Acute Ischemic Stroke In China Research Articles

Low-dose rt-PA may not decrease the incidence of symptomatic intracranial haemorrhage in patients with high risk of symptomatic intracranial haemorrhage

ABSTRACT Background: Recombinant tissue plasminogen activator (rt-PA) has been used as the standard treatment for acute ischemic stroke (AIS). The following study investigates whether low-dose rt-PA can decrease the incidence of symptomatic intracranial haemorrhage (sICH) in AIS patients with high-risk sICH compared to standard-dose rt-PA. Materials and Methods: Data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) studies were assessed to explore risk factors for sICH after intravenous thrombolysis. For high-risk sICH patients (age ≧70 years old, or with diabetes, or serum glucose on admission >9.0 mmol/L, or NIHSS on admission>20, or with cardioembolism), standard-dose rt-PA (0.85 to 0.95 mg/kg) and low- dose rt-PA (0.5 to 0.7 mg/kg) were compared. Primary outcome measure was the incidence of sICH, and the secondary outcome measures were 7-day mortality and 90-day functional independence outcome (modified Rankin scale, 0–2). Results: A total of 554 patients were enrolled (60 cases for low dose, and 494 cases for standard dose). Median rt-PA doses were 0.63 and 0.90 mg, respectively. After adjustment for the baseline variables, low-dose rt-PA did not decrease the incidence of sICH (per SITS-MOST criteria, 3.33% versus 2.23%, P = 0.3467) compared to low dose. The low-dose group revealed less functional independence outcomes (modified Rankin scale, 0–2) compared to standard-dose group (36.67% versus 52.43%; odds ratio = 0.49; p = 0.0204) at 90 days. Conclusions: Our study suggests that low-dose intravenous rt-PA for high-risk sICH stroke in Chinese patients may not decrease the incidence of sICH, and concomitant with a poor outcome compared to standard-dose rt-PA.Abbreviations: rt-PA: recombinant tissue plasminogen activator; AIS: acute ischemic stroke; sICH: symptomatic intracranial haemorrhage

Validation of the Simplified Stroke-Thrombolytic Predictive Instrument to Predict Functional Outcomes in Chinese Patients.

Background and Purpose- The simplified stroke-thrombolytic predictive instrument (s-Stroke-TPI) is useful for predicting the outcomes in thrombolysis-treated patients in Western populations. We aimed to validate its predictive value in Chinese patients. Methods- Data from thrombolysis implementation and monitor of acute ischemic stroke in China were analyzed. Patients with acute ischemic stroke and treated with thrombolysis within 4.5 hours of symptom onset were included. The 3-month functional outcomes were assessed with the modified Rankin Scale (mRS). Model discrimination was quantified by calculating the area under receiver operating characteristic curve. s-Stroke-TPI was compared with dense artery sign, mRS score, age, glucose, onset to treatment time, and National Institutes of Health Stroke Scale or stroke prognostication using age and National Institutes of Health Stroke Scale. Results- A total of 1102 patients who received thrombolysis were enrolled. The area under receiver operating characteristic curve of s-Stroke-TPI for predicting a catastrophic outcome (mRS score, 5-6), a normal/near-normal outcome (mRS score, 0-1), and independent outcome (mRS score, 0-2) at 3 months were 0.80, 0.73, and 0.75, respectively, which were significantly higher than or similar to those of dense artery sign, mRS score, age, glucose, onset to treatment time, and National Institutes of Health Stroke Scale or stroke prognostication using age and National Institutes of Health Stroke Scale. The calibration analysis of the s-Stroke-TPI showed a high correlation between the predicted and observed probabilities of the functional outcomes at 3 months. Conclusions- The s-Stroke-TPI reliably predicted the 3-month functional outcomes, especially catastrophic outcomes, in Chinese stroke patients with thrombolysis. Further validation is needed to confirm outcome predictions in patients both with and without thrombolysis.

