Intravenous Tissue Plasminogen Activator Research Articles

Clinical characteristics, in-hospital management, and outcomes among patients hospitalized for acute ischemic stroke in rural vs. urban hospitals in China: a nationwide hospital-based study.

Efforts to improve rural stroke care have intensified in China. However, high-quality comprehensive data on the differences in care and outcomes between urban and rural hospitals are limited. We analyzed data on patients with acute ischemic stroke hospitalized in the China Stroke Center Alliance hospitals from 2015 to 2022. The in-hospital management measures assessed included nine acute and five discharge management measures. Outcomes evaluated included death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACE), disability at discharge, and in-hospital complications. We enrolled 1,583,271 patients with acute ischemic stroke from 1,930 hospitals, comprising 1 086 (56.3%) rural sites with 735 452 patients and 844 (43.7%) urban sites with 847 891 patients. Patients in rural hospitals demonstrate suboptimal management measures compared to those in urban hospitals, including lower rates of intravenous recombinant tissue plasminogen activator within 4.5 h (26.0% vs. 28.3%; difference, -2.3% [-2.5% to -2.0%]), endovascular treatment (0.6% vs. 1.9%; difference, -1.3% [-1.3% to -1.2%]), vessel assessment (88.5% vs. 92.0%; difference, -3.5% [95% CI, -3.6% to -3.4%]), andanticoagulants for atrial fibrillation at discharge (42.9% vs. 47.7%; difference, -4.8% [95% CI, -5.4% to -4.2%]). Overall, the rural-urban disparity in in-hospital outcomes was small. Rural patients had a slightly higher rate of in-hospital death/DAMA (9.0% vs. 8.0%; aOR, 1.22 [95% CI, 1.20-1.23]; aRD, 1.3% [95% CI, 1.2%-1.4%]) and a slightly lower rate of complications (10.9% vs. 13.0%; aOR, 0.83 [95% CI, 0.82-0.84]; aRD, -1.3% [95% CI, -1.3%-1.3%]). No notable rural-urban differences were observed in MACE and disability at discharge. Patients in rural hospitals demonstrated suboptimal management measures and had higher rates of in-hospital death/DAMA compared to those in urban hospitals. Prioritizing the allocation of health resources to rural hospitals is essential to improve healthcare quality and outcomes. The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Silent delayed middle cerebral artery occlusion post-mechanical thrombectomy: A case report

Mechanical thrombectomy (MT) for atherothrombotic lesions entails significant risks, including reocclusion and the possibility of worsening stenotic changes through endothelial injury. We treated a 45-year-old male admitted to our hospital with the sudden onset of left hemiparesis. Magnetic resonance imaging (MRI) revealed an occlusion of the right middle cerebral artery (MCA). Immediate intravenous tissue plasminogen activator infusion followed by MT successfully reperfused the MCA, although residual stenosis persisted in the distal portion of the M1 segment. Following the procedure, the patient’s symptoms resolved, and he was discharged. Three months later, follow-up MRI showed reocclusion of the right MCA and hemodynamic changes indicating reduced cerebral blood flow and cerebrovascular reactivity in the MCA territory. Subsequently, extracranial–intracranial bypass surgery was performed, and the patient did not develop any new symptoms postoperatively. While the patient in this case did not develop permanent symptoms, diligent observation is imperative following MT due to the potential for delayed progressive stenosis or occlusion.

Mechanisms of mitophagy and oxidative stress in cerebral ischemia-reperfusion, vascular dementia, and Alzheimer's disease.

Neurological diseases have consistently represented a significant challenge in both clinical treatment and scientific research. As research has progressed, the significance of mitochondria in the pathogenesis and progression of neurological diseases has become increasingly prominent. Mitochondria serve not only as a source of energy, but also as regulators of cellular growth and death. Both oxidative stress and mitophagy are intimately associated with mitochondria, and there is mounting evidence that mitophagy and oxidative stress exert a pivotal regulatory influence on the pathogenesis of neurological diseases. In recent years, there has been a notable rise in the prevalence of cerebral ischemia/reperfusion injury (CI/RI), vascular dementia (VaD), and Alzheimer's disease (AD), which collectively represent a significant public health concern. Reduced levels of mitophagy have been observed in CI/RI, VaD and AD. The improvement of associated pathology has been demonstrated through the increase of mitophagy levels. CI/RI results in cerebral tissue ischemia and hypoxia, which causes oxidative stress, disruption of the blood-brain barrier (BBB) and damage to the cerebral vasculature. The BBB disruption and cerebral vascular injury may induce or exacerbate VaD to some extent. In addition, inadequate cerebral perfusion due to vascular injury or altered function may exacerbate the accumulation of amyloid β (Aβ) thereby contributing to or exacerbating AD pathology. Intravenous tissue plasminogen activator (tPA; alteplase) and endovascular thrombectomy are effective treatments for stroke. However, there is a narrow window of opportunity for the administration of tPA and thrombectomy, which results in a markedly elevated incidence of disability among patients with CI/RI. It is regrettable that there are currently no there are still no specific drugs for VaD and AD. Despite the availability of the U.S. Food and Drug Administration (FDA)-approved clinical first-line drugs for AD, including memantine, donepezil hydrochloride, and galantamine, these agents do not fundamentally block the pathological process of AD. In this paper, we undertake a review of the mechanisms of mitophagy and oxidative stress in neurological disorders, a summary of the clinical trials conducted in recent years, and a proposal for a new strategy for targeted treatment of neurological disorders based on both mitophagy and oxidative stress.

