Administration Of Intravenous Thrombolysis Research Articles

Critical Event Intervals in Determining Candidacy for Intravenous Thrombolysis in Acute Stroke.

BackgroundThe aim of the study was to determine the optimal set point for the critical event benchmarks described in stroke guidelines and validate the ability of these goals to predict successful administration of intravenous thrombolysis within 60 min of hospital arrival.MethodsThis was a retrospective cohort analysis of patients with acute ischemic stroke who received intravenous thrombolysis following presentation to the emergency department. The national benchmarks for time intervals associated with the completion of critical events required to determine candidacy for thrombolysis were evaluated for the ability to predict successful administration of thrombolysis within 60 min of hospital arrival. Optimal time interval cut points were then estimated using regression and receiver-operator characteristic curve analysis and compared to guidelines.ResultsOf the 523 patients included in the analysis, 229 (43.8%) received intravenous thrombolysis within 60 min of hospital arrival. Of the patients who met the critical event interval goals described in guidelines, only 51.6% received thrombolysis within 60 min. The optimized cut points suggested by the regression analysis aligned with the guideline benchmarks with the only substantial difference being a shortened goal of arrival to neuroimaging start time of 19 min. This difference did not impact the overall predictive value.ConclusionThe critical event benchmarks proposed in this study by logistic regression closely correlate with the critical event benchmarks described in the AHA/ASA acute stroke guidelines.

Safety of Intravenous Thrombolysis in Chronic Intracranial Hemorrhage: A Five-Year Multicenter Study

Although the recently updated U.S. alteplase label removed "history of intracranial hemorrhage (ICH)" as a contraindication, there are very limited data on the safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with chronic ICH. We sought to evaluate IVT safety in AIS patients with a history of ICH. We analyzed consecutive AIS patients treated with IVT at 3 tertiary stroke centers during a 5-year period. We identified AIS treated with IVT with clinical history and neuroimaging confirmation of prior ICH. The safety measure was symptomatic ICH (sICH) defined according to European Cooperative Acute Stroke Study-III criteria combined with the clinical deterioration of 4 points or higher in the National Institutes of Health Stroke Scale (NIHSS) or death. Of the 1212 AIS patients treated with IVT, 7 (.6%) (mean age 72 ± 11 years, 57% men, median NIHSS: 5 points, interquartile range: 2-8) had a history of ICH (hematoma volume: 1-21 cm3, elapsed time between previous ICH and AIS: 1.5-12 years, 5 located in basal ganglia and 2 in periventricular white matter). Patients with previous ICH did not differ in terms of demographics and admission stroke severity in comparison with the rest. The 2 groups had similar rates of sICH (0% [0/7] versus 3.6%, P = .61) and in-hospital mortality (0% [0/7] versus 6.0%, P = .50). Our study indicates that IVT might be safe among AIS patients with a history of chronic ICH. Further research with a larger sample size is required to confirm our finding and define the shortest time interval between the hemorrhagic and ischemic events that can be associated with the safe administration of IVT.

The UCP2-866G/A Polymorphism Could be Considered as a Genetic Marker of Different Functional Prognosis in Ischemic Stroke After Recanalization.

Recent studies based on experimental animal models of stroke have suggested that uncoupling protein 2 (UCP2), an inner mitochondrial membrane protein that is thought to regulate energy metabolism and reduce reactive oxygen species generation, provides protection against reperfusion damage. We aimed to investigate whether -866G/A polymorphism in the promoter of the UCP2 gene, which enhances its transcriptional activity, is associated with functional prognosis in patients with embolic ischemic stroke after early recanalization. We investigate a hospital-based prospective cohort of patients with acute ischemic stroke due to occlusion of the middle cerebral artery diagnosed by transcranial Doppler who obtained a partial/complete recanalization 24h after administration of intravenous thrombolysis. The main end point of the study was functional independence defined as modified Rankin Scale 0-2 on day 90. A total of 80 patients were enrolled. The UCP2-866G/A polymorphism was determined by polymerase chain reaction-restriction fragment length polymorphism technique (14 genotype A/A (18%), 45 genotype A/G (56%) and 21 genotype G/G (26%). The percentage of patients with good functional outcome at 3months was significantly higher in patients harboring the A/A genotype than in those with A/G or G/G genotypes (85 vs 41%, p=0.01). The A/A genotype was found to be an independent marker of good prognosis after adjustment for secondary variables (age, sex, glucose level, NIHSS score at baseline, complete recanalization and early neurological improvement) in a logistic regression analysis (OR 0.05, 95% CI 0.01-0.48, p=0.01). Our results suggest that the AA genotype of UCP2-866 may predict a better functional outcome in ischemic stroke after recanalization of proximal MCA occlusion.

