Early Neurological Recovery Research Articles

Alteplase vs. Tenecteplase: An In-depth Analysis of Their Relative Effectiveness in Treating Acute Ischemic Stroke

Dear Editor, Stroke stands as the second-leading cause of death worldwide [1, 2]. Each year, over 12 million individuals are impacted by stroke, resulting in approximately 6.5 million fatalities [1]. Stroke globally ranks as the third-leading factor causing a combination of death and disability [2]. Every year, around seven hundred thousand individuals in the United States undergo an Acute Ischemic Stroke (AIS), making up 85% of all stroke cases [2]. New treatments like intravenous thrombolysis and mechanical thrombectomy have cut mortality by 10% compared to older methods, enhancing long-term disability prevention rates following Acute Ischemic Stroke [2]. Alteplase is the sole FDA-approved thrombolytic drug in AIS within the first 4.5 hours. Despite its potential for disability-free recovery, its usage is constrained by a brief time window and adverse effects, notably a 6% risk of symptomatic bleeding. In addition, its fibrinolytic efficacy is limited, achieving vascular reopening in less than half of the patients, and can cause cytotoxicity to the already hypoxic brain with resultant cerebral edema [2]. Tenecteplase (TNK), a modified variant of alteplase, has improved features including greater fibrin selectivity and longer half-life and is given as a single bolus instead of an infusion, thanks to genetic recombinant technology [3]. Numerous studies have supported TNK's efficacy over alteplase in treating AIS. In 2016, Bruce C.V. Campbell and colleagues demonstrated that, according to the analysis of modified Rankin scale scores, tenecteplase exhibited a more favorable overall functional outcome compared to alteplase [4]. A dosage of 0.25 mg/kg of tenecteplase emerges as a promising alternative to replace alteplase as the preferred treatment for patients with AIS occurring within 4.5 hours due to TNK's superior early neurological recovery rates and comparable safety outcomes [3]. Despite gathering evidence from experimental trials indicating TNK's advantages over alteplase for AIS, the use of TNK at a dosage of 0.4 mg/kg appears to pose safety concerns when compared to alteplase [3]. Bruce C.V. Campbell and his fellow researchers revealed in their study that in spite of the beneficial effects of TNK relative to alteplase, there was no significant variation in the speed of recovery to independent function. Notably, they found no discernible distinction in the occurrence of intracranial hemorrhage [4]. ---Continue

Higher blood glucose is associated with the severity of hemorrhagic transformation after endovascular therapy for stroke

ObjectivesHyperglycemia is associated with poor outcome in large vessel occlusion (LVO) stroke, with mechanism for this effect unknown. Materials and methodsWe used our prospective, multicenter, observational study, Blood Pressure After Endovascular Stroke Therapy (BEST), of anterior circulation LVO stroke undergoing endovascular therapy (EVT) from 11/2017-7/2018 to determine association between increasing blood glucose (BG) and intracerebral hemorrhage (ICH). Our primary outcome was degree of ICH, classified as none, asymptomatic ICH, or symptomatic ICH (≥4-point increase in National Institutes of Health Stroke Scale [NIHSS] at 24 h with any hemorrhage on imaging). Secondary outcomes included 24 h NIHSS, early neurologic recovery (ENR, NIHSS 0-1 or NIHSS reduction by ≥8 within 24 h), and 90-day modified Rankin Scale (mRS) using univariate and multivariable regression. ResultsOf 485 enrolled patients, increasing BG was associated with increasing severity of ICH (adjusted OR, aOR 1.06, 95 % CI 1.02-1.1, p < 0.001), higher 24 h NIHSS (aOR 1.22, 95 % CI 1.11-1.34, p < 0.001), ENR (aOR 0.90, 95 % CI 0.82-1.00, p < 0.002), and 90-day mRS (aOR 1.06, 95 % CI 1.03-1.09, p < 0.001) when adjusted for age, presenting NIHSS, ASPECTS, 24-hour peak systolic blood pressure, time from last known well, and successful recanalization. ConclusionsIn the BEST study, increasing BG was associated with greater odds of increasing ICH severity. Further study is warranted to determine whether treatment of will decrease ICH severity following EVT.