Role of Neurologists in Stroke Treatment

Determination of indications for acute reperfusion therapy (intravenous recombinant tissue plasminogen activator administration and mechanical thrombectomy) and identification of stroke mimics and chameleons are essential components of effective stroke treatment. Moreover, neurologists select the appropriate medications and manage the patient's general condition. Therefore, a neurologist's solid diagnostic skills based on neurological symptomatology and an internist's broad knowledge and insight play key roles clinically.

Effect of post thrombolytic intracerebral hemorrhage volume on 90-day outcomes in acute ischemic stroke patients

Background and PurposePost thrombolytic intracerebral hemorrhage (ICH) is associated with higher rate of death or disability in acute ischemic stroke patients. We investigated the relationship between post thrombolytic ICH volume and change in volume and death or disability at 90 days in acute ischemic stroke patients. MethodsWe analyzed 110 patents recruited in the Safety Evaluation of 3K3A-APC in Ischemic Stroke (RHAPSODY) trial who received intravenous tissue plasminogen activator (tPA) followed by mechanical thrombectomy (if indicated) and 3K3A-APC or placebo. ICH volume was measured at Day 2 and Day 7 using susceptibility weighted sequence (SWI) on magnetic resonance imaging (MRI). We also calculated the post thrombolytic ICH volume change between Day 2 and Day 7. Outcomes were determined by using utility weighted modified Rankin scale (UW-mRs) at 90-days, Outcomes were determined by using utility weighted modified Rankin scale (UW-mRS) at 90 days. To minimize interpretation bias, outcome assessors were blinded to the treatment allocation and clinical data.We adjusted for age, gender, National Institutes of Health Stroke Scale (NIHSS) score (<10,10-19 and ≥20), location of hemorrhage (single basal ganglia hemorrhage, single lobar, single cerebellum, and multiple sites) in multivariate regression analysis. ResultsA total of 88 (80%) of 110 patients had post thrombolytic ICH (mean volume 28.3 ml ± SD 62 ml). The strata of ICH volume were not associated with UW-mRs at 90 days: <20 cc (regression coefficient (RC)-0.05, p= 0.58), 20-39 cc (RC-0.22, p=0.17), or ≥40 cc (RC-0.34, p= 0.083) compared with no ICH after adjusting for potential confounders. Change in ICH mean volume 26.78 ml ±59.68, 52 had increase in volume) between Day 2 and day 7 was not associated with UW-mRS at 90 days (RC -67.71, p= 0.06). ConclusionsWe did not observe any independent effect of post thrombolytic ICH volume on death or disability in acute ischemic stroke patients. Although further studies must be done, our data suggest that strategies to prevent ICH expansion such as antifibrinolytic medications and reduction in ICH volume such as surgical evacuation may not reduce death or disability in acute ischemic stroke patients with post thrombolytic ICH.

Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy.