Safety of Early Carotid Endarterectomy after Intravenous Thrombolysis in Acute Ischemic Stroke

The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2days (range: 0-13). A subgroup of 6 patients underwent CEA within 24hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P=0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.

Intravenous recombinant tissue plasminogen activator for acute ischemic stroke: a feasibility and safety study.

BackgroundIn developing countries, intravenous thrombolysis (IVT) is available at a limited number of centers. This study aimed to assess the feasibility and safety of IVT at Tabriz Imam Reza Hospital.MethodsIn a prospective study, over a 55-month period, any patient at the hospital for whom stroke code had been activated was enrolled in the study. Data on demographic characteristics, stroke risk factors, admission blood pressure, blood tests, findings of brain computed tomography (CT) scans, time of symtom onset, time of arrival to the emergency department, time of stroke code activation, time of CT scan examination, and the time of recombinant tissue plasminogen activator administration were recorded. National Institutes of Health Stroke Scale assessments were performed before IVT bolus, at 36 hours, at either 7 days or discharge (which ever one was earlier), and at 3-month follow-up. Brain CT scans were done for all patients before and 24 hours after the treatment.ResultsStroke code was activated for 407 patients and IVT was done in 168 patients. The rate of functional independence (modified Rankin Scale [mRS] 0–1) at 3 months was 39.2% (62/158). The mortality rate at day 7 was 6% (10/168). Hemorrhagic transformation was noted in 16 patients (9.5%). Symptomatic intracranial hemorrhage occurred in 5 (3%), all of which were fatal. One case of severe urinary bleeding and one other fatal case of severe angioedema were observed.ConclusionDuring the first 4–5 years of administration of IVT in the hospital, it was found to be feasible and safe, but to increase the efficacy, poststroke care should be more organized and a stroke center should be established.

Abstract TP248: Can the Door to Needle Time Metric Be Achieved via Telestroke?

Background: The administration of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) can be safe and effective. It remains unclear how quickly IVT occurs during TS evaluations. We sought to compare door to needle times (DNT) between patients receiving IVT who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network. Methods: Consecutive acute ischemic stroke (AIS) patients who presented to emergency departments and received IVT between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges (IQR) were calculated in each cohort. Outcomes measured included rates of symptomatic intracerebral hemorrhage, in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU). Results: During the study period, 117 AIS patients (mean age 71±15 years, 47% women) receiving IVT were included in the analysis (65 CSC, 52 TS). Median DNT at our CSC was significantly shorter compared to TS DNT (CSC 43 [IQR 35,55] minutes vs TS 54 [IQR 41,71.25] minutes, p=0.005). The proportion of patients receiving IVT within 60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, p=0.01). Favorable discharge to home or ARU was similar (CSC 76.9% vs TS 75%, p=0.83). Conclusion: Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.