Intravenous Thrombolysis Is Safe and Effective for the Cryptogenic Stroke in China: Data From the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China)

BackgroundThe intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) therapy is safe and efficient during the treatment of acute ischemic stroke. Nonetheless, the different outcomes among various stroke subgroups have limited data with regard to the safety and efficacy of cryptogenic stroke (CS). The present study compared the safety and efficacy when IVT with rt-PA was used for the treatment of CS and the other stroke subtypes. MethodsThis study classified the IVT with rt-PA patients within 4.5 hours after stroke onset, based on the trial of ORG 10172 in acute stroke treatment criteria in terms of diagnostic evaluation. The data were obtained from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China database, a large multicenter prospective registry. A multivariable logistic regression model was employed to compare the differences between the subtypes in symptomatic intracerebral hemorrhage (sICH) within 7 days and studied the mortality and the outcome during 90 days. ResultsIn total, 1118 patients were recruited; of these, 131 (11.7%) suffered from CS and 987 (88.3%) with the other etiology. In the CS group, patients were younger than those in the other etiology groups (P < .001). Moreover, it had a lower prevalence of previous stroke (P = .0117), receiving antiplatelet drug in 24 hours prior to thrombolysis (P = .0017), and functional independence (mRS > 1 before stroke, P = .003). The CS group had lower blood pressure (systolic blood pressure P = .0001; diastolic blood pressure; P = .0212) before thrombolysis, atrial fibrillation (P < .001), and diabetes mellitus (P = .0005). Transient ischemic attack, hypertension, hyperlipidemia, blood glucose, receiving anticoagulants in 24 hours prior to thrombolysis, and standard dosage of rt-PA were equally distributed in both groups. After the adjustment of confounders between the CS and the other subgroups, no obvious differences were observed in sICH rate and mortality (P > .05) The CS patients exhibited excellent recovery (mRS, 0-1; 63.78%) and functional independence (mRS, 0-2; 74.8%) than the large artery atherosclerosis patients. ConclusionsIVT with rt-PA is a safe and effective method for the treatment of CS patients.

MD3 - Cost-Effectiveness Analysis of Mechanical Thrombectomy With Revive SE® Versus Intravenous Thrombolysis for the Treatment of Acute Ischemic Stroke in China

Both intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) were recommended for treating acute ischemic stroke (AIS) by clinical guidelines. ReVive SE® is an innovative MT device with demonstrated clinical value, however, its economic evaluation in China is limited. The study aims to determine the cost-effectiveness of ReVive SE® versus IVT in AIS patients from a payer's perspective in China. A two-part model was developed to estimate the cost-effectiveness of ReVive SE® versus IVT. The short-term part (90 days) was a decision-tree that included three health states based on the modified Rankin Scale (mRS) score after treatment: independence (mRS=0-2), disability (mRS=3-5) and death (mRS=6). The long-term (lifetime) part was a Markov model that included four states: independence, disability, stroke recurrence, and death. Clinical efficacy, utility and cost data were obtained from Chinese ReVive SE® registry study and published literature. The model calculated quality-adjusted life years (QALYs) and total costs per patient. Costs and QALYs were discounted by 3.5% annually. Both one-way sensitivity analysis and probabilistic sensitivity analysis were conducted. The incremental cost-effectiveness ratios (ICERs) for ReVive SE® vs. IVT groups were ¥66,355/QALY, ¥39,062/QALY, and ¥35,305/QALY, respectively for 5-year, 15-year, and lifetime horizon. The ICER became lower than the recommended cost-effectiveness threshold (3 times of gross domestic product per capita, ¥161,940) beginning at the 1 year following the procedure till lifetime. Both one-way and probabilistic sensitivity analysis confirmed the robustness of the results. With the 3 times of gross domestic product threshold, ReVive SE ® is 87.46% cost-effective compared with IVT for lifetime horizon in the model. MT with ReVive SE® is a cost-effective treatment of AIS in China compared to IVT. This evidence supports the broad clinical application of MT with ReVive SE® over IVT. With caregivers’ costs unmeasured, ReVive SE® could be even more cost-effective.

Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China

In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. Twenty hospitals received a multifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, -0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, -2.03% [95% CI, -3.51% to -0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, -2.18% [95% CI, -4.0% to -0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, -3.13% [95% CI, -5.28% to -0.97%]; P = .005). Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. ClinicalTrials.gov Identifier: NCT02212912.