Transfer of miR-877–3p via extracellular vesicles derived from dental pulp stem cells attenuates neuronal apoptosis and facilitates early neurological functional recovery after cerebral ischemia–reperfusion injury through the Bclaf1/P53 signaling pathway

Cerebral ischemia-reperfusion injury (I/RI) is one of the principal pathogenic factors in the poor prognosis of ischemic stroke, for which current therapeutic options to enhance neurological recovery are notably insufficient. Dental pulp stem cell-derived extracellular vesicles (DPSC-EVs) have promising prospects in stroke treatment and the specific underlying mechanisms have yet to be fully elucidated. The present study observed that DPSC-EVs ameliorated the degree of cerebral edema and infarct volume by reducing the apoptosis of neurons. Furthermore, the miRNA sequencing and functional enrichment analysis identified that miR-877–3p as a key component in DPSC-EVs, contributing to neuroprotection and anti-apoptotic effects. Following target prediction and dual-luciferase assay indicated that miR-877–3p interacted with Bcl-2-associated transcription factor (Bclaf1) to play a function. The miR-877–3p inhibitor or Bclaf1 overexpression reversed the neuroprotective effects of DPSC-EVs. The findings reveal a novel therapeutic pathway where miR-877–3p, transferred via DPSC-EVs, confers neuroprotection against cerebral I/RI, highlighting its potential in promoting neuronal survival and recovery post-ischemia.

Abstract WP188: Differences in Outcomes Due to Anesthesia Management During Endovascular Treatment of Patients With Acute Ischemic Stroke Due to Tandem Lesions

Background: Endovascular therapy (EVT) has been reported to be safe and effective for acute ischemic stroke (AIS) patients with tandem lesions (TLs). However, the optimal anesthetic management during EVT for TL patients is unknown. We aimed to assess the impact of anesthesia modality on clinical outcomes in AIS patients with TLs. Methods: Patient level data were pooled from 16 centers for anterior circulation TLs from 2015-2020. Patients were divided into general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression was used to assess the association of outcomes including modified Rankin Score (mRS) 0-2, ordinal shift is mRS, symptomatic intracranial hemorrhage (sICH), successful reperfusion (mTICI score ≥2b), excellent reperfusion (mTICI 3), first pass effect (FPE), early neurological recovery (ENI), door to skin puncture and reperfusion, and 90-day mortality. Results: Among 691 patients, 595 (GA:230 [38.7%] and PS:365 [61.3%]) were included in the final analysis. Patients treated with GA had lower odds of mRS 0-2 (36.6% vs. 52.5%, aOR: 0.56, 95% CI: 0.38-0.84, p =0.005) and favorable shift in 90 days mRS (aOR: 0.71, 95% CI: 0.51-0.99, p =0.041) when compared to PS. No differences were noted for sICH (3.9% vs. 4.7%, aOR: 0.66, 95% CI: 0.26-1.66, p =0.38), successful reperfusion (89.1% vs 86.5%, aOR: 1.59, CI: 0.87-2.89, p=0.13), excellent reperfusion (48.5% vs 50.3%, aOR: 0.85, CI: 0.56-1.30, p=0.462), FPE (53.6% vs 63.4%, aOR: 0.67, CI 0.45-1.0, p=0.05), ENI (38.9% vs 38.8%, aOR: 0.70, CI: 0.44-1.12, p=0.138), mortality at 90 days (20.3% vs 16.3%, aOR: 0.74, CI: 0.29-1.87, p=0.525), door to skin puncture (80 [46-117.5] mins vs 54 [21-100], p=0.607) and skin puncture to reperfusion (59 [39.5-85.5] mins vs 54 [38-81], p=0.836). Conclusions: In patients with AIS with TLs treated with EVT, GA was associated with lower odds of functional independence without a significant increased risk of sICH, mortality, or treatment delays.

