Intravenous Administration Of rt-PA Research Articles

Platelet-to-neutrophil ratio predicts hemorrhagic transformation and unfavorable outcomes in acute ischemic stroke with intravenous thrombolysis

BACKGROUND Acute ischemic stroke (AIS) retains a notable stance in global disease burden, with thrombolysis via recombinant tissue plasminogen activator (rtPA) serving as a viable management approach, albeit with variable outcomes and the potential for complications like hemorrhagic transformation (HT). The platelet-to-neutrophil ratio (P/NR) has been considered for its potential prognostic value in AIS, yet its capacity to predict outcomes following rtPA administration demands further exploration. AIM To elucidate the prognostic utility of P/NR in predicting HT and clinical outcomes following intravenous rtPA administration in AIS patients. METHODS Data from 418 AIS patients treated with intravenous rtPA at Thammasat University Hospital from January 2018 to June 2021 were retrospectively analyzed. The relationship between P/NR and clinical outcomes [early neurological deterioration (E-ND), HT, delayed ND (D-ND), and 3-mo outcomes] was scrutinized. RESULTS Notable variables, such as age, diabetes, and stroke history, exhibited statistical disparities when comparing patients with and without E-ND, HT, D-ND, and 3-mo outcomes. P/NR prognostication revealed an optimal cutoff of 43.4 with a 60.3% sensitivity and a 52.5% specificity for 90-d outcomes. P/NR prognostic accuracy was statistically significant for 90-d outcomes [area under the curve (AUC) = 0.562], D-ND (AUC = 0.584), and HT (AUC = 0.607). CONCLUSION P/NR demonstrated an association with adverse 3-mo clinical outcomes, HT, and D-ND in AIS patients post-rtPA administration, indicating its potential as a predictive tool for complications and prognoses. This infers that a diminished P/NR may serve as a novel prognostic indicator, assisting clinicians in identifying AIS patients at elevated risk for unfavorable outcomes following rtPA therapy.

Impact of the COVID-19 pandemic on acute stroke care: Ananalysis of the 24-month data from a comprehensive strokecenter in Shanghai, China.

Whether the coronavirus disease-2019 (COVID-19) pandemic is associated with a long-term negative impact on acute stroke care remains uncertain. This study aims to compare the timing of key aspects of stroke codes between patients before and after the COVID-19 pandemic. This retrospective cohort study was conducted at an academic hospital in Shanghai, China and included all adult patients with acute ischemic stroke hospitalized via the emergency department (ED) stroke pathway during the 24 months since the COVID-19 outbreak (COVID-19: January 1, 2020-December 31, 2021). The comparison cohort included patients with ED stroke pathway visits and hospitalizations during the same period (pre-COVID-19: January 1, 2018-December 31, 2019). We compared critical time points of prehospital and intrahospital acute stroke care between patients during the COVID-19 era and patients during the pre-COVID-19 era using t test, χ2 , and Mann-Whitney U test where appropriate. A total of 1194 acute ischemic stroke cases were enrolled, including 606 patients in COVID-19 and 588 patients in pre-COVID-19. During the COVID-19 pandemic, the median onset-to-hospital time was about 108 min longer compared with the same period of pre-COVID-19 (300 vs 192 min, p=0.01). Accordingly, the median onset-to-needle time was 169 min in COVID-19 and 113 min in pre-COVID-19 (p=0.0001), and the proportion of patients with onset-to-hospital time within 4.5h was lower (292/606 [48.2%] vs 328/558 [58.8%], p=0.0003) during the pandemic period. Furthermore, the median door-to-inpatient admission and door-to-inpatient rehabilitation times increased from 28 to 37 h and from 3 to 4 days (p=0.014 and 0.0001). During the 24 months of COVID-19, a prolongation of stroke onset to hospital arrival and to intravenous rt-PA administration times were noted. Meanwhile, acute stroke patients needed to stay in the ED for a longer time before hospitalization. Educational system support and process optimization should be pursued in order to acquire timely delivery of stroke care during the pandemic.

Intravenous Alteplase Treatment of Acute Ischemic Stroke Patients Exhibiting Mild Neurological Deficits.