Abstract TP335: Lower NIHSS Score on Presentation to the Emergency Center Delays Head CT Turnaround Times

Background: Rapid assessment of patients that present to the emergency center with acute stroke symptoms is crucial to the timely administration of intravenous thrombolysis. The “golden hour” is recognized by the American Heart Association as the standard of care for treatment of acute ischemic stroke [1]. Door to treatment in ≤ 60 minutes can be difficult to achieve, and in 2010 < 30% of hospitals participating in GWTG attained this goal [2]. One step that can be particularly challenging during the expedited stroke assessment is door to head CT interpretation time in ≤ 45 minutes. We sought to determine factors that delay head CT turnaround times > 45 minutes. Methods: A retrospective stroke database review was completed on 165 patients presenting to the emergency center with acute stroke symptoms in the 0-4.5 hour time window from January 2014 to May 2015. Inclusion criteria was age 18-95 years with an initial NIHSS of 1-42, and a head CT completed at our hospital. Inpatients that developed acute stroke symptoms were excluded from the study. Patients were further stratified by NIHSS and age. Results: The mean age was 75 years and 50% were female. The average head CT turnaround time was 38.1 minutes and the average NIHSS was 8.11. Fifty three patients (32.1%) received acute reperfusion therapy. The average head CT turnaround time for a NIHSS of 1-3 was 47.4 minutes; NIHSS of 4-9 was 38.4 minutes; NIHSS of 10-24 was 25.2 minutes; NIHSS ≥ 25 was 34.5 minutes. There was no significant difference in the head CT turnaround time based on age. Conclusion: Patients presenting to the emergency center with a NIHSS of 1-3 had delayed head CT turnaround times compared to patients presenting with more severe stroke symptoms, and furthermore, did not meet the goal head CT interpretation time of ≤ 45 minutes. One possible reason for this finding is that patients with minor stroke symptoms are less likely to receive intravenous thrombolysis. However, expanding literature suggests that nearly 30% of patients with lower NIHSS scores at discharge have significant disability at 90 days [3]. Multiple educational interventions will be implemented in the emergency center to improve head CT turnaround times in patients with low NIHSS scores on presentation.

Renal dysfunction and thrombolytic therapy in patients with acute ischemic stroke: a systematic review and meta-analysis.

Renal dysfunction is a prevalent comorbidity in acute ischemic stroke patients requiring thrombolytic therapy. However, the effect of renal dysfunction on the clinical outcome of this population remains controversial.This study aimed to evaluate the safety and effectiveness of thrombolytic therapy in acute stroke patients with renal dysfunction using a meta-analysis.We systematically searched PubMed and EMBASE for studies that evaluated the relationship between renal dysfunction and intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke. Poor outcome (modified Rankin Scale ≥2), mortality, and symptomatic intracranial hemorrhage (ICH) and any ICH were analyzed.Fourteen studies were included (N = 53,553 patients). The mean age ranged from 66 to 75 years. The proportion of male participants was 49% to 74%. The proportion of renal dysfunction varied from 21.9% to 83% according to different definitions. Based on 9 studies with a total of 7796 patients, the meta-analysis did not identify a significant difference in the odds of poor outcome (odds ratio [OR] = 1.06; 95% confidence interval [CI]: 0.96–1.16; I2 = 44.5) between patients with renal dysfunction and those without renal dysfunction. Patients with renal dysfunction were more likely to die after intravenous thrombolysis (OR = 1.13; 95% CI: 1.05–1.21; I2 = 70.3). No association was observed between symptomatic ICH (OR = 1.02; 95% CI: 0.94–1.10; I2 = 0) and any ICH (OR = 1.07; 95% CI: 0.96–1.18; I2 = 25.8).Renal dysfunction does not increase the risk of poor outcome and ICH after stroke thrombolysis. Renal dysfunction should not be a contraindication for administration of intravenous thrombolysis to eligible patients.

Stroke code improves intravenous thrombolysis administration in acute ischemic stroke.

