Candidates For Thrombolytic Therapy Research Articles

Success of the emergency physician to recognize pathological diffusion-weighted magnetic resonance imaging in acute stroke patients

This study is aimed to evaluate the proficiency of emergency physicians in identifying ischemic strokes via diffusion-weighted magnetic resonance imaging (DW-MRI), and to determine the inter-rater agreement between emergency department (ED) residents and radiologists. The suspected ischemic stroke patients undergoing DW-MRI and not the candidates for thrombolytic therapy were eligible for the study. Diffusion MRI images were evaluated by the on-duty senior ED residents having two or more years in residency program, and a radiologist. Prior to the study, an instructor from radiology department delivered 2-hour theoretical and 2-hour practical lectures to ED physicians on the evaluation of diffusion MRI. A total of 604 patients were included in the study wherein 145 patients (24%) were detected with ischemic areas. The parietal lobe was the most prevalent ischemic area according to ED physicians’ and radiologist’s findings. ED residents and the radiologist had different interpretations for 54 patients. ED physicians ascribed 15 (3.4%) ischemic stroke patients as normal and 39 (23.1%) normal patients as stroke. ED physicians had 89.7% sensitivity (95% confidence interval (CI): 84% to 94%) and 91.5% specificity (95% CI: 89% to 94%) in diagnosing ischemic stroke. A good inter-rater agreement was found between ED physicians and the radiologist with kappa value of 0.77 (95% CI: 0.71 to 0.83). ED physicians have better success rate in interpreting DW-MRI to detect ischemic stroke in non-candidate cases of thrombolytic therapy (cases whose National Institutes of Health Stroke Skale (NIHSS) score is not appropriate, symptom onset exceeds 4.5 hours, and thrombolytic administration is contraindicated). There is a good inter-rater agreement between ED physicians and radiologist.

Pre-Hospital Delaying Factors in Patients of Acute Ischemic Stroke who are Candidates for Thrombolytic Therapy

Objective: To identify and statistically evaluate pre-hospital delaying factors for thrombolysis in Acute Ischemic Stroke (AIS).
 Study Design: Cross-sectional study.
 Place And Duration OF Study: Emergency/Neurology Department, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Dec 2020 to Mar 2021.
 Methodology: Patients older than 18 years and who reported to the emergency/Neurology clinic with stroke symptoms were included in the study. The patients or their relatives were interviewed with a detailed questionnaire that recorded patients' National Institute of Health Stroke Scale and other socio-demographic variables. In addition, the patients were grouped based on time of arrival to the hospital: Early (<4.5 hours) and Late (>4.5 hours), and the variables recorded were compared with each other.
 Results: Of 98 patients, 71(72.5%) arrived early, and 27(27.5%) arrived late. Seventy patients (72%) were male, and 28(28%) were female. Only 18 patients availed of the ambulance service, whereas the rest of the study participants reached the hospital using private transportation.
 Conclusion: Female gender, NIHSS score of 10 or below and using transport other than ambulance adversely affect the hospital arrival time of acute ischemic stroke patients.

Low-dose thrombolytic therapy versus unfractionated heparin in patients with intermediate-high risk pulmonary embolism.

Patients with intermediate-high risk pulmonary embolism (PE) who have acute right ventricular dysfunction and myocardial injury without overt hemodynamic compromise may be candidates for thrombolytic therapy (TT). In this study, we aimed to compare the clinical outcomes of low-dose prolonged TT and unfractionated heparin (UFH) in intermediate-high risk PE patients. This study enrolled 83 (female: 45 [54.2%], mean age: 70.07±10.7 years) retrospectively evaluated patients with the diagnosis of acute PE who were treated with low-dose and slow-infusion of TT or UFH. The primary outcomes of the study were de-fined as a combination of death from any cause and hemodynamic decompensation, and severe or life-threatening bleeding. Secondary endpoints were recurrent PE, pulmonary hypertension, and moderate bleeding. The initial management strategy of intermediate-high risk PE was TT in 41 (49.4%) patients and UFH in 42 (50.6%) cases. Low-dose prolonged TT was successful in all patients. While the frequency of hypotension decreased significantly after TT (22 vs. 0%, P<0.001), it did not decrease after UFH (2.4 vs. 7.1%, p=0.625). The proportion of hemodynamic decompensation was significantly lower in the TT group (0 vs. 11.9%, p=0.029). The rate of secondary endpoints was significantly higher in the UFH group (2.4 vs. 19%, P=0.016). Moreover, the prevalence of pulmonary hypertension was significantly higher in UFH group (0 vs. 19%, p=0.003). Prolonged TT regimen with low dose, slow infusion of tissue plasminogen activator was found to be associated with a lower risk of hemodynamic decompensation and pulmonary hypertension in patients with acute intermediate-high-risk PE compared to UFH.