Alteplase is increasingly used for treating ischemic stroke cases with low NIHSS scores, but the guidelines and evidence regarding outcomes are lacking. So, the authors conducted an updated meta-analysis to better understand the effects of alteplase for the treatment of acute mild ischemic stroke. PubMed, Cochrane, EMBASE were systematically explored for all relevant investigations published as in September 2021. Study quality was assessed as per the Cochrane system criteria, and Stata 15.1 was utilised to carry out a meta-analysis. In total, 16 trials incorporating 5,846 patients were analysed (1,926 and 3,920 cases in the rt-PA and non-thrombolytic groups, respectively). The main outcome measure revealed that the treatment of rt-PA was correlated with better odds of a modified Rankin Scale (mRS) score of 0-1 relating to the non-thrombolytic group (OR = 1.12, 95% CI = 1.02-1.23, p <0.05), and with moderate heterogeneity (I2 = 0.0%, p = 0.930). For the secondary study outcomes, symptomatic intracranial hemorrhage incidence was 4.46 times greater in the group of rt-PA, relating to the non-thrombolytic group (OR = 4.46, 95% CI = 2.75-7.23, p <0.001). There were no considerable differences in the mortality between the two groups (OR = 0.64, 95% CI = 0.39-1.03, p >0.05). No significant heterogeneity was detected in secondary study outcomes. Subgroup analysis showed that the function outcomes was the best within 3-4.5 hours; and the risk and mortality of sICH were the lowest within 3-4.5 hours. Intravenous rt-PA administration is associated with improved functional outcomes at three months after the stroke in mild ischemic stroke patients. Key Words: Acute ischemic stroke, Mild, Alteplase, Meta-analysis.

Tissue plasminogen activator for the treatment of adults with critical COVID-19: A pilot randomized clinical trial

Tissue plasminogen activator for the treatment of adults with critical COVID-19: A pilot randomized clinical trial

The Value of ADAMTS13 in Predicting Clinical Outcomes in Patients With Acute Ischemic Stroke Receiving Thrombolysis.

Objective: To determine the association between baseline ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) antigen level and 90-days clinical outcome in patients with acute ischemic stroke (AIS) receiving recombinant tissue plasminogen activator (rt-PA) thrombolysis.Methods: AIS patients receiving rt-PA thrombolytic therapy from Huashan Hospital and Fifth People's Hospital of Shanghai, China in 2014–2017 were consecutively enrolled. Blood samples for ADAMTS13 tests were drawn before intravenous rt-PA administration. The primary outcome was defined as the poor functional outcome of modified Rankin Scale (mRS) >2 at 90-days follow-up. Secondary outcome was hemorrhagic transformation after rt-PA therapy. Moreover, for AIS patients with large vessel occlusion from Huashan Hospital, the association between baseline ADAMTS13 level and cerebral collateral flow was also assessed.Results: A total of 163 AIS patients (median age 66.2 years, 63.8% male) were included. Baseline ADAMTS13 level was marginally decreased in patients with 90-days mRS >2 than in those with mRS ≤ 2 (mean ± SD, 1458.4 ± 323.3 vs. 1578.3 ± 395.4 ng/mL, p = 0.046). However, no difference of ADAMTS13 level was found after adjusting for age, history of atrial fibrillation, glycemia, baseline NIHSS score and TOAST classification (p = 0.43). We found no difference in ADAMTS13 level between patients with parenchymal hemorrhage after rt-PA therapy and those without (p = 0.44). Among 66 patients with large vessel occlusion, there was also no association between ADAMTS13 level and cerebral collateral flow in multivariable analyses.Conclusion: In our cohort, blood ADAMTS13 antigen level before rt-PA therapy could not be used as an independent biomarker in predicting clinical outcomes of AIS patients at 90 days.

Does SSRI have a neuroprotective effect in patent after ischemic stroke?