Economic evaluation of human urinary kallindinogenase for patients with acute ischemic stroke in China

Objectives: In China, both human urinary kallindinogenase (HUK) and 3-n-butylphthalide (NBP) are recommended for clinical use to improve cerebral blood circulation during an acute ischemic stroke (AIS). The objective was to evaluate the economic value of HUK vs NBP for patients with AIS from a Chinese payer’s perspective.Methods: An economic evaluation based on data of patients who have been treated with either HUK (n = 488) or NBP (n = 885) from a prospective, phase IV, multi-center, clinical registry study (Chinese Acute Ischemic Stroke Treatment Outcome Registry, CASTOR) was conducted to analyze the cost and effectiveness of HUK vs NBP for AIS in China. Before the analysis, the patients were matched using propensity score. Both a cost-minimization analysis and a cost-effectiveness analysis were conducted to compare the matched pairs. A bootstrapping exercise was conducted for the matched arms to demonstrate the probability of one intervention being cost-effective over another for a given willingness-to-pay for an extra quality-adjusted life-year (QALY).Results: After propensity score matching, 463 pairs were matched. The overall medical cost in the HUK arm is USD 2,701.20, while the NBP arm is USD 3,436.83, indicating HUK is preferred with cost-minimization analysis. Although the QALY gained in the HUK arm (0.77176) compared with the NBP arm (0.76831) is statistically insignificant (p = .4862), the cost-effectiveness analysis as exploratory analysis found that, compared with NBP, HUK is a cost-saving strategy with the lower costs of USD 735.63 and greater QALYs gained of 0.00345. Among the 5,000 bootstrapping replications, 100% indicates that HUK is cost-effective compared with NBP under a 1-time-GDP threshold; and 97.12% indicates the same under a 3-time-GDP threshold.Conclusion: This economic evaluation study indicates that administrating HUK is a cost-saving therapy compared with NBP for managing blood flow during AIS in the Chinese setting.

Expert consensus of Chinese and Western medicine emergency treatment for acute ischemic stroke in China

Expert consensus of Chinese and Western medicine emergency treatment for acute ischemic stroke in China

Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China

ObjectivesEndovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China,...

THRIVE-c score predicts clinical outcomes in Chinese patients after thrombolysis.

ObjectivesTotal Health Risks in Vascular Events‐calculation score (THRIVE‐c) is an easy use and patient‐specific outcome predictive score by computing the logistic equation with patients’ continuous variables. We validated its performance in Chinese ischemic stroke patients receiving intravenous thrombolysis (IVT) therapy.Materials and MethodsWe used data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS‐China) registry to validate the THRIVE‐c score in patients receiving IVT therapy. We evaluated the score performance using area under the receiver operating characteristic curve (AUC). Receiver operator characteristic curve (ROC) was used to compare THRIVE‐c score performance with other scores in predicting clinical outcome and symptomatic intracranial hemorrhage (SICH). Calibration was assessed by Pearson correlation coefficient and Hosmer–Lemeshow test.ResultsAmong the 1,128 patients receiving IVT therapy included in this study, AUC of the THRIVE‐c score for 3‐month SICH, poor functional outcome, and mortality rate was 0.70 (95% CI: 0.63–0.76), 0.75 (95% CI: 0.73–0.78) and 0.81 (95% CI: 0.77–0.85), respectively. The increased THRIVE‐c score was associated with higher risk of developing SICH, poor functional outcome, or mortality in patients with acute ischemic stroke at 3 months after thrombolysis. The performance of the THRIVE‐c score was similar to or superior to other predictive scores (THRIVE score, SEDAN score, DRAGON score, HIAT2 score).ConclusionsThe THRIVE‐c score reliably predicts the risks of 3‐month SICH, poor functional outcome, and mortality after IVT therapy in Chinese patients with ischemic stroke.

