25). Odds ratios of achieving target door-to-CT times and door-to-needle (DTN) times, and outcomes of rtPA-treated patients, are shown in the Table. Conclusions: Young acute ischemic stroke patients did not receive rt-PA treatment at lower rates than older patients. Outcomes were better and the rate of symptomatic intracranial hemorrhage was lower in the young patients. However, younger patients had significantly longer door-to-CT and DTN times, providing an opportunity to improve the care of these patients.

scholarly journals Thrombolysis in acute ischemic stroke in patients with dementia

Neurology ◽  
2017 ◽  
Vol 89 (18) ◽  
pp. 1860-1868 ◽  
Author(s):  
Eva Zupanic ◽  
Mia von Euler ◽  
Ingemar Kåreholt ◽  
Beatriz Contreras Escamez ◽  
Johan Fastbom ◽  
...  
Keyword(s):  
Cohort Study ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcomes ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Younger Patients ◽  
Everyday Activities ◽  
Symptomatic Intracerebral Hemorrhage ◽  
To Receive

Objective:To compare access to intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) and its outcomes in patients with and without dementia.Methods:This was a longitudinal cohort study of the Swedish dementia and stroke registries. Patients with preexisting dementia who had AIS from 2010 to 2014 (n = 1,356) were compared with matched patients without dementia (n = 6,755). We examined access to thrombolysis and its outcomes at 3 months (death, residency, and modified Rankin Scale [mRS] score). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic and ordinal logistic regression.Results:The median age at stroke onset was 83 years in both groups. IVT was administered to 94 (7.0%) patients with dementia and 639 (9.5%) patients without dementia. The OR of receiving IVT was 0.68 (95% CI 0.54–0.86) for patients with dementia. When the analysis was repeated exclusively among patients independent in everyday activities, dementia status was no longer significant (OR 0.79, 95% CI 0.60–1.06). However, differences persisted in patients ≤80 years of age (OR 0.58, 95% CI 0.36–0.94). In patients who received thrombolysis, the incidence of symptomatic intracerebral hemorrhage (sICH; 7.4% vs 7.3%) and death at 3 months (22.0% vs 18.8%) did not differ significantly between the 2 groups. However, mRS score and accommodation status were worse among patients with dementia after 3 months in adjusted analyses (both p < 0.001). Unfavorable outcomes with an mRS score of 5 to 6 were doubled in patients with dementia (56.1% vs 28.1%).Conclusions:Younger patients with dementia and AIS are less likely to receive IVT. Among patients receiving thrombolysis, there are no differences in sICH or death, although patients with dementia have worse accommodation and functional outcomes at 3 months.

Endovascular Thrombectomy in Young Patients With Stroke: A MR CLEAN Registry Study

Stroke ◽  
2021 ◽  
Author(s):  
Josje Brouwer ◽  
Johanna A. Smaal ◽  
Bart J. Emmer ◽  
Inger R. de Ridder ◽  
Ido R. van den Wijngaard ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Older Patients ◽  
Adjusted Odds Ratio ◽  
Young Patients ◽  
Modified Rankin Scale ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: Acute ischemic stroke due to large vessel occlusion is uncommon in young adults. We assessed stroke cause in young patients and compared their outcomes after endovascular thrombectomy with older patients. Methods: We used data (March 2014 until November 2017) of patients with an anterior circulation large vessel occlusion stroke from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a nationwide, prospective study on endovascular thrombectomy in the Netherlands. We compared young patients (18–49 years) with older patients (≥50 years). Outcomes included modified Rankin Scale score after 90 days (both shift and dichotomized analyses), expanded Thrombolysis in Cerebral Infarction score, and symptomatic intracranial hemorrhage. Analyses were adjusted for confounding. Results: We included 3256 patients, 310 (10%) were 18 to 49 years old. Young patients had lower median National Institutes of Health Stroke Scale scores (14 versus 16, P <0.001) and less cardiovascular comorbidities than older patients. Stroke etiologies in young patients included carotid dissection (16%), cardio-embolism (15%), large artery atherosclerosis (10%), and embolic stroke of undetermined source (31%). Clinical outcome was better in young than older patients (acOR for modified Rankin Scale shift: 1.8 [95% CI, 1.5–2.2]; functional independence [modified Rankin Scale score 0–2] 61 versus 39% [adjusted odds ratio, 2.1 [95% CI, 1.6–2.8]); mortality 7% versus 32%, adjusted odds ratio, 0.2 [95% CI, 0.1–0.3]). Symptomatic intracranial hemorrhage occurred less frequently in young patients (3% versus 6%, adjusted odds ratio, 0.5 [95% CI, 0.2–1.00]). Successful reperfusion (expanded Thrombolysis in Cerebral Infarction Score 2b-3) did not differ between groups. Onset to reperfusion time was shorter in young patients (253 versus 255 minutes, adjusted B in minutes 12.4 [95% CI, 2.4–22.5]). Conclusions: Ten percent of patients with acute ischemic stroke undergoing endovascular thrombectomy were younger than 50. Cardioembolism and carotid dissection were common underlying causes in young patients. In one-third of cases, no cause was identified, indicating the need for more research on stroke cause in young patients. Young patients had better prognosis and lower risk of symptomatic intracranial hemorrhage than older patients.