Impact of Metabolic Syndrome in Patients With Acute Myocardial Infarction After Thrombolytic Therapy

Background: Metabolic syndrome (MetS) comprises a group of conditions that happen together and increase the risk of heart disorders. MetS has known characteristic diagnostic criteria and is diagnosed through physical examination and blood tests. This syndrome is extremely prevalent in patients with acute myocardial infarction. We aimed to determine the prevalence of MetS and its relationship with myocardial infarction and response to treatment in patients suffering from acute myocardial infarction under fibrinolytic treatment. Methods: In this cross-sectional study, 145 patients with acute ST-elevation myocardial infarction (STEMI) were enrolled. They were referred to Bu-Ali Sina Hospital in Qazvin, Iran, between January 2018 and January 2019 and were candidates for thrombolytic therapy. The patients were divided into two groups with and without MetS according to the NCEP ATP III definition (the National Cholesterol Education Program-Adult Treatment Panel III). In each group, the ST resolution of more than 50% in electrocardiogram was evaluated 90 minutes after thrombolytic administration. In addition, angiographic information and left ventricular ejection fraction (LVEF) were compared between the two groups. Results: Overall, the prevalence of MetS was 57.2% in the study population. After treatment, ST-segment resolution of more than 50%, the number of involved coronary vessels, the thrombolysis in myocardial infarction flow grade, mean LVEF, and type of myocardial infarction were similar in both study groups. Conclusion: Our study indicates that MetS does not affect the response rate to thrombolytic treatment.

Clinical safety and efficacy of thrombolytic therapy with low-dose prolonged infusion of tissue type plasminogen activator in patients with intermediate-high risk pulmonary embolism.

: The patients with intermediate-high risk pulmonary embolism who have acute right ventricular (RV) dysfunction and myocardial injury without overt hemodynamic compromise may be candidates for thrombolytic therapy. Alternative low-dose thrombolytic therapy strategies with prolonged infusion may further decrease the complication rates as its efficacy and safety have been previously proven in the management of prosthetic valve thrombosis. In this study, we aimed to investigate the clinical outcomes of low-dose prolonged thrombolytic therapy regimen in intermediate-high risk pulmonary embolism patients. This study enrolled 16 retrospectively evaluated patients (female 9, mean age: 70.9 ± 13.5 years) with the diagnosis of acute pulmonary embolism who were treated with low-dose and slow-infusion of tissue-type plasminogen activator (t-PA). All patients underwent transthoracic echocardiography and computed tomography scan for assessment of thrombolytic therapy success. Low-dose prolonged thrombolytic therapy was successful in all patients. The mean t-PA dose used was 48.4 ± 6.3 mg. There was residual segmental thrombus in nine (56.3%) patients after thrombolytic therapy. The arterial oxygen saturation and tricuspid annular plane systolic excursion increased after thrombolytic therapy whereas heart rate, RV to left ventricular (LV) ratio, systolic pulmonary artery pressure, and the frequencies of hypotension and tachypnea significantly decreased. There was no cerebrovascular accident or major bleeding requiring transfusion. There were two minor bleedings (12.5%) including hemoptysis and epistaxis. Thrombolytic therapy in these intermediate-high risk pulmonary embolism patients was associated with excellent clinical outcomes and survival to discharge (100%) without any 60-day mortality. Prolonged thrombolytic therapy regimen with low-dose and slow-infusion of t-PA may be associated with lower complication rates without comprimising effectiveness in patients with acute intermediate-high risk pulmonary embolism.