Background and PurposeTimely intravenous (IV) thrombolysis for acute ischemic stroke is associated with better clinical outcomes. Acute stroke care implemented with “Stroke Code” (SC) may increase IV tissue plasminogen activator (tPA) administration. The present study aimed to investigate the impact of SC on thrombolysis.MethodsThe study period was divided into the “pre-SC era” (January 2006 to July 2010) and “SC era” (August 2010 to July 2013). Demographics, critical times (stroke symptom onset, presentation to the emergency department, neuroimaging, thrombolysis), stroke severity, and clinical outcomes were recorded and compared between the two eras.ResultsDuring the study period, 5957 patients with acute ischemic stroke were admitted; of these, 1301 (21.8%) arrived at the emergency department within 3 h of stroke onset and 307 (5.2%) received IV-tPA. The number and frequency of IV-tPA treatments for patients with an onset-to-door time of <3 h increased from the pre-SC era (n = 91, 13.9%) to the SC era (n = 216, 33.3%) (P<0.001). SC also improved the efficiency of IV-tPA administration; the median door-to-needle time decreased (88 to 51 min, P<0.001) and the percentage of door-to-needle times ≤60 min increased (14.3% to 71.3%, P<0.001). The SC era group tended to have more patients with good outcome (modified Rankin Scale ≤2) at discharge (49.5 vs. 39.6%, P = 0.11), with no difference in symptomatic hemorrhage events or in-hospital mortality.ConclusionThe SC protocol increases the percentage of acute ischemic stroke patients receiving IV-tPA and decreases door-to-needle time.

Significant Improvement in Door-to-Needle Times and Clinical Outcomes with “Target: Stroke”

Earlier administration of intravenous thrombolysis for acute ischemic stroke is associated with improved outcomes. Yet, despite nearly two decades of practical experience developing systems of care to rapidly deliver tissue plasminogen activator (TPA), in-hospital delays are still common. To address this challenge, the American Heart Association/American Stroke Association and partner organizations launched the “Target: Stroke” quality improvement initiative in 2010 among hospitals …

Door-to-Needle Time and the Proportion of Patients Receiving Intravenous Thrombolysis in Acute Ischemic Stroke

Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) is one of very few effective treatments for acute ischemic stroke. Still, in most centers, only a small proportion (2%–7%) of patients with ischemic stroke receive this treatment in daily practice.1–3 The most important factor limiting IVT administration is time because it has to be administered within 4.5 hours of symptom onset. Even within this time window, the clinical benefit from IVT declines rapidly (time is brain), and every minute counts.4 If IVT is started within 90 minutes after stroke onset, the number of patients needed to treat to achieve an excellent clinical outcome modified Rankin scale score (0–1) is 4. Within the 180–270-minute time window, this number dramatically increases to 14.5 In other words, a shorter delay from symptom to IVT, the so-called symptom-to-needle time, can make the difference between being independent and being dependent. Reducing the symptom-to-needle time requires several hurdles to be jumped. Most time is lost in the prehospital period, the so-called symptom-to-door time to symptom-to-needle time, mainly because of patients waiting before they seek medical attention. However, this is difficult to accomplish because campaigns aimed at raising public awareness of stroke symptoms have only limited impact on behavior.6 Inside the hospital, focus should be on decreasing the time from arrival to IVT administration, the so-called door-to-needle time (DNT). Besides improved functional outcome, a reduced DNT will also increase the proportion of patients eligible for IVT because more patients can be treated before the 4.5-hour time limit.7 Unfortunately, >15 years after IVT was proven to be clinically effective, in most institutions, the DNT is still >60 minutes for the majority of patients.7,8 In most countries, national guidelines recommend that the DNT should not exceed this 60-minute limit. …

Acute Combined Revascularization in Acute Ischemic Stroke with Intracranial Arterial Occlusion: Self-expanding Solitaire Stent during Intravenous Thrombolysis

PurposeTo investigate the safety and efficacy of the self-expanding Solitaire stent used during intravenous thrombolysis (IVT) for intracranial arterial occlusion (IAO) in acute ischemic stroke (AIS). Materials and MethodsConsecutive nonselected patients with AIS with IAO documented on computed tomographic angiography or magnetic resonance angiography and treated with IVT were included in this prospective study. Stent intervention was initiated and performed during administration of IVT without waiting for any clinical or radiologic signs of potential recanalization. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS), and 90-day clinical outcome was assessed by modified Rankin scale (mRS), with a good outcome defined as an mRS score of 0–2. Recanalization was rated by thrombolysis in cerebral infarction (TICI) scale. ResultsFifty patients (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalization was achieved in 94% of patients, and complete recanalization (ie, TICI 3 flow) was achieved in 72% of patients. The mean time from stroke onset to maximal recanalization was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalization of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mRS score at 90 days was 1, and 60% of patients had a good outcome (ie, mRS score 0–2). The overall 3-month mortality rate was 14%. ConclusionsCombined revascularization with the Solitaire stent during IVT appears to be safe and effective in the treatment of acute IAO.