Acute ischemic stroke (AIS) from primary medium vessel occlusions (MeVO) is a prevalent condition associated with substantial morbidity and mortality. Despite the common use of mechanical thrombectomy (MT) in AIS, predictors of poor outcomes in MeVO remain poorly characterized. In this prospectively collected, retrospectively reviewed, multicenter, multinational study, data from the MAD-MT (Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy) registry were analyzed. The study included 1568 patients from 37 academic centers across North America, Asia, and Europe, treated with MT, with or without intravenous tissue plasminogen activator (IVtPA), between September 2017 and July 2021. Among the 1568 patients, 347 (22.2%) experienced very poor outcomes (modified Rankin score (mRS), 5-6). Key predictors of poor outcomes were advanced age (odds ratio (OR): 1.03; 95% confidence interval (CI): 1.02 to 1.04; p < 0.001), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (OR: 1.07; 95% CI: 1.05 to 1.10; p < 0.001), pre-operative glucose levels (OR: 1.01; 95% CI: 1.00 to 1.02; p < 0.001), and a baseline mRS of 4 (OR: 2.69; 95% CI: 1.25 to 5.82; p = 0.011). The multivariable model demonstrated good predictive accuracy with an area under the receiver-operating characteristic (ROC) curve of 0.76. This study demonstrates that advanced age, higher NIHSS scores, elevated pre-stroke mRS, and pre-operative glucose levels significantly predict very poor outcomes in AIS-MeVO patients who received MT. These findings highlight the importance of a comprehensive risk assessment in primary MeVO patients for personalized treatment strategies. However, they also suggest a need for cautious patient selection for endovascular thrombectomy. Further prospective studies are needed to confirm these findings and explore targeted therapeutic interventions.

Evaluation of Hemoglobin and Eosinophil Count in Patients Receiving Thrombolytic Treatment.

Background and aim Stroke ranks among the primary contributors to disability and mortality on a global scale. Recent advances in ischemic stroke pathophysiology emphasize the significant role of the immune system in both stroke-related damage and neuroprotection. This article investigates the relationship between hemoglobin level and white blood cell count. Materials and methods From January 1, 2019, to April 1, 2022, all patients aged 18 years and over who were diagnosed with acute ischemic stroke in the emergency department of Kanuni Sultan Süleyman Training and Research Hospital and treated with intravenous recombinant tissue plasminogen activator (r-tPA) within 4.5 hours of stroke onset were included in this cross-sectional retrospective study. Gender, age, onset of symptoms, complaints, National Institutes of Health Stroke Scale (NIHSS) score, stroke-affected area, as well as leukocyte, neutrophil, platelet, eosinophil, lymphocyte, and hemoglobin levels were recorded and compared between mortality and survivor groups. Results A total of 61 people, including 33 menand 28 women, were included in the study. Four patients died during follow-ups. The mean duration of symptoms upon admission was 86.23 ± 56.37 minutes. The mean NIHSS score of patients was found to be 9.16 ± 3.88 (minimum: 4, maximum: 18). There was a statistically significant positive correlation between age and symptom duration (p < 0.002, r: 0.391). A statistically significant negative correlation was found between eosinophil count and NIHSS score (p < 0.012, r: -0.321) and between eosinophil count and symptom duration (p < 0.042, r: -0.261). There was a negative correlation between hemoglobin levels and mortality (p < 0.013, r: -0.318). A statistically significant negative correlation was observed between the eosinophil-to-neutrophilratio (ENR) and NIHSSscore (p < 0.017, r: -0.305) as well as between ENR and symptom duration (p < 0.034, r: -0.271). Hemoglobin is a significant predictor of mortality in the logistic regression model (p < 0.05, CI: 0.253-0.942). For each one-unit increase in hemoglobin, the odds of mortality decrease by a factor of 0.488. Conclusion Certain blood cell types (neutrophils, eosinophils, and lymphocytes) play an active role in determining stroke prognosis. A detailed explanation of the role of leukocytetypes lays the foundation for "immunomodulation," which could be a promising novel treatment modality for future stroke patients.

EVALUATION OF DEPRESSION FREQUENCY AND ITS EFFECT ON PROGNOSIS IN PATIENTS TREATED FOR ACUTE ISCHEMIC STROKE

Background: Stroke is one of the most important causes of mortality and morbidity in the world. Although mortality and morbidity rates decrease with mechanical thrombectomy and intravenous thrombolytic treatments in suitable patients, post-stroke depression may develop in these patients. Poststroke depression occurs in approximately 30% of patients with stroke and is associated with poor prognosis and quality of life. Objective: Depression is a common complication that leads to dysfunction even years after a stroke. In this study, we aimed to evaluate the frequency of depression, determine the risk factors, the relationship between the infarct localization and stroke severity in patients who underwent acute ischemic stroke treatment (intravenous tissue plasminogen activator (IV-tPA) and/or endovascular mechanical thrombectomy (MT)). Methods: In this prospective study, 230 patients older than 18 years of age who were hospitalized with the diagnosis of acute ischemic stroke between 2021-2022 and treated for acute ischemic stroke were evaluated. Patient characteristics such as age, gender, education level, stroke risk factors, infarct localization were noted in the first month follow up outpatient clinic as well as their Modified Rankin Score (MRS), National Health Institutes Stroke Scale (NIHSS) and Beck Depression Scale (BDI). Results: There was a statistically significant difference in age groups compared to BDI values (x2=10.215, p=0.037). A statistically significant difference was found between BDI levels and MRS (x2=21.177, p&lt;0.001) and BDI score and NIHSS (x2=28.074, p&lt;0.001). There was a statistically significant difference between education levels and MRS values (x2=17.147, p=0.002) and NIHSS scores(x2=14.715, p=0.005). Conclusion: Whereas disability can lead to depression, depression is one of the leading causes of disability. Despite the benefit of acute stroke treatments, they are ineffective in preventing post-stroke depression and subsequent disability. Therefore identification, and prevention of risk factors and early treatment of depression are necessary to effectively prevent morbidity.