Abstract 136: A Cluster Randomized Trial of a Multifaceted Intervention to Improve Adherence to Evidence-Based Treatments in Acute Ischemic Stroke in China

Background: There are considerable gaps in adherence to evidence-based stroke care in China. Our primary aim was to determine whether a multifaceted quality improvement (QI) intervention could improve adherence to the 9 evidence-based performance measures among Chinese patients with acute ischemic stroke (AIS). Methods: The Multifaceted Intervention to Improve AIS Care (GOLDEN BRIDGE-AIS) trial was a two-arm, multicenter, cluster-randomized, controlled trial. Patient hospitalized with AIS were included. Hospitals were randomized (1:1) to the intervention or a usual care control arm. The multifaceted QI intervention involved a clinical pathway, written care protocols, oversight by a quality coordinator, and a monitoring and feedback system of performance measures. The primary outcome was adherence to AIS evidence-based performance measures. Results: 4800 patients were enrolled from 40 hospitals, n=2400 intervention and n=2400 control with 12-month follow-up. Interventional hospital patients were more likely to receive acute and discharge treatments than those in the control hospitals (composite measure 88.2% vs 84.8%, adjusted OR, 1.38 [95% CI, 1.11-1.71], p value=0.003) (Table). Kaplan-Meier estimates showed a reduction in the secondary outcomes of 12-month new clinical vascular events in the intervention versus control group (HR 0.73, 95% CI, 0.61-0.87; p value&lt;0.001) (Figure). Conclusion: Among patients with AIS treated in China, a multifaceted QI intervention improved the composite adherence to the evidence-based treatments as well as significantly reduced new vascular events. Trial Registration: clinicaltrials.gov Identifier: NCT02212912.

Predictors of post-thrombolysis symptomatic intracranial hemorrhage in Chinese patients with acute ischemic stroke.

Background and purposePredictors of symptomatic intracranial hemorrhage (sICH) in Chinese patients with acute ischemic stroke treated with recombinant tissue plasminogen activator remain unclear.MethodsData from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) study were assessed to explore risk factors for symptomatic intracranial hemorrhage after intravenous thrombolysis. Three candidate sICH definitions were analyzed.ResultsAmong 1128 patients with acute ischemic stroke treated with intravenous rtPA within 4.5 hours of symptom onset, 23 (2.0%), 44(3.9%) and 61 (5.4%) experienced modified mSITS-MOST, ECASS II, and NINDS defined sICH, respectively. Multivariate logistic regression revealed independent risk factors for sICH were age≧70 years-old(sICH per NINDS, adjusted OR = 1.73[95%CI1.02–2.95],p = 0.04),diabetes(sICH per SITS-MOST, adjusted OR = 3.50 [95%CI1.34–9.16], p = 0.01), serum glucose on admission >9.0mmol/L(sICH per ECASS II, adjusted OR = 2.84[95%CI1.48–5.46], p = 0.002),NIHSS on admission>20(sICH per SITS-MOST, adjusted OR = 5.06[95%CI1.68–15.20], p = 0.004 or sICH per NINDS, adjusted OR 2.81[95%CI1.42–5.57], p = 0.003) and cardioembolism(sICH per SITS-MOST, adjusted OR = 7.09[95%CI2.41–20.87], p<0.001 or sICH per ECASS II, adjusted OR = 4.99[95%CI2.53–9.84], p<0.001)or sICH per NINDS, adjusted OR = 2.47[95%CI1.39–4.39], p = 0.002).ConclusionCardioembolism, NIHSS on admission higher than 20, serum glucose on admission higher than 9.0 mmol/L and age ≧70 years were independent risk factors for symptomatic intracranial hemorrhage in Chinese patients with acute ischemic stroke treated with recombinant tissue plasminogen activator.

Chinese acute ischemic stroke treatment outcome registry (CASTOR): protocol for a prospective registry study on patterns of real-world treatment of acute ischemic stroke in China