57-Year-Old Man With Vertigo

57-Year-Old Man With Vertigo

Underutilization of Thrombolytic Therapy for Patients Diagnosed with Acute Deep Venous Thrombosis in the Outpatient Setting

Acute deep venous thrombosis (DVT) is not uncommonly diagnosed in the outpatient vascular laboratory as patients are often sent to an outpatient vascular laboratory for evaluation of limb swelling or pain to rule out a DVT. Many patients who might have been candidates for thrombolytic therapy were never referred to a specialist for evaluation.

Underutilization of Thrombolytic Therapy for Patients Diagnosed with Acute Deep Venous Thrombosis in the Outpatient Setting

Catheter-directed thrombolysis (CDT) has been shown to be a safe and effective treatment for the management of acute iliofemoral deep venous thrombosis (DVT). The potential benefits of this therapy include more rapid resolution of symptoms and possible reduction in the long-term sequelae. Many patients diagnosed with DVT in the inpatient setting have contraindications to lytic therapy, but less is known regarding the suitability of thrombolysis for outpatients diagnosed with acute DVT. We sought to determine the proportion of patients who were candidates for thrombolytic therapy and referred to a vascular specialist for evaluation. A manual search of an outpatient vascular laboratory associated with a tertiary medical center was performed to identify all patients referred for the purpose of ruling out DVT between January 2013 and December 2014. Vascular laboratory studies conducted for evaluation of venous insufficiency were excluded. The electronic medical records were reviewed to evaluate for contraindications for thrombolysis. Over a 2-year period, there were 689 referrals to the outpatient vascular laboratory for the evaluation of patients with suspected DVT. Of the 689 referrals, 47 (6.8%) were found to have acute DVT, and 66 (9%) were found to have chronic DVT. Of the 47 patients with acute DVT, 41 involved the lower extremities. Fifteen of the 41 patients (37%) with extensive acute iliofemoral DVT had no absolute or major contraindications for CDT. Of these 15 patients, only 33% were referred to a vascular specialist (4 to vascular surgery and 1 to IR). Two patients (13%) agreed to and underwent successful CDT. Although the majority of patients with acute lower extremity DVT diagnosed in the outpatient vascular laboratory were not candidates for thrombolysis, one-third of those who may have benefited from CDT were referred to a vascular specialist to discuss lytic therapy. Given the potential benefits of CDT, it is imperative that patients with acute iliofemoral or extensive femoral DVT be offered an evaluation by a vascular specialist to optimize outcomes after this diagnosis.

Stroke Management: Nursing Roles

Introduction: The subacute and long-term assessment and management of patients who have suffered a stroke includes physical therapy and testing to determine the precise etiology of the event so as to prevent recurrence. The acute management differs. Immediate goals include minimizing brain injury, treating medical complications, and moving toward uncovering the pathophysiologic basis of the patient's symptoms.Methods: This is a review paper that report up to date finding with review some research papers and databases.Results: Sudden loss of focal brain function is the core feature of the onset of ischemic stroke. However, patients with conditions other than brain ischemia may present in a similar fashion. The goals in the initial phase include: ensuring medical stability, with particular attention to airway, breathing, and circulation, quickly reversing any conditions that are contributing to the patient's problem, determining if patients with acute ischemic stroke are candidates for thrombolytic therapy, moving toward uncovering the pathophysiologic basis of the patient's neurologic symptoms. Time is of the essence in the hyperacute evaluation of stroke patients. In addition to stabilization of airway, breathing, and circulation, and rapid neurologic evaluation, early key management issues that often arise in acute stroke include blood pressure control, fluid management, treatment of abnormal blood glucose levels, swallowing assessment and treatment of fever and infection. Care in a dedicated stroke unit is associated with better outcomes.Conclusion: The main goals in the initial phase of acute stroke management are to ensure medical stability, to quickly reverse conditions that are contributing to the patient's problem, to determine if patients with acute ischemic stroke are candidates for thrombolytic therapy, and to begin to uncover the pathophysiologic basis of the neurologic symptoms.