Demographic Characteristics and Functional Outcome in Posterior Circulation Strokes.

The constantly increasing incidence of stroke in Saudi Arabia substantiates an urgent need to elucidate underlying risk factors and etiologies. In terms of improving outcomes, the predictors of functional outcomes need to be identified as well. As posterior circulation strokes (PCS) have not been studied in detail, the current study aimed to identify the risk factors, etiology, and predictors of outcome in PCS. This retrospective study included the data for 138 patients with PCS. Demographics, risk factors, clinical signs/symptoms, etiology, and outcome at discharge and 3-month follow-up were recorded. Factors associated with outcomes were identified, and the difference was ascertained using Chi-square, odds ratios, and 95% confidence intervals. The mean participant age was 58 ± 14.8 years with 73% being males. The mean arrival time was 26.5 ± 31.6 h; with a mean National Institute of Health Stroke scale (NIHSS) score of 7.2 ± 5.6. Motor deficit and dysarthria were the most common presentations. Twenty percent of patients received intravenous recombinant tissue plasminogen activator, whereas endovascular thrombectomy was performed in 9 (6.5%). Follow-up outcome at 3 months was available in 113 (81.8%). Male sex, baseline modified Rankin scale of <2, low baseline NIHSS, and stable or improvement in baseline NIHSS during 24 h of admission were documented as predictors of a good outcome, whereas history of atrial fibrillation and prior stroke, high NIHSS at admission and worsening of symptoms during 24 h of admission, as well as bilateral body involvement were associated with poor outcome. The functional outcomes and the predictors of functional outcomes did not differ from the previously published literature; however, significant differences were observed in the risk factors and etiological profile in our population. These differences are of potential interest to the researchers and clinicians, as they carry important therapeutic and prognostic implications and need to be verified through large prospective studies.

Patterns of Acute Ischemic Stroke Treatment from 2010 to 2020: An Evolving Landscape in Stroke Management Following Thrombectomy Trials.

Population-based studies on stroke can help guide the care of patients with acute ischemic stroke (AIS) by providing health care communities with information regarding the current usage of stroke treatments. It remains unclear how rapidly new techniques, particularly endovascular stroke treatment (EST), are being adopted and whether there is any disparity in their availability. Although studies using the National Inpatient Sample (NIS) have been conducted, updated studies over a longer period may provide further insights. This study aimed to understand patterns of AIS treatment, discharge disposition, in-hospital mortality, and mean length of stay (LOS) for each modality from 2010 to 2020 using the NIS database. This retrospective longitudinal study was conducted using NIS data from 2010 to 2020. Patients were categorized into groups based on whether they received intravenous recombinant tissue plasminogen activator (rt-PA), EST, both rt-PA and EST (combined therapy), or supportive care alone. Demographic, socioeconomic, regional, insurance, and hospital data were also obtained. The primary outcome was the proportion of patients receiving each modality, whereas the secondary outcomes were in-hospital mortality, mean LOS, and discharge disposition. The usage rates increased (p < 0.001) in all groups between 2010 and 2020 (rt-PA: 5.09% to 8.39%, EST: 0.31% to 4.40%, and rt-PA+EST: 0.46% to 1.09%). The highest increase in usage was observed for EST, with a thirteen-fold increase. Mortality decreased from 2010 to 2020 in all groups (rt-PA: 8.45% to 3.54%, EST: 25.22% to 12.50%, and rt-PA+EST: 21.12% in 2010 to 9.30%) (p < 0.001). Combination therapy demonstrated the greatest improvement, with an 11.2% reduction in absolute mortality. Mean LOS was reduced for patients who received rt-PA (6.8 to 4.8 days), EST (9.3 to 8.9 days), and combined therapy (10.0 to 8.3 days) (p < 0.001) over the study period. The proportion of patients discharged to home increased for rt-PA (29.01% to 41.85%), EST (14.13% to 17.70%), and combined therapy (12.89% to 24.29%) (p < 0.001). Overall, stroke treatment usage was higher among the higher income groups, regardless of race. Higher usage was also observed for Whites in the West and Hispanic ethnicities in the South and West. Regardless of income or treatment method, utilization rates were lower for Black patients. Utilization rates were lower for Black patients with Medicare, Medicaid, or self-pay than for White patients. Our study demonstrated that endovascular stroke treatment continues to expand, leading to better outcomes for mortality, LOS, and home discharge. Despite these positive patterns, there are visible inequities across regions, income status, and races.