Impact of Mobile Stroke Units on Patients With Large Vessel Occlusion Acute Ischemic Stroke: A Prespecified BEST‐MSU Substudy

Background The impact of mobile stroke units (MSUs) on outcomes in patients with large vessel occlusions eligible for endovascular thrombectomy (EVT) has yet to be characterized. Methods We completed a prespecified substudy of patients with EVT‐eligible stroke with anterior and posterior circulation large vessel occlusions on computed tomography and/or computed tomography angiography who were enrolled in BEST‐MSU (Benefits of Stroke Treatment using a Mobile Stroke Unit). Primary outcome was 90‐day utility‐weighted modified Rankin scale. Groups were compared using chi‐square or Fisher's exact tests for categorical variables, and 2‐sample t ‐tests for continuous variables. Multiple logistic regression was used to assess the effect of MSU on binary outcomes after adjusting for other baseline factors. Results Of 1515 trial patients, 293 had large vessel occlusions eligible for EVT: 168 in the MSU group and 125 in the emergency medical services group. Baseline characteristics were comparable, with the exception of baseline National Institutes of Health Stroke Scale score (MSU median 19 [interquartile range 13, 23] versus emergency medical services 16 [11, 20], P = 0.002) and study site. The mean (±SD) score on the utility‐weighted modified Rankin scale at 90 days was 0.63±0.39 in MSU group and 0.51±0.41 in emergency medical services group (mean difference 0.13, 95% CI [0.03–0.22]). After adjustment, MSU had significantly higher odds of functional independence (odds ratio 2.60 [95% CI, 1.45–4.77], P = 0.002). Secondary outcomes also favored MSU: early neurologic recovery (30% improvement in National Institutes of Health Stroke Scale score at 24 hours) 68% versus 52%; adjusted odds ratio 1.98 [95% CI, 1.19–3.33]; time of tissue plasminogen activator bolus from symptom onset 65.0 minutes [50.5–92.0] versus 96.0 [79.3–130.0], P ≤0.001. The groups had similar onset to arterial puncture (169.0 minutes [133.5, 210.0] versus 162.0 [135.0–207.0], P = 0.83). Conclusions In patients with EVT‐eligible large vessel occlusion stroke, MSU management was associated with better clinical outcomes compared with standard emergency medical services management. MSU management sped thrombolysis but did not expedite EVT treatment times. Future MSU processes should include efforts to capitalize on the potential of MSUs to provide earlier EVT.

Evaluation of effectiveness and safety of the large-format pRESET 6-50 thrombectomy stent-retriever in the endovascular treatment of ischemic stroke: real-world experiences from two tertiary comprehensive stroke centers.

Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO). First-pass (FP) reperfusion of the occluded vessel and fewer passes with stent retrievers show improvement in functional outcomes in stroke patients, while higher numbers of passes are associated with higher complication rates and worse outcomes. Studies indicate that a larger size of the stent-retriever is associated with a higher rate of first-pass reperfusion and improved clinical outcomes. In this retrospective study, we investigated the clinical performance of a recently developed and one of the largest stent-retrievers available in the treatment of LVO (pRESET 6-50, phenox GmbH, Bochum). All consecutive patients with ischemic stroke due to proximal large vessel occlusion treated with MT using the pRESET 6-50 stent-retriever in two tertiary stroke centers between 09/2021 and 07/2022 were included in this study. The reperfusion rate after MT was quantified by the modified thrombolysis in cerebral infarction (mTICI) score, and functional neurological outcome was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score and the major early neurological recovery (mENR) rate after 24 h. Successful FP reperfusion was defined as mTICI ≥ 2b. Successful and complete reperfusion were defined as mTICI ≥ 2b and mTICI ≥ 2c, respectively. In total, 98 patients (52 men and 46 women) with a median age of 75 (range 25-95 years) were included. A total of 70 (72%) patients presented with an occlusion of the middle cerebral artery (MCA) in the M1 segment, 6 (6%) patients with an occlusion of the M2 segment, 17 (17%) patients with an occlusion of the internal carotid artery (ICA), and 5 (5%) patients with an occlusion of the obstructed basilar artery (BA). Successful FP reperfusion was achieved in 58 patients (62%). Successful and complete reperfusion were achieved in 95 (97%) and 82 (83%) patients, respectively. The median National Institutes of Health Stroke Scale (NIHSS) in all treated patients improved from 17 to 7.5. Major early neurological recovery (mENR) was observed in 34 patients (35.1%). MT with the pRESET 6-50 stent-retriever achieves high successful first-pass and final reperfusion rates in patients with AIS and LVO. The results of this study support the thesis to use large-format stent-retriever in proximal vessel occlusion MT whenever feasible in order to improve high FP and final reperfusion rate, which are known predictors of good clinical outcome.