Capabilities of perfusion ASPECTS in predicting the efficiency of intravenous thrombolytic therapy

Perfusion computed tomography (PCT) is increasingly used to diagnose ischemic stroke (IS), as well as to identify candidates for thrombolytic therapy (TLT). The feasibility of using this technique in all patients within the therapeutic window has not yet been established. Objective: to investigate cerebral blood flow according to PCT findings and its relationship to clinical and instrumental indicators and functional status of patients who had received TLT in the acute period of IS. Patients and methods. 62 patients with acute IS who had received TLT were examined. All the patients underwent clinical, laboratory, and instrumental examinations and PCT, by assessing cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) in 10 brain regions in accordance with the Alberta Score Program Early CT Score (ASPECTS). The total result of perfusion ASPECTS was calculated separately for CBV, CBF and MTT, as well as combinations of these parameters. The penumbra size was calculated as CBV minus MTT (CBV - MTT) ASPECTS, the infarct core size was measured as CBV + MTT ASPECTS. Results. There was an increase in MTT in most regions of interest of the affected hemisphere as compared to the intact one and a predominance of reversible perfusion disorders. The averaged penumbra size constituted three zones according to ASPECTS. No relationship was found between ASPECTS scores and time after the onset of symptoms prior to hospital admission. Perfusion parameters, particularly penumbra size (CBV - MTT), were associated with the degree of stenosis in the contralateral common carotid artery, body mass index, and blood triglyceride level. Cerebral blood flow indices were also influenced by red blood cell counts and heart ejection fraction. The scores of the perfusion scales were correlated with those of the non-contrast scale. The data of the investigated ASPECTS variants correlated with the level of neurological deficit in patients, its course, and the functional outcome of acute IS. Conclusion. The perfusion variants of ASPECTS have a high predictive value for patients' neurologic and functional status upon completion of the first treatment stage. The penumbra size (CBV - MTT ASPECTS) is a marker for the expected regression of neurological impairment during TLT. The infarct core size (CBV + MTT ASPECTS) determines the degree of neurologic deficit at a patient's discharge.

Dependence of the effectiveness of thrombolytic therapy at ischemic stroke from clinical and paraclinical predictors

The aim of the work. The aim of the work is an assessment of informativeness of several clinical and paraclinical predictors in prognostics of the results of effectiveness of thrombolytic therapy at the most acute period of ishemic stroke with the further definition of the most significant ones for achieving the least neurologic deficiency. Methods of research: There were retrospectively considered 61 patients 60,5±7,8 years old with ishemic stroket who sucsessfully underwent thrombolytic therapy as an intravenous administration of Actilyse. These patients demonstrated the next factors of gemostasis: prothrombin time, prothrombin index, fibrinogen. For the research there were also used the scales of neurological deficiency activisation (Rankin and NIHSS); ultrasound of the magistral arteries and extracranial CT of brain; methods of mathematical statistics (the definition of chances and confidence intervals ratio, Pirson and Student criteria, verification of hypothesis about the law of distribution and equality of the mean values in the both samplings. Results. There were defined the most informative factors in prognostication of the good result after thrombolytic therapy. There was formed the list of output factors that the results of actilyse thrombolytic therapy effectiveness in Lviv region are depending on. There was grounded the necessity of laboratory data monitoring in patients with stroke for receiving the best results of thrombolytic therapy. There was established that thrombolytic therapy of ishemic stroke must begin as early as possible (in computed tomography department if possible) for receiving the maximal effectiveness. There was detected that ultrasound of magistral vessels that supply brain with blood is necessary for all patients who are candidates for thrombolytic therapy because the stenosis of the vessel lumen more than 60 % significantly worsens an effectiveness of treatment

Developments in the management and treatment of pulmonary embolism.

Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended.

Production and Characterization of New Fibrinolytic Protease from &amp;lt;i&amp;gt;Mucor subtillissimus&amp;lt;/i&amp;gt; UCP 1262 in Solid-State Fermentation

Fibrinolytic enzymes have received attention regarding their medicinal potential for thrombolytic diseases, a leading cause of morbidity and mortality worldwide. Various natural enzymes purified from animal, plant and microbial sources have been extensively studied. The aim of this work was to produce fibrinolytic protease by solid state fermentation using agro industrial substrates. Rhizopus arrhizus var. arrhizus UCP 1295 and Mucor subtillissimus UCP 1262 filamentous fungi species isolated from soil of Caatinga-PE, Brasil, were used as producer microorganisms. Wheat bran was shown to be the best substrate for the production of the enzyme and by using a 23 full factorial design the main effects and interactions of the quantity of the substrate wheat bran, moisture and temperature on the fibrinolytic enzyme production and protease were evaluated. The best results for fibrinolytic and protease activities, 144.58 U/mL and 48.33 U/mL, respectively, were obtained with Mucor subtillissimus UCP 1262 using as culture medium 3 g wheat bran, 50% moisture at a temperature of 25°C for 72 hours. The optimum temperature for the produced enzyme was 45°C and most of its original activity was retained after being subjected to 80°C for 120 min. The protease activity was enhanced by K+, Ca+ and Mn+; but with Cu+ there was an inhibition. The specificity to chromogenic substrate and the inhibition by PMSF indicates that it is a chymotrypsin-like serine protease. Presented results suggest that this enzyme produced by solid-state fermentation is an interesting alternative as a candidate for thrombolytic therapy.