The effect of the mean platelet volume on short-term prognosis in acute ischemic stroke patients who underwent intravenous thrombolytic therapy

Objective: To evaluate the effect of the mean platelet volume (MPV), on the short-term prognosis and bleeding complications of acute ischemic stroke patients who underwent intravenous tissue plasminogen activator (IV-tPA) treatment. Patients and Methods: Between 01.01.2018 and 01.06.2021, 314 ischemic stroke patients who applied to our clinic with acute neurological deficit were included in the study retrospectively. Alteplase was administered as IV-tPA treatment for 1 hour. MPV value was measured before the treatment and was evaluated as the main parameter. The patients were examined under 4 groups (≤8.8fL, &amp;gt;8.8 – ≤9.9, &amp;gt;9.9-≤10.8, &amp;gt;10.8fL) according to their MPV values, and age, gender, comorbidities, and treatment initiation parameters were standardized by statistical methods. It was compared whether there was a significant difference between the MPV groups in terms of short-term prognosis according to the admission National Institutes of Health Stroke Scale (NIHSS) scores and discharge NIHSS scores and also bleeding complications. Results: A total of 314 patients, 145 women with a mean age of 76.7±13.0, and 169 men with a mean age of 66.3±13.1, were included in the study. 31 patients (9.9%) died before discharge. The mean MPV value was 9.64±1.15fL and the mean NIHSS score was 9.1±4.9 at admission, and the mean NIHSS score was 4.3±4.7 at discharge. When the NIHSS difference between admission and discharge was compared in the 4 groups, it was found that the prognosis was better in Group 3 with MPV &amp;gt;9.9-≤10.8 compared to Groups 1 and 4. (p=0.002; p&amp;lt;0.01). Despite this, it was seen that low or high MPV values could not be considered as a prognostic factor alone in patients who received IV-tPA treatment, since, there was no significant difference between the 3rd group and the 2nd group in terms of NIHSS decrease and the 4th group had a worse prognosis than the 3rd group. There was no statistical significance between MPV groups in terms of hemorrhage complications (p value for intracerebral, gastrointestinal, urogenital hemorrhage complications were 0.540, 0.980, 0.783, respectively). Conclusion: In our study, it was revealed that MPV value, is not an independent risk factor in patients with acute ischemic stroke receiving IV-tPA treatment and cannot be used as a prognostic marker.

Evaluation of a prehospital endovascular therapy stroke bypass program.

Prehospital stroke endovascular therapy bypass transports patients with suspected large vessel occlusion directly to an endovascular therapy capable center. Our objective was to determine if an endovascular therapy bypass protocol improved access to stroke treatments. Secondary objectives were to determine safety, effectiveness, and rate of subsequent interfacility transfers. Endovascular therapy bypass in 2018 was implemented in Eastern Ontario, for patients with a Los-Angeles-Motor-Scale ≥ 4 (positive large vessel occlusion screen) with a 90-min transport time if < 6h from last seen well. A before-after health record review was conducted from Dec 1, 2017 to Nov 30, 2019. A piloted data form was used to extract demographics, times, primary outcomes (endovascular therapy and intravenous (IV) tissue plasminogen activator (tPA) rate), and secondary outcomes (redirect to closer hospital, airway intervention, and subsequent interfacility transfer). We present descriptive statistics and odds ratios (OR) with 95% confidence intervals (CI) from multivariable logistic regression. We included 379 stroke patients (165 pre and 214 post-implementation). The endovascular therapy rate between groups was similar (14.1% vs 15.1%). The bypass had an OR of 0.98 (95% CI 0.54-1.78) for receiving endovascular therapy. IV tPA was given to 25.4% of patients pre vs 27.4% post-implementation (OR 1.06, 95% CI 0.65-1.74). No patients became unstable during transport, only one patient had an intubation attempt. The inappropriate bypass (false positive) rate was 12.7% pre vs 12.8% post-implementation (positive predictive value 87%). The bypass protocol had an OR of 1.06 (95% CI 0.58-1.95) for subsequent interfacility transfer with a mean of 2.7h at the community site before transfer. Endovascular therapy stroke bypass with 90-min transport radius and Los-Angeles-Motor-Scale ≥ 4 was safe and well executed by paramedics. Our study did not show any difference in endovascular therapy rate from its implementation. The IV tPA rate was similar between groups despite potentially bypassing thrombolysis capable centers.