Performance measures for in-hospital care of acute ischemic stroke in public hospitals in Chile

BackgroundThe aim of this study were to describe acute care of ischemic stroke patients and adherence to performance measures, as well as the outcomes of these events, in a sample of patients treated in public hospitals in Chile.MethodsWe retrospectively reviewed the medical charts of patients with ischemic stroke from a sample of seven public hospitals in the Metropolitan Region of Santiago. We analyzed adherence to the following evidence-based measures: clinical evaluation at admission, use of intravenous thrombolysis, dysphagia screening and prescription of antithrombotic therapy at discharge. As outcome measures we analyzed post-stroke pneumonia and 30-day case-fatality. We used a logistic regression model by each outcome with generalized estimating equations, which accounted for clustering of patients within hospitals and included sex, age (years), clinical status at admission (reduced level of consciousness, speech disturbance, aphasia and hemiplegia), comorbidities, dysphagia screening and neurological evaluation at admission as measures of acute stroke care.ResultsWe reviewed the charts of 677 patients, of which 52.3% were men. The mean age was 69.8 years in women and 66.3 years in men. Diagnosis of stroke was confirmed by a computed tomography scan within 4.5 hours of symptom onset in only 9.6% of the patients. Intravenous thrombolysis was administered in 1.7%. Dysphagia screening was performed in 12.1% (95% CI 9.7-15.0) and antithrombotic therapy was prescribed in 68.9% (95% CI 64.6-72.9). Pneumonia was diagnosed in 23.6% (95% CI 20.4-27.2). Thirty-day fatality was 8.7% (95% CI 6.7-11.3). The variables independently associated with 30-day case fatality were age (OR 1.08, 95% 1.06-1.10), pneumonia (OR 7.7, 95% 95% CI 4.0-14.7), aphasia (OR 2.4, 95% CI 1.1-5.6), reduced level of consciousness (OR 2.4, 95% CI 1.3-4.4), and speech disturbance (OR 1.4, 95% CI 1.0-1.9). No association was found between 30-day case fatality and dysphagia screening or neurological evaluation at admission. The factors associated with post-stroke pneumonia were female sex (OR 1.6, 95% CI 1.0-2.3), age (OR 1.04 95% CI 1.03-1.05), diagnosis of diabetes (OR 1.8, 95% CI 1.4-2.4), aphasia (OR 2.0, 95% CI 1.5-2.7), hemiplegia (OR 1.6, 95% CI 1.1-2.4), and reduced level of consciousness on admission (OR 3.4, 95% CI 2.1-5.5). No association was found between pneumonia and dysphagia screening or neurological evaluation at admission.ConclusionsAdherence to evidence-based performance measures was low. Administration of intravenous thrombolysis was particularly low and diagnostic confirmation of ischemic stroke was delayed. The occurrence of post-stroke pneumonia was frequent and should be reduced. To improve acute stroke care in Chile, organizational change in the health service is urgently needed.

Stroke Mimics Treated with Thrombolysis: Further Evidence on Safety and Distinctive Clinical Features