Abstract 14130: Efficacy and Safety of Endovascular Therapy in Stroke Patients With Large Ischemic Core in Comparison to Medical Management: Meta-Analysis of Randomized Control Studies

Introduction: Endovascular therapy (EVT) is a treatment recommended for stroke patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥6. However, the utility of EVT in patients with large core ischemic stroke has not been well established. Methods: This meta-analysis assesses EVT's efficacy and safety using available trials comparing EVT to medical management (MM) in stroke patients with large ischemic core. Eligibility criteria: 1) were randomized controlled trials, 2) compared EVT with MM alone, 3) studied patients presenting with LIC cerebrovascular events, and 4) reported outcomes of interest. We extracted data for the major imaging inclusion criteria, the National Institutes of Health Stroke Scale (NIHSS) score, pre-stroke mRs score, and occlusion site. We also extracted outcome data for the EVT groups vs MM groups, including measurement of early neurological recovery, and definition of sICH. Results: Our primary end point was the mean modified Rankin scale score (RSS) at 90-day follow up. EVT was associated with higher odds of significant improvement in functional status with reduction in mean mRS by -0.31 [-0.47; -0.14]) compared to MM. The odds of achieving mRS 0 to 2 was higher in the EVT arm compared to the MM arm (2.53 [1.59; 4.02]). There was no difference in achieving mRS 0 to 3, early neurologic improvement defined according to NIHSS score, overall 90-day mortality and risk of symptomatic ICH between patients treated with EVT or MM in our analysis. Conclusions: Our study suggests that EVT may lead to improved outcomes in stroke patients with large core ischemia.

Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Systematic Review and Meta-analysis.

A number of clinical trials have compared tenecteplase (TNK) and alteplase for the management of acute ischemic stroke (AIS) and the results are inconsistent. Present systematic review and meta-analysis is undertaken to analyse the efficacy and safety of TNK in AIS compared to alteplase. A thorough literature search was performed through the databases Embase, Cochrane Library, PubMed, and clinicaltrials.gov, for a period from inception to September 2022, with the keywords i.e., "tenecteplase" and "alteplase" and "acute ischemic stroke." Clinical trials published in English that compared the efficacy and safety of TNK to alteplase in AIS were included. The major outcomes of this meta-analysis were proportion of patients free from disability and functional independence at 90 days, early neurological improvement at 24 hours, all-cause mortality at 90 days, patients with intra cranial hemorrhage (ICH), and patients with severe disability at 90 days. A total of nine studies with 3,573 patients were included in the analysis. The proportion of patients with freedom from disability was comparable in both groups (relative risk [RR] = 1.04, 95 per cent CI = 0.92-1.17; p = .53). Similarly, proportion of patients with functional independence was comparable (RR = 1.12, 95 per cent CI = 0.96-1.31; p = .14). TNK group had a higher rate of early neurological recovery (RR = 1.56, 95 per cent CI = 0.96-2.54; p = .07). All-cause mortality at 90 days was comparable in both groups (RR = 0.97; 95 per cent CI = 0.72-1.29; p = .82). The proportion of patients with ICH was higher in TNK group (RR = 1.14, 95 per cent CI = 0.77-1.68; p = .52). The proportion of patients with severe disability was less in TNK group (RR =0.84, 95 per cent CI = 0.53-1.32; p = .44). TNK was similar to alteplase in terms of efficacy and safety. The patients in TNK group showed early neurological improvement but were simultaneously at higher risk of ICH. The TNK can be an alternative to alteplase if the benefits outweigh the risks.