Left ventricular systolic dysfunction predicts clinical prognosis in patients with acute ischemic stroke after intravenous thrombolysis.

Although intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis is the most effective early treatment for acute ischemic stroke (AIS), outcomes vary greatly among patients. Left ventricular systolic dysfunction (LVSD) is prone to distant organ ischemia and may be a predictor for poor prognosis in AIS patients undergoing intravenous thrombolysis (IVT). Our aim was to investigate the predictivity of LVSD diagnosis (as measured by left ventricular ejection fraction (LVEF)) on 90-day clinical outcomes in AIS patients undergoing thrombolysis. The current prospective cohort study continuously enrolled 273 AIS patients from the National Stroke Prevention and Treatment Engineering Management Special Database who underwent IVT and completed echocardiography within 24 h of admission between 2021 and 2023. LVSD was examined by evaluation of the echocardiographic LVEF values using Simpson's biplane method of discs in line with international guidelines, and defined as a LVEF value < 50%. Multivariable ordinal logistic regression model was performed to analyze the association between LVEF and functional outcome at 3 months. Restricted cubic spline (RCS) was used to examine the shape of the dose-response association between reduced LVEF and poor functional outcomes. Subgroup analysis was also employed to further verify the reliability and practicability of the results. Baseline data analysis showed LVSD patients had more comorbidities including on multivariate analyses, LVSD (OR 2.78, 95% CI 1.23 to 6.24, P=0.014), pre-existing diabetes mellitus (OR 2.08, 95% CI 1.11 to 3.90, P=0.023) and NIHSS on arrival (OR 1.31, 95% CI 1.21 to 1.49, P<0.001) were independent predictors of poor functional outcomes (mRS ≥ 3) at 3 months. Multivariable-adjusted spline regression indicated a linear dose-response association between LVEF after IVT and poor functional outcomes (p for linearity < 0.001), with the optimal cutoff values of LVEF being 0.48. Our finding indicated that AIS patients with LVSD after IVT had poorer outcomes, suggesting the need to monitor and optimize LVEF in stroke management.

Health budget implications of mechanical thrombectomy for acute ischaemic stroke in Australia.

This research evaluates the budget impact of treating acute ischaemic stroke (AIS) using a combination of mechanical thrombectomy (MT) with stent retrievers (SR) and intravenous tissue-plasminogen activator (IV-tPA) in Australia. This study examined the economic impact over five years for a patient cohort based on the number of patients treated with MT+ IV-tPA in Australia 2021, versus treatment with IV-tPA alone. A budget impact (BI) model was developed to project direct medical costs (economic impact) of IV-tPA+ MT with SR vs. Intravenous tissue-plasminogen activator alone over a five-year period (2021-2025 inclusive) from a healthcare perspective. The model is composed of a short-run decision tree model based on a 3-month post-treatment modified Rankin Scale (mRS) from the EXTEND-IA study and a published long-run Markov state transition model. Acute, mid-term and long-term care costs were projected based on anticipated mRS scores from the EXTEND-IA trial. Estimated yearly and cumulative budget impact were reported to indicate the economic impact of the two treatment strategies for AIS in the Australian healthcare system. MT+IV-tPA had a greater budgetary impact than IV-tPA alone, with annual savings starting at Year 1 and continuing through to Year 5. Cost savings of 21% or approximately $36 million can be achieved over five years for the patient cohort treated in Australia in 2021. Each MT procedure performed delivers approximately $3280 in annual health system savings per patient. Treatment of AIS with a combination of MT+IV-tPA generates significant savings in the Australian healthcare system compared with IV-tPA alone.