Background: Patients who present with symptoms mimicking ischaemic stroke (IS), but have a different diagnosis, are known as stroke mimics (SM). The necessity for rapid administration of intravenous thrombolysis in patients with acute IS may lead to treatment of patients with conditions mimicking stroke. A variable proportion of patients with SM (1.4–14%) are currently treated with intravenous tissue plasminogen activator therapy (IV-tPA). The outcome of these patients is generally favourable and complications are rather infrequent. We aimed to determine the frequency, clinical features and prognosis of SM patients treated with IV-tPA in an experienced stroke centre. Methods: A prospective registry was assembled with patients treated with IV-tPA at our stroke unit from January 2004 to December 2011. We recorded age, gender, baseline National Institutes of Health Stroke Scale (NIHSS) score, treatment delay, vascular risk factors, clinical syndrome and aetiology. We retrospectively analysed the clinical characteristics of SM, safety (symptomatic intracranial haemorrhage and mortality) and outcome measures (modified Rankin Scale at 3 months, mRS) and compared them with IS patients. Results: 621 patients were treated with IV-tPA during the study period, 606 (97.5%) were IS and 15 (2.4%) were SM. The aetiology of SM was somatoform disorders (5), headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) syndrome (3), herpetic encephalitis (2), glial tumours (2), and migraine with aura, focal seizure and cortical vein thrombosis in single cases. SM were younger (72 ± 14 vs. 53.7 ± 16 years, p < 0.05), had a lower baseline deficit [NIHSS 13 (9–18) vs. 8 (5–10), p < 0.05], fewer vascular risk factors, and left hemisphere symptoms were predominant (80 vs. 52.4%, p < 0.05). Global aphasia without hemiparesis (GAWH) was the presenting symptom in 8 (54%) SM and 44 (7%) IS (p < 0.05). Multimodal computed tomography was performed in 3 SM patients and showed perfusion deficits in 2 of them. No intracranial haemorrhage or disability (functional outcome at 3 months, mRS >2) was recorded in any SM patient. Conclusions: The use of intravenous thrombolysis appears to be safe in our SM patients, and prognosis is universally favourable. Somatoform disorder and HaNDL syndrome were prominent causes, and GAWH the most common presentation. The safety of thrombolysis in SM suggests that delaying or withholding treatment may be inappropriate: the benefit of thrombolysis in case of IS may outweigh the risks of treating an SM. Further studies may assess the future role of multimodal computed tomography in the differential diagnosis between IS and SM.

Effect of Prior Antiplatelet Therapy on Risk and Type of Hemorrhagic Transformation in Patients with Acute Ischemic Stroke after Intravenous Thrombolysis (P06.240)

Objective: To investigate how prior aspirin therapy affected hemorrhagic transformation in acute ischemic stroke patients after intravenous thrombolysis. Background There is conflicting data regarding prior antiplatelet therapy and risk of hemorrhagic transformation of ischemic stroke after intravenous thrombolysis. Our goal was to investigate how prior aspirin therapy affected the incidence and type of hemorrhagic transformation after intravenous thrombolysis. Design/Methods: We conducted a retrospective study of consecutively enrolled acute ischemic stroke patients at one hospital who received intravenous thrombolysis with recombinant tissue Plasminogen Activator (rt-PA) over a 5 year period between 2005 and 2011. Baseline characteristics including age, gender and prior antiplatelet therapy were registered on admission. Using computerized tomography (CT) scan we identified the patients with hemorrhagic transformation of ischemic stroke after intravenous rt-PA and classified them into hematomas or petechial hemorrhages. Results: We identified 119 patients at our institution with acute ischemic stroke who had received intravenous rt-PA. The mean age was 74.2 years and 46% were male. Of the 119 patients, 27 had hemorrhagic transformation (23%), out of which 16 were hematomas (59%) and 11 were petechial hemorrhages (41%). Of a total of 41 patients on prior Aspirin therapy, 10 had hemorrhagic transformation (24%), 9 of which were hematomas (90%). Of a total of 58 patients on no prior antiplatelet therapy, 16 had hemorrhagic transformation (28%), of which 7 were hematomas (44%). Three patients were on dual antiplatelet therapy with Aspirin and Plavix, none of which had hemorrhagic transformation. Conclusions: In our retrospective study, we found similar rates of hemorrhage between the aspirin and no aspirin group after administration of intravenous thrombolysis. The aspirin group was, however, associated with a greater percentage of hematomas than petechial hemorrhages when compared to the no aspirin group. More data is needed to determine if aspirin promotes a tendency towards hematoma formation in these patients. Disclosure: Dr. Sonni has nothing to disclose. Dr. Drobnis has nothing to disclose. Dr. Fitzgerald has nothing to disclose. Dr. Hreib has nothing to disclose. Dr. Tilem has nothing to disclose.