RationaleStroke presents a serious health problem in China. Despite progresses made in recent years, there is still a lack of effective treatments for acute ischemic stroke (AIS) in clinical practices.AimsThe Chinese Acute Ischemic Stroke Treatment Outcome Registry (CASTOR) is designed to evaluate the patterns and cost-effectiveness of current treatments for AIS in real-world settings in China.DesignCASTOR is a prospective, multi-center study registered with ClinicalTrials.gov (NCT02470624) with a target sample size of 10,000 patients who are experiencing AIS. The patients are treated for AIS following the Chinese stroke guideline and local practice. Real-world data on treatment regimens, outcomes and costs are collected at baseline (Visit 1) and during subsequent visits (Visit 2 to Visit 5) after medication treatments.OutcomeThe primary objective of the present study is to analyze the current treatment status of AIS in real world settings. The secondary objectives include: 1) to compare the effectiveness of common treatment regimens, 2) to analyze the cost-effectiveness of different treatment regimens for AIS, 3) to analyze the incidence of adverse events and complications in enrolled patients with AIS, 4) to analyze the effect of Trial of Org 10,172 in Acute Stroke Treatment (TOAST) classification on the specific therapies during acute phase treatment period.DiscussionIn face of changing treatment patterns and increasing demand from medical insurers for cost-effectiveness data in China, a large-scale registry study examining the real-world patterns of AIS in hospitals is needed. The CASTOR study will help to find favorable cost-utility treatment regimens for AIS and improve the overall treatment outcome of Chinese patients with AIS.

Clopidogrel loading dose versus maintenance dose to treat patients with acute ischaemic stroke in China (CLASS-China): results from a prospective double-blind randomised clinical trial

AimThe role of clopidogrel in treating patients with acute ischaemic stroke is unclear. We have conducted the clinical trial in order to evaluate the efficacy and safety of clopidogrel with...

Intravenous Thrombolysis in Chinese Patients with Different Subtype of Mild Stroke: Thrombolysis in Patients with Mild Stroke

Thrombolysis treatment for patients with mild stroke is controversial. The aim of our study was to investigate whether patients with mild stroke or its specific etiologic subtype might benefit from rt-PA therapy. Data were derived from two cohorts of patients with and without rt-PA treatment: (1) the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) and (2) the China National Stroke Registry (CNSR) database. Patients with mild stroke (defined as National Institutes of Health Stroke Scale ≤5) receiving the rt-PA therapy and without rt-PA therapy were matched in 1:2 for age, sex, stroke severity and etiologic subtype. A total of 134 rt-PA-treated patients were matched to 249 non-rt-PA-treated patients in the study. Among them, 104 (76%) rt-PA-treated patients with mild stroke had good outcome after 3 months compared with 173 (69.5%) non-rt-PA-treated matching cases (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.91–2.43; P = 0.12). Compared with non-rt-PA-treated group, rt-PA-treated patients had good outcome after 3 months in those with stroke subtype of large-artery atherosclerosis (LAA) (80.5% vs 65.1%; OR, 2.19; 95%CI, 1.14–4.21; P = 0.02). For patients with mild stroke, intravenous rt-PA treatment may be effective. Patients with stroke subtype of LAA might benefit more from rt-PA treatment.

Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in China: Findings from the China National Stroke Registry II.

Background Stroke rehabilitation improves functional recovery among stroke patients. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation among patients with acute ischemic stroke. Aims We examined the frequency and determinants of an assessment for rehabilitation among acute ischemic stroke patients from the China National Stroke Registry II. Methods Data for 19,294 acute ischemic stroke patients admitted to 219 hospitals from June 2012 to January 2013 were analyzed. The multivariable logistic regression model with the generalized estimating equation method accounting for in-hospital clustering was used to identify patient and hospital factors associated with having a rehabilitation assessment during the acute hospitalization. Results Among 19,294 acute ischemic stroke patients, 11,451 (59.4%) were assessed for rehabilitation. Rates of rehabilitation assessment varied among 219 hospitals (IQR 41.4% vs 81.5%). In the multivariable analysis, factors associated with increased likelihood of a rehabilitation assessment ( p < 0.05) included disability prior to stroke, higher NIHSS on admission, receipt of a dysphagia screen, deep venous thrombosis prophylaxis, carotid vessel imaging, longer length of stay, and treatment at a hospital with a higher number of hospital beds (per 100 units). In contrast, patients with a history of atrial fibrillation and hospitals with higher number of annual stroke discharges (per 100 patients) were less likely to receive rehabilitation assessment during the acute stroke hospitalization. Conclusions Rehabilitation assessment among acute ischemic stroke patients was suboptimal in China. Rates varied considerably among hospitals and support the need to improve adherence to recommended care for stroke survivors.