Language assessment in persons with aphasia early after thrombolysis: the utility of multilevel procedures of discourse analysis

ABSTRACT Background Clinical guidelines recommend the administration of intravenous recombinant tissue plasminogen activator thrombolytic treatment to persons who suffered ischemic stroke within 4,5 hours since onset. However, the available evidence on the potential improvement of language after thrombolysis is still scanty. Aims This study assessed the effect of thrombolytic treatment in language recovery in persons with stroke aphasia (PWA) comparing the efficacy of traditional language assessments and a multilevel procedure of discourse analysis applied to the Cookie Theft picture descriptions taken from the National Institute of Health Stroke Scale (NIHSS). Methods and procedures Fortyeight individuals participated in the study: sixteen PWA who received thrombolysis; sixteen PWA who did not receive it; sixteen healthy controls. The two groups of PWA were balanced in terms of age, education, gender, lateralization of the lesion, and stroke severity. They were administered the NIHSS and a bedside language assessment battery when entering the neurological clinic (T0) and after approximately 72 hours (T1). Their narrative discourse descriptions were analyzed with a multilevel procedure for discourse analysis. Outcomes and results The two groups of PWA had similar linguistic difficulties at T0 as reflected by comparable Composite Verbal Scores and performance on traditional linguistic bedside assessment (Aphasia PostStroke Acute Assessment test; Furlanis et al., 2018). Discourse analysis highlighted the presence of more omissions of function words and errors of cohesion in the PWA who would receive thrombolysis with respect to healthy controls and allowed for the identification, in both groups, of difficulties that could not be detected through a traditional assessment. At T1 the analyses showed the presence of improvements likely reflecting a generalized spontaneous recovery in both groups of PWA and a more specific recovery triggered by thrombolysis concerning the production of global coherence errors in treated patients only. An inspection of the gravity of the linguistic symptoms at the individual level revealed high interindividual variability in this early phase suggesting that thrombolysis reduced the severity of the impairment also in the production of informative words. Conclusions Thrombolysis reduces the gravity of some linguistic symptoms within a few hours after treatment. Multilevel procedures of discourse analysis can identify these subtle improvements.

Dual antiplatelet therapy versus intravenous tissue plasminogen activator with acute minor ischemic stroke: A systematic review and meta-analysis of safety and efficacy

ObjectivesTo compare the safety and efficacy of Dual Antiplatelet Therapy (DAPT) and Intravenous (IV) Tissue Plasminogen Activator (t-PA) in minor Acute Ischemic Stroke (AIS). Materials and MethodsFollowing Cochrane and PRISMA guidelines, we analyzed observational studies and clinical trials comparing DAPT and IV t-PA in patients with minor AIS. Databases included PubMed, Scopus, and Web of Science. Data extraction included study characteristics, patient demographics, and analyzed outcomes. RevMan 5.3 and OpenMetaAnalyst 2021 were used to analyze the data and assess heterogeneity, respectively. The risk of bias was determined using RoB 2.0 and the Newcastle-Ottawa scale. ResultsThis meta-analysis included five studies with 3,978 DAPT-treated patients and 2,224 IV t-PA-treated patients. We found no significant differences in achieving modified Rankin scale (mRS) scores of 0-1 (OR 1.11, 95 % CI: 0.79, 1.55, p = 0.56) and 0-2 (OR 0.90, 95 % CI: 0.61, 1.31, p = 0.57), as well as combined mRS scores (OR 1.05, 95 % CI: 0.82, 1.34, p = 0.72). Similarly, there were no significant disparities between the two treatment groups in NIHSS score change from baseline (MD 0.32, 95 % CI: -0.35, 0.98, p = 0.35) and in mortality rates (OR 0.87, 95 % CI: 0.26, 2.93, p = 0.83). Notably, in comparison to the IV t-PA group, the DAPT group exhibited a significantly lower incidence of bleeding (OR 0.31, 95 % CI: 0.14, 0.69, p = 0.004) and symptomatic intracranial hemorrhage (sICH) (OR 0.10, 95 % CI: 0.04, 0.26, p < 0.00001). ConclusionsOur meta-analysis found no significant differences in efficacy between DAPT and IV t-PA. However, DAPT demonstrated a significantly lower risk of sICH and bleeding compared with IV t-PA.

The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina

ObjectiveTo examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. Materials and methodsEncounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure—stroke coordinators and stroke center certifications—across all hospitals and within hospital subgroups defined by size and rurality. ResultsTelestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. ConclusionsStroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.