Thrombolysis and thrombectomy for stroke in octogenarians and nonagenarians: A regional observational study

IntroductionElderly patients are a growing population in stroke units, characterized by higher frailty, but underrepresented in clinical trials about acute care. We investigated efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in elderlies in current practice. MethodsWe assessed consecutive patients with acute ischemic stroke (AIS) hospitalized in the four stroke units of the French Northern Alps Emergency Network between 2015 and 2020. We compared baseline characteristics, early neurological evolution and outcome of patients aged 80–89 and≥90years old (yo). ResultsAmong 8367 patients, 2744 (32.8%) were 80–89 yo and 541 (6.5%) were≥90 yo. IVT and/or MT were performed in 787 patients≥80 yo (632 patients aged 80–89, 155 patients aged>90). Early neurological improvement was more frequent in patients≥80 yo treated by IVT and/or MT compared to untreated patients (45.6% versus 38.4%, P=0.002). After adjustment, reperfusion treatments improved likelihood of good outcome at discharge (OR=2.0 [1.6–2.7]) and reduced in-hospital mortality (OR=0.5 [0.4–0.7]). Age and initial NIHSS score were independent factors of poor functional outcome at discharge and in-hospital mortality. The rate of successful recanalization was comparable between octogenarians and nonagenarians (87% versus 85.2%, P=0.8). Octogenarians had better functional outcome at discharge compared to nonagenarians [modified Rankin scale (mRS) 0–2: 36% versus 25.7%, P=0.02], whatever IVT or MT strategy. In-hospital mortality was lower for octogenarians compared to nonagenarians (19.5% versus 27.1%, P=0.04). DiscussionIVT and MT improve early neurological recovery and functional outcome at discharge of both octogenarians and nonagenarians in current practice. Despite a poorer outcome for nonagenarians than octogenarians, these reperfusion treatments should not be withheld on the basis of age only.

How do early perioperative changes in AIS grade correlate with long-term neurological recovery? A retrospective cohort study

Context/Objective: Providing accurate counseling on neurological recovery is crucial after traumatic spinal cord injury (TSCI). The early neurological changes that occur in the subacute phase of the injury (i.e. within 14 days of early decompressive surgery) have never been documented. The objective of this study was to assess peri-operative neurological improvements after acute TSCI and determine their relationship with long-term neurological outcomes, measured 6–12 months following the injury. Methods: A retrospective cohort study of 142 adult TSCI patients was conducted. Early peri-operative improvement was defined as improvement of at least 1 AIS grade between the pre-operative and follow-up (6–12 months post-TSCI) assessment. neurological improvement of at least 1 AIS grade. Results: Out of the 142 patients, 18 achieved a peri-operative improvement of at least 1 AIS grade. Presenting a pre-operative AIS grade B and having shorter surgical delays were the main factors associated with stronger odds of achieving this outcome. Out of the 140 patients who still had potential for improvement at the time of the post-operative assessment, 44 achieved late neurological recovery (improvement of at least 1 AIS grade between the post-operative assessment and follow-up). Patients who presented a perioperative improvement seemed more likely to achieve later neurological improvement as well, although this was not statistically significant. Conclusion: Our results suggest that it is important to assess early perioperative neurological changes within 14 days of surgery because it can provide beneficial insight on long-term neurological outcomes for some patients. In addition, earlier surgery may promote early neurological recovery.