Meta-analysis on indirect comparison of Erigeron breviscapus injection and Breviscapus injection in treatment of acute ischemic stroke

Erigeron breviscapus injection(DZXI) and Breviscapus injection(DZSI) are two popular injections in treatment of acute ischemic stroke in China. Both of them are manufactured from a same herbal medicine, E. breviscapus, but DZXI is an herbal extract(mixture) preparation and DZSI is a pure compound injection. This article was aimed to systemically evaluate and compare their efficacy and safety in treatment of acute ischemic stroke. The randomized controlled trials(RCTs) were collected for comparing DZXI and DZSI with Salvia miltiorrhiza injection(FDI) as the medium, and they were compared with indirect Meta-analysis(ITC). Thirty-nine RCTs with 4 180 patients were included. Meta-analysis results showed that both DZXI and DZSI had better efficacy than FDI in acute ischemic stroke. In the indirect comparison, DZSI had a higher total efficacy than DZXI, with significantly statistical differences[OR=0.634, 95%CI = (0.432,0.928), P<0.000 01], but there was no significant difference in improvement of neurological deficit [MD=-1.19, 95%CI=(－3.57,1.19), P=0.953]. On the safety aspect, adverse reaction rate of DZXI was 1.14%, mainly including head swelling, fever and chills while DZSI had no significant adverse reactions. The limited evidences in this study showed that Breviscapine injection had higher total efficiency and safety than E. breviscapine injection, but due to the low quality of the included RCTs, these two medicines should be comprehensively compared in further high-quality clinical trials.

Atherosclerotic plaque burden of middle cerebral artery and extracranial carotid artery characterized by MRI in patients with acute ischemic stroke in China: association and clinical relevance

Objectives: This study sought to compare the atherosclerotic plaque burden between middle cerebral artery (MCA) and extracranial carotid artery (ECA) in ischemic stroke patients using high-resolution, black-blood (HR BB) MRI and to investigate the relationship between plaque burden found in both arteries and stroke severity.Methods: All subjects with recent ischemic stroke underwent MCA and ECA HR BB MRI at 3.0 Tesla. For each artery segment, the thickness, area and signal intensities of plaques were recorded. Plaque burden, as measured by normalized wall index (NWI = wall area/total vessel area × 100%) were calculated. All patients received a clinical stroke severity score as measured by the National Institutes of Health Stroke Scale (NIHSS) scores at the time of admission.Results: A total of 65 stroke subjects were included in the final analysis. MCA exhibited significantly greater NWI than the ipsilateral ECA (symptomatic MCA vs. ECA: 58.04 ± 8.19 vs. 37.53 ± 10.25, p < 0.001; asymptomatic MCA vs. ECA: 53.80 ± 4.49 vs. 34.85 ± 4.27, p < 0.001, respectively). NWI in symptomatic MCA and ECA were significantly associated with NIHSS scores (r = 0.779 vs. 0.645; p < 0.001 respectively). Moreover, stronger statistical correlations between NIHSS scores and NWI were found in MCA, as compared with ECA during multivariate linear regression analysis.Conclusion: Greater atherosclerotic plaque burden and a closer association with stroke severity were found for the MCA as compared to the ipsilateral ECA. Identification of MCA plaque lesions by MRI may be helpful for developing more aggressive strategies for stroke prevention.

Smoking-Thrombolysis Relationship Depends on Ischemic Stroke Subtype.