Factors predicting functional outcome after rtPA for patients with acute ischemic stroke

BackgroundAccurate outcome prediction for patients with acute ischemic stroke after intravenous recombinant tissue plasminogen activator (rtPA) treatment is essential for optimizing patients’ management. We aimed to identify factors associated with unfavorable outcomes following intravenous rtPA treatment. This study was carried out on 162 patients who presented with acute ischemic stroke within 4.5 h from onset of neurological symptoms and were eligible for intravenous rtPA. After exclusion of 48 patients, 114 patients were finally eligible for follow-up. After complete medical and neurological history, complete medical and neurological examination and brain image (CT and or MRI brain) were collected from the patients. patients eligible were included in the study. NIHS scale was assessed for all patients at time of admission, after 24 h, and follow-up for 3 months.ResultsAfter a 90-day follow-up period for 114 patients with acute ischemic stroke after rtPA, 35.8% had good outcome (MRS; 0–2), 18.5% had partial outcome (MRS; 3–4) and 12.5% had poor outcome (MRS; 5–6). Atrial fibrillation (AF), PH of stroke, stroke severity, and severity of symptom (NIHSS) score were significantly (P: 0.004, 0.001, 0.007 and 0.001) correlated with poor outcome after rtPA. Similarly, old age, high blood pressure at time of presentation, hypertension, and dyslipidemia were showed to carry poor outcome.ConclusionsAF, high NIHSS score, PH of stroke, previous stroke, hypertension, dyslipidemia, and high blood pressure on presentation were significantly correlated with poor functional outcome.

Readmission Rates Among Acute Reperfusion Treatment Modalities for Patients With Ischemic Stroke.

Understanding various aspects associated with readmission after acute ischemic stroke (AIS) is an important priority. Our study aims to examine whether 60-day readmission rates differed among patients with AIS who were treated with different acute reperfusion treatment modalities along with associated clinical factors. This is a retrospective analysis of a continuous cohort of patient with AIS, who received either intravenous recombinant tissue plasminogen activator (IV rtPA), endovascular treatment (EVT) or both, and were discharged alive. Patients readmitted within 60days were identified as the readmission group. Multivariable logistic regression was used to identify all-cause readmission post-stroke between treatment groups. The final cohort comprised of 358 patients with AIS receiving IV rtPA only (N = 160), EVT only (N = 106), or both (N = 92). Fifty-six patients were readmitted to the hospital within 60-day follow-up period. The adjusted logistic regression model indicated that compared to patients who received IV tPA only, patients receiving both IV rtPA and EVT had significantly lower odds (OR = .27; 95% CI = .10, .75)) of getting readmitted within 60-day post-discharge from stroke admission. In this sample of AIS hospitalizations, treatment-type was positively associated with 60-day readmission. Future studies are necessary to understand whether treatment-related adverse events, and readmission are avoidable.

Abstract TP269: Determining Differences in the Association Between Atrial Fibrillation and Ischemic Stroke Outcomes by Acute Therapy Received

Introduction: Whether the association between atrial fibrillation (AF) and ischemic stroke (IS) outcomes differs by IS therapy is unknown. Hypothesis: AF IS patients will have a worse discharge NIH Stroke Scale (NIHSS) and 90-day modified Rankin Scale (mRS) scores than non-AF, with differences by IS therapy. Methods: We studied a cohort of AF and non-AF IS patients from Johns Hopkins (2020-2023) with IS characteristics and demographics who received acute IS therapy (intravenous tissue plasminogen activator (IVtPA), mechanical thrombectomy (MT), or both). Multivariable regression models were used to examine the association between AF and either NIHSS (continuous or dichotomized at the mean (5)) or mRS (ordinal) separately, with interaction terms for IS therapy as appropriate. Results: Of the 240 patients (mean age 67, 52.5% female, 56.2% Black), 26.2% received IVtPA, 45.8% MT, and 27.9% both. There was no association between AF and NIHSS (β 1.53, 95% CI 0.38-3.4) in the final model, but there were higher odds of an NIHSS &gt; 5 among AF patients (OR 3.46, 95% CI 1.16-10.30). AF patients had an increased odds of a worse mRS (Ordinal OR 2.05, 95% CI 1.14-3.71), but not after adjustment (Ordinal OR 1.07, 95% CI 0.52-2.20). The association between AF and IS outcomes differed by IS therapy (Table 1). AF patients who did not receive MT had a worse NIHSS and higher odds of a one unit increase in mRS, compared to AF patients who received MT (p-interaction 0.07, 0.01 respectively). Conversely, AF patients who received IVtPA had a worse NIHSS, compared to those who did not receive IVtPA (p-interaction 0.07), with essentially no difference in the association between AF and mRS in the final model when considering IVtPA use (p-interaction 0.09). Conclusion: In this study, AF patients had a higher mRS and worse discharge NIHSS versus non-AF, with differences by treatment; not receiving MT was detrimental for AF patients while our found worse outcome with IVtPA may reflect AF-associated treatment delays.