Spinal Hydatid Cyst – A Rare Case Report from North-East India

Spinal hydatid cyst is an uncommon manifestation of Echinococcus granulosus in the human spine as a result of feco–oral contamination. Cysts are usually seen in highly vascularized parenchymal organs such as the brain, liver, and lung. Spinal involvement is rare, with an incidence of &lt;1%. Here, we report the case of a 35-year-old female with spinal hydatid cyst, who had a history of upper back pain and gradually progressive weakness of both lower limbs for 2 years. She underwent surgery and the hydatid cysts were removed completely. Postoperative recovery was uneventful. Lower limb weakness recovered dramatically and completely within a month. The current case study demonstrates the importance of proper diagnosis, surgical treatment, and adequate intraoperative prophylaxis to prevent cyst rupture and for early neurological recovery.

Alternative Arterial Access Routes for Endovascular Thrombectomy in Patients with Acute Ischemic Stroke: A Study from the MR CLEAN Registry.

Background: Endovascular thrombectomy (EVT) through femoral access is difficult to perform in some patients with acute ischemic stroke due to challenging vasculature. We compared outcomes of EVT through femoral versus alternative arterial access. Methods: In this observational study, we included patients from the MR CLEAN Registry who underwent EVT for acute ischemic stroke in the anterior circulation between 2014 and 2019 in the Netherlands. Patients who underwent EVT through alternative and femoral access were matched on propensity scores in a 1:3 ratio. The primary endpoint was favorable functional outcome (modified Rankin Scale score ≤ 2) at 90 days. Secondary endpoints were early neurologic recovery, mortality, successful intracranial reperfusion and puncture related complications. Results: Of the 5197 included patients, 17 patients underwent EVT through alternative access and were matched to 48 patients who underwent EVT through femoral access. Alternative access was obtained through the common carotid artery (n = 15/17) and brachial artery (n = 2/17). Favorable functional outcome was less often observed after EVT through alternative than femoral access (18% versus 27%; aOR, 0.36; 95% CI, 0.05-2.74). The rate of successful intracranial reperfusion was higher for alternative than femoral access (88% versus 58%), although mortality (59% versus 31%) and puncture related complications (29% versus 0%) were more common after alternative access. Conclusions: EVT through alternative arterial access is rarely performed in the Netherlands and seems to be associated with worse outcomes than standard femoral access. A next step would be to compare the additional value of EVT through alternative arterial access after failure of femoral access.

Abstract Number ‐ 277: Mobile Stroke Unit Direct to Angiosuite Process Metrics and Clinical Outcomes

Introduction Mobile Stroke Units (MSUs) speed treatment with tPA, but did not affect time from alert to puncture time for endovascular therapy (EVT) in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management. The lack of improvement in EVT treatment time could be because the CTA to identify large vessel occlusions (LVOs), and alerting of the EVT team, were delayed in most MSU patients until after Emergency Department (ED) arrival. The impact of identifying LVOs by imaging on the MSU enabling a direct (from MSU) to angiosuite (DTAS) protocol has yet to be studied. Methods We conducted a pre‐specified substudy of tPA‐eligible stroke patients with LVOs on computed tomography (CT) and/or CT angiography (CTA) who were enrolled into the MSU arm of the BEST‐MSU study. We compared alert to puncture time and other process metrics, mean utility‐weighted modified Rankin Scale (uw‐mRS) and functional independence (mRS 0–2) at 90 days, and rate of early neurologic recovery (30% improvement in NIHSS score) at 24 hours in patients who were managed by DTAS vs post‐ED arrival diagnosis and alerting. Results A total of 169 MSU patients with LVOs were identified; 22 in the DTAS group and 111 in the non DTAS group. Data were not available for 36 LVO patients. Baseline characteristics including age, sex, ethnicity, prestroke mRS, and initial NIHSS were comparable between the groups. 100.0% of patients in the DTAS group vs 90.1% in the non DTAS received tPA (p = 0.264). EVT was performed on 85.0% of patients in the DTAS group vs 77.1% in the non DTAS group (p = 0.634). DTAS group had a faster alert to puncture time (108.00 min [94.75,124.75.] vs 150.50 min [121.25, 179.00], p&lt; 0.001) and door to puncture time (37.00 min [25.50,62.75 vs 86.50 min [62.50,116.00], p&lt; 0.001). The mean score on the uw‐mRS at 90 days was 0.626 ±0.367 in the DTAS group and 0.660 ±0.382 in the non DTAS group and after adjustment for age, baseline NIHSS, premorbid functional status, prior stroke/TIA and site, no significant difference was observed; (p = 0.54). In an unadjusted analysis, early neurologic recovery (72.7% vs 67.6%, (OR = 0.634, 95% CI [0.46,3.82]) and functional independence (50.0% vs 51.4%, p = 1.000) were comparable between DTAS and non DTAS patients. Patients in the DTAS group were less likely to receive general anesthesia (36.4% vs 71.2%, p = 0.004). Rates of recanalization (77.3% vs73,4%, p = 0.947) and post procedural PH‐2 hemorrhage (4.5% vs 0.9%, p = 0.746) were similar in the DTAS and non DTAS group respectively. Conclusions In tPA‐eligible LVO stroke patients, DTAS management resulted in shorter alert to puncture (42 minutes) and door to puncture times (50 minutes) with similar safety and clinical outcomes compared with non DTAS management. MSU DTAS represents an optimized pathway for LVO patients triaged and treated in the field.