The relationship between smoking and the outcome in patients received thrombolysis is undetermined. The outcome could be influenced by different stroke subtypes. This study aimed to explore whether smoking had any impact on the outcome in patients with stroke of different subtypes who received intravenous thrombolysis. All patients who received intravenous thrombolysis within 4.5 hours after symptom onset from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) database were eligible to be entered into this analysis. Smokers were considered if they smoked at least 1 cigarette/d for >6 months before stroke. Ischemic stroke subtype was classified by using the Trial of Org 10172 in Acute Stroke Treatment criteria. Outcome measurements included post-intravenous thrombolysis symptomatic intracranial hemorrhage within 7 days, mortality, and functional independence at 90 days. The relationship between smoking and thrombolysis was analyzed by using univariate and multivariate logistic regression models. Of 1118 patients enrolled, we identified 454 smokers and 664 nonsmokers. After stratifying for ischemic stroke subtypes, multivariate analysis revealed a significant relationship between smoking and functional independence in patients with noncardioembolism stroke subtypes (large artery atherosclerosis: odds ratio [OR], 1.452; 95% confidence interval [CI], 1.053-2.264; small artery occlusion: OR, 4.275; 95% CI, 1.098-16.649; other: OR, 3.120; 95% CI, 1.162-8.373). Furthermore, smoking was specially related to lower rates of symptomatic intracranial hemorrhage (OR, 0.316; 95% CI, 0.120-0.832) and mortality (OR, 0.272; 95% CI, 0.128-0.577) in patients with large artery atherosclerosis subtype. In patients treated with intravenous thrombolysis, smoking could be related to a better chance of functional independence if their subtype of stroke was noncardioembolic, and a lower risk of symptomatic intracranial hemorrhage and mortality in those with large artery atherosclerosis.

Relationship between Blood Pressure and Outcomes in Acute Ischemic Stroke Patients Administered Lytic Medication in the TIMS-China Study.

ObjectiveIncreased blood pressure (BP) management following acute ischemic stroke (AIS) remains controversial. This study aimed to identify the association between BP and clinical outcomes in AIS patients administered lytic medication in the TIMS-China (thrombolysis implementation and monitor of acute ischemic stroke in China) database.MethodsThe sample comprised 1128 patients hospitalized within 4.5 hours (h) of AIS for intravenous recombinant tissue plasminogen activator (i.v. rt-PA) thrombolysis. Systolic BP (SBP) and diastolic BP (DBP) at baseline, 2 h and 24 h after treatment, and changes from baseline were analyzed. The study outcomes comprised a favorable outcome (modified Rankin Scale 0–1 at 90 days) and symptomatic intracerebral hemorrhage (SICH), analyzed using logistic regression, with low BP as the reference group.ResultsLower BP (baseline, 2 h, and 24 h) was beneficial in AIS patients and significantly related to a favorable outcome (P<0.05). A substantial BP decrease at 24 h after rt-PA thrombolysis was significantly associated with a favorable outcome compared with a moderate BP decrease (P = 0.0298). A SBP >160 mmHg 2 h after rt-PA thrombolysis was significantly associated with SICH compared with a SBP <140 mmHg (P = 0.0238). An increase or no change (>25 mmHg) in SBP was significantly associated with SICH (P = 0.002) compared with a small SBP decrease (1–9 mmHg).ConclusionsThis study provides novel evidence that lower BP within the first 24 h is associated with a more favorable outcome and less frequent SICH in AIS patients administered lytic medication. Routine BP-lowering treatment should be considered in AIS patients following lytic medication.

Determinants of Emergency Medical Services Utilization Among Acute Ischemic Stroke Patients in Hubei Province in China.

Emergency medical services (EMS) can effectively shorten the prehospital delay for patients with acute ischemic stroke. This study aimed to investigate EMS utilization and its associated factors in patients with acute ischemic stroke in China. A cross-sectional study was conducted from October 1, 2014, to January 31, 2015, which included 2096 patients admitted for acute ischemic stroke from 66 hospitals in Hubei province in China. A multivariable stepwise logistic regression model was undertaken to identify the factors associated with EMS utilization. Of the 2096 participants, only 323 cases (15.4%) used EMS. Those acute ischemic stroke patients who previously used EMS (odds ratio [OR] =9.8), whose National Institutes of Health Stroke Scale score was ≥10 (OR=3.7), who lived in urban communities (OR=2.5), who had sudden onset of symptoms (OR=2.4), who experienced their first stroke (OR=1.8), and who recognized initial symptom as stroke (OR=1.4) were more likely to use EMS. Additionally, when acute ischemic stroke patients' stroke symptom were noticed first by others (OR=2.1), rather than by the patients, EMS was more likely to be used. A very low proportion of patients with acute ischemic stroke used the EMS in Hubei province in China. Considerable education programs are required regarding knowledge of potential symptoms and the importance of EMS for stroke.