Abstract W P195: Standardized Patient Simulation Can Be Incorporated Into Emergency Medicine Resident Training on Performance of the National Institutes of Health Stroke Scale

Introduction: The National Institutes of Health Stroke Scale (NIHSS) quantifies physical impairment caused by stroke. Emergency Medicine (EM) physicians must be competent to perform the NIHSS as scale cut points are utilized to identify patients with acute ischemic stroke who may be candidates for thrombolytic therapy. Simulation is a teaching method that integrates imitation of real life scenarios into educational exercises. This study discerned if standardized patient simulation can be adopted into an educational exercise aimed at training EM residents to adequately perform the NIHSS. Methods: This preliminary study was completed with EM residents, in various years of training, from a single academic center. All residents attended a lecture on performance of the NIHSS. Each resident then performed the NIHSS on 2 patients with chronic, fixed neurological deficits. Residents were observed by a NIHSS certified healthcare professional who gave immediate feedback on examination technique. Data was analyzed with basic statistics using means and standard deviations (± SD). Results: Twenty eight EM residents, 7 NIHSS certified healthcare professionals (1 Neurologist, 5 Neurology residents, 1 nurse), and 7 patients participated in the trial. Mean certifier NIHSS score of patients was 2.7 (SD ±1.6). Resident score exactly correlated with certifier score in 11/56 examinations (20%), was within ±2 points of the certifier score in 28 examinations (50%), and within ±3 or 4 in 17 examinations (30%). Average time to complete one patient examination was 5 minutes 36 seconds (SD ±1 min 3 sec). In a post exercise survey, all residents rated this training experience as being beneficial to their medical training. Conclusions: An educational format incorporating didactic and return demonstration aimed at training a large group of EM residents to competently perform the NIHSS is practical. Immediate feedback on examination technique and a relatively short time to complete the educational exercise are advantages of this format compared to on-line training modules often used to educate physicians. Further refinement of this exercise is necessary before it can be used for the purpose of NIHSS certification.

Abstract WP53: Can Attenuation Characteristics On Non Contrast CT Be Used In Place Of Diffusion FLAIR Mismatch In The Imaging Triage Of Acute Ischemic Stroke Patients?

Purpose: We aimed to determine if attenuation characteristics on NCCT can be used in place of DWI FLAIR“mismatch”as an imaging paradigmto detect patients within a recommended time window for thrombolysis. Methods: Data is from consecutive acute stroke patients (2005-2009) from Keimyung University, South Korea analyzed at the University of Calgary. Only patients with visible anterior circulation occlusions on baseline CT-angio, known stroke symptom onset time and MRI within 60 minutes of baseline CT were included. All patients received revascularization therapy (IV tPA and/or IA). DWI FLAIR mismatch and CT changes at baseline were diagnosed by consensus. Ratio of ipsilateral vs. contralateral CT HU (rCT) within baseline DWI lesion was calculated. CT attenuation within DWI lesion was qualitatively graded into a) equal or more (subtle)or b) less than contralateral white matter (obvious). ROC analyses was used to compare the ability of models using DWI FLAIR mismatch vs. rCT in predicting onset to imaging time&lt; 4.5 hrs and ICH at 24 hours. Results: Of 136 patients included [mean age 67.6 yrs (SD 11.2 yrs), 55.1% male, median onset to MR time was 159.5 minutes (IQR 128-226 mins)], 131/136 (96.3%) had DWI changes on baseline MRI. DWI FLAIR mismatch was seen in 88/136 (64.7%) andNCCT hypo-attenuation in 93/136 (68.9%). A rCT&gt;=0.85predicted DWI FLAIR mismatch with a sensitivity of 72.5%, specificity of 75.6% and PPV of 85.3%. No patient without baseline CT changes had rCT&lt;0.9. DWI FLAIR mismatch was not better than rCT&gt;=0.85 in predicting onset to MRtime&lt;4.5 hrs (AUC 0.66 95% CI 0.57-0.75 vs. 0.61 95% CI 0.51-0.70, p=0.23). Subtle or no CT hypo-attenuation within DWI lesion measured qualitatively predicted presence of DWI FLAIR mismatch. (p=0.002) Conclusion: CT hypo-attenuation is as good as DWI FLAIR mismatch in identifying patients who are good candidates for thrombolytic therapy.