Establishing a hyperacute stroke service during the COVID-19 pandemic: our institution’s one year experience

Background and aimsThe corononavirus 2019 (COVID-19) pandemic resulted in modifications in the workflow and redistribution of human resources, causing challenges in setting up of an acute stroke service. We would like to share our preliminary outcome amid this pandemic, to determine if the implementation of COVID-19 standard operating procedures (SOPs) affected the delivery of our hyperacute stroke service.MethodsWe retrospectively analyzed one-year data from our stroke registry that began with the establishment of our hyperacute stroke service at Universiti Putra Malaysia Teaching Hospital from April 2020 until May 2021.ResultsSetting up acute stroke services during the pandemic with constrained manpower and implementation of COVID-19 SOPs, was challenging. There was a significant dip of stroke admission from April to June 2020 due to the Movement Control Order (MCO) implemented by the government to curb the spread of COVID-19. However, the numbers of stroke admission steadily rose approaching 2021, after the implementation of recovery MCO. We managed to treat 75 patients with hyperacute stroke interventions i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT) or both. Despite implementing COVID-19 SOPs and using magnetic resonance imaging (MRI) as our first line acute stroke imaging modality, clinical outcomes in our cohort were encouraging; almost 40% of patients who underwent hyperacute stroke treatment had early neurological recovery (ENR), and only 33% of patients had early neurological stability (ENS). In addition, we were able to maintain our door-to-imaging (DTI) and door-to-needle (DTN) time in line with international recommendations.ConclusionsOur data reflects that COVID-19 SOPs did not deter successful delivery of hyperacute stroke services in our center. However, bigger and multi center studies are required to support our findings.

Thrombectomy-Capable Stroke Centre-A Key to Acute Stroke Care System Improvement? Retrospective Analysis of Safety and Efficacy of Endovascular Treatment in Cardiac Cathlab.

The optimal structure of the acute ischaemic stroke treatment network is unknown and eagerly sought. To make it most effective, different treatment and transportation strategies have been developed and investigated worldwide. Since only a fraction of acute stroke patients with large vessel occlusion are treated, a new entity-thrombectomy-capable stroke centre (TCSC)-was introduced to respond to the growing demand for timely endovascular treatment. The purpose of this study was to present the early experience of the first 70 patients treated by mechanical means in a newly developed cardiac Cathlab-based TCSC. The essential safety and efficacy measures were recorded and compared with those reported in the invasive arm of the HERMES meta-analysis-the largest published dataset on the subject. We found no significant differences in terms of clinical and safety outcomes, such as early neurological recovery, level of functional independence at 90 days, symptomatic intracranial haemorrhage, parenchymal haematoma type 2, and mortality. These encouraging results obtained in the small endovascular centre may be an argument for the introduction of the TCSC into operating stroke networks to increase patient access to timely treatment and to improve clinical outcomes.