Abstract 2940: Arrival in the Emergency Department on Nights and Weekends Results in Delayed Administration of Intravenous Thrombolysis for Ischemic Stroke

Background: Reduced time to administration of intravenous thrombolysis for acute ischemic stroke (AIS) is associated with improved functional outcomes. Less than one-third of AIS patients receive IV rt-PA with a door-to-needle (DTN) ≤ 60 minutes with only modest improvements reported over time. We investigated factors that may adversely prolong DTN time including reduced resident physician experience, low stroke severity on presentation, patient presentation time (day, evening, night) and day of week. Methods: A consecutive series of 258 patients with AIS received IV rt-PA at an academic comprehensive stroke center with a developed process for IV rt-PA administration and a neurology training program. Patient presentation times in the emergency department were divided into shifts defined as 07:00-14:59 (day), 15:00-22:59 (evening) and 23:00-06:59 (night). Neurology resident experience level was grouped as July-December (less experienced) vs. January-June (more experienced). Day of the week was grouped into weekday (Monday-Friday) and weekend (Saturday-Sunday). Variables associated with DTN time were assessed by t-test, ANOVA and by logistic regression. Results: The group had a mean age of 70.7±14.3 years, NIHSS score 13.3±6.8, DTN time 70.0±28.1 minutes, onset to ED arrival time 77.5±38.0 minutes. Patients presenting during evening and night hours had prolonged DTN times, day=65.5, evening=71.8 and night=78.3 minutes (p=0.05) by ANOVA. Patients arriving on weekends also had prolonged DTN times weekdays= 66.6 vs. weekends=77.2 minutes (p=.01). Increased time from onset to ED arrival was also associated with reduced DTN time (p&lt;0.001). Age, gender, race, stroke severity on presentation, and resident experience level were not related to DTN time. Both presentation time by shift and day of week were predictive of prolonged DTN time by multivariable analysis (p&lt;0.01). Conclusions: Presentation time during the evening and night hours and weekends is associated with prolonged DTN times. Reduced staffing and support on nights and weekends may adversely affect DTN time.

Stroke Mimics and Intravenous Thrombolysis

The necessity for rapid administration of intravenous thrombolysis in patients with acute ischemic stroke may lead to treatment of patients with conditions mimicking stroke. We analyze stroke patients treated with intravenous thrombolysis in our center to characterize cases classified as stroke mimics. We identified and reviewed all cases with a diagnosis other than ischemic stroke in our large-scale single-center stroke thrombolysis registry. We compared these stroke mimics with patients with neuroimaging-negative and neuroimaging-positive ischemic stroke results. Among 985 consecutive intravenous thrombolysis-treated patients, we found 14 stroke mimics (1.4%; 95% confidence interval 0.8% to 2.4%), 694 (70.5%) patients with neuroimaging-positive ischemic stroke results, and 275 (27.9%) patients with neuroimaging-negative ischemic stroke results. Stroke mimics were younger than patients with neuroimaging-negative or -positive ischemic stroke results. Compared with patients with neuroimaging-positive ischemic stroke results, stroke mimics had less severe symptoms at baseline and better 3-month outcome. No differences appeared in medical history or clinical features between stroke mimics and patients with neuroimaging-negative ischemic stroke results. None of the stroke mimics developed symptomatic intracerebral hemorrhage compared with 63 (9.1%) among patients with neuroimaging-positive ischemic stroke results and 6 (2.2%) among patients with neuroimaging-negative ischemic stroke results. Stroke mimics were infrequent among intravenous thrombolysis-treated stroke patients in this cohort, and their treatment did not lead to harmful complications.