Impact of Vena Cava Filters on In-hospital Case Fatality Rate from Pulmonary Embolism

BackgroundThe effects of vena cava filters on case fatality rate are not clear, although they are used increasingly in patients with pulmonary embolism. The purpose of this investigation is to determine categories of patients with pulmonary embolism in whom vena cava filters reduce in-hospital case fatality rate. MethodsIn-hospital all-cause case fatality rate according to the use of vena cava filters was determined in patients with pulmonary embolism discharged from short-stay hospitals throughout the United States using data from the Nationwide Inpatient Sample. ResultsIn-hospital case fatality rate was marginally lower in stable patients who received a vena cava filter: 21,420 of 297,700 (7.2%) versus 135,240 of 1,712,800 (7.9%) (P<.0001). Filters did not improve in-hospital case fatality rate if deep venous thrombosis was diagnosed in stable patients. A few stable patients (1.4%) received thrombolytic therapy. Such patients who received a vena cava filter had a lower case fatality rate than those who did not: 550 of 8550 (6.4%) versus 2950 of 19,050 (15%) (P<.0001). Unstable patients who received thrombolytic therapy had a lower in-hospital case fatality rate with vena cava filters than those who did not: 505 of 6630 (7.6%) versus 2600 of 14,760 (18%) (P<.0001). Unstable patients who did not receive thrombolytic therapy also had a lower in-hospital case fatality rate with a vena cava filter: 4260 of 12,850 (33%) versus 19,560 of 38,000 (51%) (P<.0001). ConclusionAt present, it seems prudent to consider a vena cava filter in patients with pulmonary embolism who are receiving thrombolytic therapy and in unstable patients who may not be candidates for thrombolytic therapy. Future prospective study is warranted to better define in which patients a filter is appropriate.

Acute endovascular recanalization therapy in wake-up stroke

Background and Purpose Up to 15–25% of patients with ischemic stroke wake up with their deficits. Because of the uncertainty about the time of onset, these patients are generally not offered thrombolytic therapy. Some of these wake-up stroke patients may be eligible for acute endovascular stroke therapy based on hyperacute CT or MR imaging independent of the time window. Report We report two patients with acute ischemic stroke whose symptoms were present upon awakening and who were successfully treated with endovascular interventions. Results The first patient was discharged with complete neurological recovery on second day after endovascular intervention. The second patient went home on fifth day with a mild left facial paresis and left arm drift. Both these patients did not have any neurological deficit on 18-month follow up. Conclusions Some patients who present with stroke on awakening may be candidates for thrombolytic therapy or recanalization techniques irrespective of mode of therapy (intravenous, intravenous + intra-arterial or intra-arterial tPA alone). Further randomized, controlled studies are warranted to safely identify those candidates who would benefit from thrombolysis and endovascular interventions in ischemic wake-up strokes.