Treatment of progressive ischemic stroke with low‑dose eptifibatide: A retrospective case‑control study.

Progressive ischemic stroke (PIS) is a therapeutic challenge in clinical practice. The present retrospective study aimed to investigate the safety and effectiveness of eptifibatide in the treatment of PIS. The present study enrolled patients with PIS admitted to Xiangtan Central Hospital (Xiangtan, China) between March 2020 and March 2021 with National Institutes of Health Stroke Scale (NIHSS) progression scores of ≥2 points during the initial 72 h. Patients were then divided into two groups according to their different anti-platelet treatment regimens. The control group was administered anti-platelet aggregation with aspirin 100 mg/day, or aspirin 100 mg/day in combination with clopidogrel 75 mg/day, whilst eptifibatide was administered in the eptifibatide group in addition to the treatment regimen used in the control group. Changes in NIHSS scores at the time of progression and 7 days after treatment (∆NIHSS) were used to assess early neurological recovery, and there were no significant differences in ∆NIHSS and adverse reactions between the groups (P>0.05). Subgroup analysis was subsequently performed according to the type of blood vessel that was involved [large artery atherosclerosis (LAA) or small artery occlusion (SAO)]. For the SAO subgroup, the ∆NIHSS in the eptifibatide group was significantly superior to that of the control group (P=0.008), while for the LAA subgroup, there were no significant differences in ∆NIHSS between groups (P=0.334). The present retrospective study found that patients with PIS tolerated eptifibatide treatment well. Eptifibatide exerted different effects on patients with acute PIS involving different types of blood vessels compared with oral antiplatelet drugs. In addition, application of eptifibatide may lead to faster and earlier recovery in patients with SAO, but not in those with LAA. Low-dose eptifibatide is a safe and effective treatment option for patients with PIS caused by SAO.

Time is spine: What's over the horizon

The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of “Time is Spine”. The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.

327 Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Finding the Correct '-ase' and 'Dosage' Using Network Meta-analysis Approach

327 Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Finding the Correct '-ase' and 'Dosage' Using Network Meta-analysis Approach

Influence Factors and Predictive Models for the Outcome of Patients with Ischemic Stroke after Intravenous Thrombolysis: A Multicenter Retrospective Cohort Study.

Objective Intravenous thrombolysis (IVT) is currently the main effective treatment for patients with ischemic stroke. This study aimed to analyze the factors affecting the early neurological recovery and prognosis of thrombolytic therapy after surgery and to construct predictive models. Materials and Methods A total of 849 patients with ischemic stroke who received IVT treatment at six centers from June 2017 to March 2021 were included. Patients were divided into the training cohort and the validation cohort. Based on the independent factors that influence the early recovery of neurological function and the prognosis, the respective predictive nomograms were established. The predictive accuracy and discrimination ability of the nomograms were evaluated by ROC and calibration curve, while the decision curve and clinical impact curve were adopted to evaluate the clinical applicability of the nomograms. Results The nomogram constructed based on the factors affecting the prognosis in 3 months had ideal accuracy as the AUC (95% CI) was 0.901 (0.874~0.927) in the training cohort and 0.877 (0.826~0.929) in the validation cohort. The accuracy of the nomogram is required to be improved, since the AUC (95% CI) of the training cohort and the validation cohort was 0.641 (0.597~0.685) and 0.627 (0.559~0.696), respectively. Conclusions Based on this ideal and practical prediction model, we can early identify and actively intervene in patients with ischemic stroke after IVT to improve their prognosis. Nevertheless, the accuracy of predicting nomograms for the recovery of early neurological function after IVT still needs improvement.

Intra-arterial thrombolytics during endovascular thrombectomy for acute ischaemic stroke in the MR CLEAN Registry

IntroductionThe efficacy and safety of local intra-arterial (IA) thrombolytics during endovascular thrombectomy (EVT) for large-vessel occlusions is uncertain. We analysed how often IA thrombolytics were administered in the Multicenter Randomized...