Introduction and purpose:Ischemic stroke accounts for the majority of all stroke cases, with recurrence rates of around 12% within the first year, rising to around 30% within five years.Thrombolytic therapy based on the intravenous administration of rtPA (recombinant plasminogen activator) is the only treatment that has been proven to improve treatment outcomes after ischemic stroke. New methods that would increase the number of motor function returns are still being sought.A brief description of the state of knowledge: SSRIs, selective serotonin reuptake inhibitors are used primarily in the treatment of depression and emotional lability after stroke. Many clinical and preclinical studies have suggested that SSRIs have a beneficial effect on the outcomes of stroke patients.Our work is a brief overview of the current knowledge and clinical trials conducted. Review of the available literature using the PubMed database. Search criteria for scientific articles published from 2010 to 2020, search term: "SSRI ischaemic stroke". Ultimately, 12 randomized clinical trials were analyzed (3 articles apply for one study). One of the studies does not have unequivocal results. Conclusions: The safety of SSRIs in stroke patients has been confirmed. Further multi-center studies are required to investigate the neuroprotective role of SSRIs.

Implementation of a telestroke system for general physicians without a nearby stroke center to shorten the time to intravenous thrombolysis for acute cerebral infarction.

AimWe aimed to establish a telestroke system for general physicians in areas without a nearby stroke center and investigate its usefulness for recombinant tissue plasminogen activator (rt‐PA) therapy for patients with acute cerebral infarction.MethodsWe used a hub and spoke model, in which a hub hospital provided telestroke support to the spoke hospitals in rural areas that were not nearby a stroke center. The telestroke support device enabled the sharing of images and real‐time face‐to‐face discussion with a stroke specialist for diagnosis and treatment. We evaluated the effect of this telestroke system on shortening time to start rt‐PA therapy.ResultOne hub and three spoke hospitals were selected. From May 2017 to November 2018, seven patients (77.2 ± 6.3 years old) suspected to have acute cerebral infarction were treated at the spoke hospitals via this system, three of whom received intravenous rt‐PA administration by a general physician under telestroke support. If these patients would have been sent via ground ambulance to the nearby stroke center, it would have taken approximately 48 min more to administer rt‐PA.ConclusionEstablishment of a telestroke support system for general physicians in areas without a nearby stroke center was useful for promptly performing rt‐PA therapy.

Current Drug Treatment of Acute Ischemic Stroke: Challenges and Opportunities.

Patient-level health outcomes for acute ischemic stroke have significantly improved in the last decade primarily because of superior overall case management, availability of tailored drug interventions, and advances in endovascular procedures. Nevertheless, disease registries show a "quality gap" across social determinants of health and between in-hospital and community-onset strokes. Several factors, including financing and infrastructure constraints, limited expertise, and clinical uncertainty, still prevent adherence to evidence-based clinical guidelines and optimal care pathways. This paper critically appraises existing evidence on the use of drug therapies in acute ischemic stroke, in an attempt to resolve physician-related subjective barriers for effective acute management of the disease. We conclude that intravenous administration of rt-PA (recombinant tissue-type plasminogen activator, alteplase) is an essential component of acute-phase pharmacologic treatment and a driver for the improvement of overall ischemic stroke health outcomes. The safety profile of alteplase and similar treatments are well within the patient benefit zone of eligible patients when compared to non-treatment alternatives. Monomodal neuroprotective drugs with single or pleiotropic mechanisms of action have failed to support long-term sustainable results. Drugs with complex mechanisms of action that promote neurorecovery, such as cerebrolysin, are valid options for adjunctive treatment of acute ischemic stroke. Recent years have shown clear improvements in the methodology and design of clinical trials, with an increase in overall internal and external validity. A better understanding of study limitations has not hindered, but enhanced their potential to contribute, together with sometimes superior data sources, to health decision making.

Characteristics of blood tests in patients with acute cerebral infarction who developed symptomatic intracranial hemorrhage after intravenous administration of recombinant tissue plasminogen activator.