Diabetes Mellitus, Acute Hyperglycemia, and Ischemic Stroke

Opinion statementAcute brain ischemia is a dynamic process susceptible to multiple modulating factors, such as blood glucose level. During acute ischemic brain injury, hyperglycemia exacerbates multiple deleterious derangements. Timely and sufficient correction of hyperglycemia during acute brain ischemia may limit the brain injury and improve clinical outcomes. The clinical efficacy of such intervention remains to be proven. Although results from animal and clinical observational studies suggest that hyperglycemia during acute brain ischemia may exacerbate the brain injury, there is no evidence from randomized treatment trials that rapid correction of the hyperglycemia improves outcomes. Given the excess effort, cost, and risk involved in rapid and safe correction of hyperglycemia during acute stroke, less aggressive treatments with subcutaneous insulin seem appropriate at this time. Subcutaneous insulin protocols can maintain blood glucose levels below 200 mg/dL a majority of the time in most patients, especially if basal insulin is added. When available, an endocrinology consultant can optimize the acute treatment and help the transition to long-term care. Given the multiple reports linking admission hyperglycemia with symptomatic hemorrhagic conversion of ischemic stroke treated with thrombolytic drugs, it may be best to rapidly lower severe hyperglycemia in such patients. For example, if the admission blood glucose is approximately 300 mg/dL and the patient is a candidate for thrombolytic therapy, consider giving an intravenous bolus of regular insulin 8 units. Somewhat lower or higher insulin doses may be best for lesser or greater hyperglycemia. Such a bolus will start lowering the blood glucose in about 5 min. A temporary continuous intravenous insulin infusion may then be used in most patients to maintain the glucose closer to normal levels (eg, below 180 or 140 mg/dL).

Shortening time to stroke treatment using ambulance telemedicine: TeleBAT

Patients with ischemic stroke treated with tissue plasminogen activator (rt-PA) have better outcomes when treated closer to the time of symptom onset and within the 3-hour window. We previously demonstrated the clinical use of TeleBAT, a mobile telemedicine system for stroke. We tested the impact of that system on time to treatment for patients with acute stroke. Validity and reliability were tested by comparing neurologic examination scores obtained using our wireless system, which transmits video of a patient from a moving ambulance to desktop computers, with those obtained using the National Institute of Neurological Disorders and Stroke training videotape. TeleBAT validity and good interrater reliability were defined a priori as a kappa statistic of r > 0.5. We compared the average time to treatment for our TeleBAT-evaluated intervention group with that for our control group. The intervention group consisted of two actor patients with stroke mimicking 12 stroke scenarios and evaluated using TeleBAT. The control group consisted of patients with stroke evaluated and treated with rt-PA on arrival to the emergency department. Data were analyzed using standard t test. National Institutes of Health Stroke Scale items calculated by the neurologists suggest TeleBAT is valid for assessing patients with stroke remotely. Interrater reliability was high: the neurologists gleaned the same information from TeleBAT transmissions. Kappa values for both validity and reliability exceeded 0.5. The mean time to treatment for patients assessed by TeleBAT was 17 +/- 4 minutes compared with 33 +/- 17 minutes for our control group (P = .0033). TeleBAT seems to be a valid and reliable means of evaluating stroke neurologic deficits. Time to treatment was shortened using ambulance transport time to evaluate patients as candidates for thrombolytic therapy. Future studies should use a randomized design with patients with acute stroke.

Thrombolysis and antithrombotic therapy for coronary artery disease

Aspirin in a dose of 160 to 325 mg should be administered on day 1 of an acute MI and continued indefinitely on a daily basis. Thrombolytic therapy should be administered within 6 to 12 hours after the onset of an acute MI with ST segment elevation or with left bundle branch block. Primary coronary angioplasty when available should be used rather than thrombolytic therapy in the treatment of older persons with acute MI who are poor candidates for thrombolytic therapy. Intravenous heparin should be given in persons with acute MI undergoing primary coronary angioplasty or surgical coronary revascularization and in persons with acute MI at high risk for systemic embolization. Long-term oral warfarin should be given after MI for the secondary prevention of MI in post-MI persons unable to tolerate daily aspirin, in post-MI persons with persistent atrial fibrillation, and in post-MI persons with left ventricular thrombus. Platelet GP IIb/IIIa inhibitors should be administered along with aspirin and enoxaparin in the acute phase of management of persons with unstable angina pectoris or non-Q wave MI. Aspirin should be administered daily indefinitely to persons after MI, to persons with unstable angina pectoris, to persons with stable angina pectoris, and to persons undergoing coronary revascularization. Aspirin plus ticlopidine or aspirin plus clopidogrel should be used in persons undergoing coronary artery stenting. Platelet GP IIb/IIIa inhibitors should be used at the time of coronary angioplasty, coronary atherectomy, or coronary stenting. Aspirin, 160 to 325 mg daily, is recommended in older men and postmenopausal women who are at high risk for developing coronary events in addition to treating their coronary risk factors.