Predictors of major neurological improvement after intravenous thrombolysis in acute ischemic stroke: A hospital-based study from south India

Despite the increasing use of recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke, uncertainty persists about the short- and long-term outcome of the thrombolysed patients. To identify predictors of major neurological improvement at 24 h after intravenous rt-PA administration in patients of acute ischemic stroke and their relationship with outcome at 12 months. We analyzed the data of the patients with acute ischemic stroke treated as per the National Institute of Neurological Disorders and Stroke (NINDS) criteria with intravenous rt-PA between January 2000 and June 2009 at a tertiary care center in south India. Major neurological improvement was defined by an 8-point improvement in National Institute of Health Stroke Scale (NIHSS) score or an NIHSS score of 0 or 1 at 24 h. Good outcome was defined as a 12-month modified Rankin Scale (mRS) of 0 to 1. Of the 72 patients with acute ischemic stroke treated with intravenous rt-PA, 23 (32%) patients had major neurological improvement at 24 h. Age <60 years (OR 1.9, 95% CI 1.7 to 3.2), admission glucose levels <8 mmol/L (OR 3.87, 95% CI 1.9 to 9.2) and mild to moderate baseline stroke severity (NIHSS median score 10+ 6) were associated with major neurological improvement after adjusting for co variables. Major neurological improvement at 24 h was an independent predictor of good outcome (mRS=1) at 12 months (OR 13.9, 95% CI 6.84 to 40.2). Age <60 years, glucose levels <8 mmol/L and mild to moderate stroke severity (NIHSS median score 10+/-6) was associated with major neurological improvement after intravenous rt-PA. Major neurological improvement at 24 h after the administration of intravenous thrombolysis independently predicted good outcome at 12 months.

Eligibility of stroke units in Poland for administration of intravenous thrombolysis

Systemic thrombolysis treatment was approved in Poland in 2003 and should be performed in specialist stroke units (SU). We performed a survey to determine stroke service preparedness for thrombolysis treatment in Poland. We sent a questionnaire evaluating the neurological departments in Poland, where stroke patients are treated. We divided them into four categories: (i) class A SU (fulfilling criteria of the National Program for Stroke Prevention and Therapy and European Stroke Initiative guidelines), (ii) class B (conditionally fulfilling criteria), (iii) class C (not fulfilling criteria), and (iv) departments without SU. Only class A units are eligible for implementing thrombolysis. We obtained response from 194 of 222 (87.4%) departments; 90 (46.4%) declared having an SU. According to criteria, 20 class A, 56 class B, 14 class C. During one year, 71 208 patients were admitted to hospitals; 69,982 (98.2%) to neurological departments. A total of 10,959 (15.4%) were treated in class A SU, 23,650 (33.2%) in class B, 5153 (7.2%) in class C, whereas 30,220 (42.4%) in neurological departments without SU. Our survey showed that only 15.4% stroke patients in Poland are admitted to high-quality SU, where thrombolysis may potentially be administered. Improvement of SU quality in Poland is necessary for wide implementation of new methods of stroke therapy.

Influence of diabetes mellitus on intravenous thrombolysis effectiveness in patients with ST elevation myocardial infarction

Background-Early resolution of ST-segment elevation is associated with enhanced clinical outcome following ST elevation myocardial infarction (STEMI). Despite the improvements in the management of type 2 diabetic patients with STEMI these patients have unfavorable prognosis. The present prospective study investigated the hypothesis that type 2 diabetic patients may have a delayed ST-segment recovery during administration of intravenous thrombolysis even though within the desirable margin. Methods-The study cohort included 137 consecutive patients with STEMI; 105 were non-diabetic and 32 type 2 diabetic. All patients received thrombolysis in r6 hours from index pain and attained steady 250% ST-segment recovery within 90min. The course of ST-segment recovery was assessed utilizing continuous 12.lead electrocardiographic monitoring. Results-The time required for 250% ST-segment steady resolution was significantly greater in type 2 diabetics (P <O.OOi). Additionally, although there was no difference in the mcidence of TIMI 2 or 3 flow between the two groups, type 2 diabetics had significantly higher values of corrected TIMI frame count in the infarct-related arteries (P <O.OOl). By multwariate linear regression analysis diabetes mellitus was independently and positively related to the time for 150% ST-segment recovery (P ~0.001). Conclusions-The present study implies that type 2 diabetic patients may have delayed recovery of ST-segment elevation even dunng successful thrombolysis.