Abstract W P57: Thrombolytic Therapy in Patients With Mild Stroke: An Observational Study

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Jose G Romano ◽  
Eric E Smith ◽  
Li Liang ◽  
Hannah Gardener ◽  
Sara Camp ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Multivariable Analysis ◽  
Hospital Death ◽  
Stroke Patients ◽  
Short Term ◽  
Stroke Registry ◽  
Symptomatic Intracranial Hemorrhage ◽  
Mild Stroke ◽  
Independent Ambulation ◽  
Get With The Guidelines

Objective: Mild stroke has traditionally been excluded from thrombolytic treatment trials and only few series have reported outcomes after IV rtPA in this group. The objectives of this study are to determine the proportion of mild stroke patients treated with IV rtPA and evaluate complications and short-term outcomes in this population. Methods: We analyzed patients in the Get With The Guidelines-Stroke registry that arrived within 4.5 hours from symptom onset with a mild ischemic stroke defined as a baseline NIHSS ≤5 who received IV rtPA between May 2010 and October 2012. The following outcomes and complications were analyzed: in-hospital mortality, home discharge, independent ambulation, length of stay (LOS), in-hospital death, and symptomatic intracranial hemorrhage (sICH) <36 h. Multivariable analysis was performed for predictors of outcomes and complications. Results: Of 147,917 patients who arrived <4.5 hours, 39,821 were treated with IV rtPA, of whom 8,243 (20.7%) had an NIHSS ≤5. We analyzed 5,910 treated patients with NIHSS ≤5 and complete data. The mean baseline NIHSS was 3.5 (median 4); 98.2% arrived within 3 hours and 78.6% were treated within 3 hours. Outcomes and predictors of worse outcome are described in the table. There was no difference in short-term outcomes amongst those treated at 0-3 vs. 3-4.5 hours. Conclusions: A sizeable minority of ischemic stroke patients treated with IV rtPA have a NIHSS ≤5. sICH occurred at a low rate of 1.8% and about 30% of these patients were unable to return home and could not ambulate independently. Longer-term outcomes are needed to define predictors of poor outcome in this population and which patients may benefit most from treatment.

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.

Comparing the efficacy and safety of the Skyflow device with those of the Solitaire FR stent in patients with acute ischemic stroke: a prospective, multicenter, randomized, non-inferiority clinical trial

2021 ◽  
pp. neurintsurg-2021-018117
Author(s):  
Tengfei Zhou ◽  
Tianxiao Li ◽  
Liangfu Zhu ◽  
Zhaoshuo Li ◽  
Qiang Li ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stent Retriever ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Thrombectomy Device ◽  
Symptomatic Intracranial Hemorrhage ◽  
Solitaire Fr ◽  
To Receive

BackgroundMechanical thrombectomy is the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO) in the anterior circulation. This trial aimed to indicate whether Skyflow, a new thrombectomy device, could achieve the same safety and efficacy as Solitaire FR in the treatment of AIS.MethodsThis study was a prospective, multicenter, randomized, single blind, parallel, positive controlled, non-inferiority clinical trial. Patients with intracranial anterior circulation LVO within 8 hours from onset were included to receive thrombectomy treatment with either the Skyflow or Solitaire FR stent retriever. The primary endpoint was the rate of successful reperfusion (modified Treatment In Cerebral Infarction (mTICI) ≥2b) after the operation. The safety endpoints were the rate of symptomatic intracranial hemorrhage (sICH) and subarachnoid hemorrhage (SAH) at 24 hours after operation.ResultsA total of 95 and 97 patients were involved in the Skyflow group and Solitaire FR group, respectively. A successful reperfusion (mTICI ≥2b) was finally achieved in 84 (88.4%) patients in the Skyflow group and 80 (82.5%) patients in the Solitaire FR group. Skyflow was non-inferior to Solitaire FR in regard to the primary outcome, with the criterion of a non-inferiority margin of 12.5% (p=0.0002) after being adjusted for the combined center effect and the National Institutes of Health Stroke Scale (NIHSS) score. The rate of periprocedural sICH and SAH did not differ significantly between the two groups.ConclusionEndovascular thrombectomy with the Skyflow stent retriever was non-inferior to Solitaire FR with regard to successful reperfusion in AIS due to LVO (with a pre-specified non-inferiority margin of 12.5%).

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