ObjectivePatients suspected as having acute ischemic stroke usually undergo blood tests, including coagulation-related indexes, because thrombocytopenia and coagulopathy are contraindications for recombinant tissue plasminogen activator (rtPA) administration. We aimed to identify blood test indexes associated with symptomatic intracranial hemorrhage (sICH) in patients with acute ischemic stroke who received intravenous rtPA.MethodsThis retrospective observational study included patients diagnosed with acute ischemic stroke who were treated with intravenous rtPA at the emergency department of a tertiary hospital in Seoul between February 2008 and January 2018. Blood test indexes were compared between the sICH and non-sICH groups. Logistic regression and receiver-operating characteristic curve analyses were performed.ResultsIn this study, 375 patients were finally included. Of 375 patients, 42 (11.2%) showed new intracranial hemorrhage on follow-up brain computed tomography, of whom 14 (3.73%) had sICH. Platelet count, aspartate aminotransferase and lactate dehydrogenase levels were significantly different between the sICH and non-sICH groups, and platelet count showed statistical significance in the regression analysis. Significantly lower platelet counts were observed in the sICH group than in the non-sICH group (174,500 vs. 228,000/mm3, P=0.020). The best cutoff platelet count was 195,000/mm3, and patients with platelet counts of <195,000/mm3 had a 5.4- times higher risk of developing sICH than those with platelet counts of ≥195,000/mm3.ConclusionPlatelet count was the only independent parameter associated with sICH among the blood test indexes. Mild thrombocytopenia may increase the risk of sICH after intravenous administration of rtPA.

Rheumatoid meningitis presenting with a stroke-like attack treated with recombinant tissue plasminogen activator: a case presentation

BackgroundRheumatoid meningitis presenting with a stroke-like attack (RMSA) is a rare manifestation of rheumatoid arthritis (RA). When the patients arrive within the time-window for recombinant tissue plasminogen activator (rt-PA) infusion therapy, no diagnostic protocol has been established.Case presentationA 55-year-old woman was brought by ambulance to our hospital with complaints of sudden-onset dysarthria and left arm numbness. The National Institutes of Health Stroke Scale (NIHSS) score was 5, and the Alberta Stroke Program Early CT Score was 8. She was diagnosed with acute embolic stroke. At 4 h, 6 min after onset, intravenous administration of rt-PA (alteplase, 0.6 mg/kg) was started. Her neurological deficits improved rapidly, and her NIHSS score was 1. Brain MRI was then performed. There was no hemorrhagic transformation, but the MRI findings were not compatible with ischemic stroke. She had a past history of RA diagnosed 6 months earlier, and she had been treated with methotrexate (10 mg daily). She was diagnosed with RMSA, and continuous infusion of methylprednisolone 1000 mg daily was started for 3 days. The high signal intensity on the FLAIR image disappeared.ConclusionCT-based decision-making for rt-PA injection is reasonable, but MRI is needed for the early diagnosis of RMSA. In this case, it is particularly important that neither adverse events nor bleeding complications were observed, suggesting the safety of CT-based thrombolytic therapy in RMSA.

Metric-Based Virtual Reality Simulation: A Paradigm Shift in Training for Mechanical Thrombectomy in Acute Stroke.

Ischemic stroke is the second leading cause of death and the predominant cause of long-term disability in the Western world. Until recently, the standard treatment for ischemic stroke was intravenous administration of r-tPA (recombinant tissue-type plasminogen activator) within the accepted time limit of 4.5 hours from the onset of symptoms. Given later, risks such as intracranial hemorrhage outweigh the potential benefits. In large vessel occlusion (if no contraindication), r-tPA followed by mechanical thrombectomy improves outcomes. In a meta-analysis of large multicenter trials,1 patients receiving usual care (most often r-tPA) followed by mechanical thrombectomy showed significantly higher rates of functional independence at 90 days (46%) than those receiving usual care alone (26.5%). Benefits from mechanical thrombectomy have also been demonstrated in selected patient groups ≤162 and 24 hours3 after they were last known to be well. Despite the proven effectiveness of mechanical thrombectomy, access is limited. One of the main reasons is because of a shortage of interventional neuroradiologists trained to perform this procedure. Traditionally, doctors acquire their skills on new procedures on patients. However, image-guided procedures impose unique human factor challenges on the operator, which expose patients to potential risk during their learning curve. This current traditional process–driven approach to training4 (ie, procedure numbers done and time in training are assumed to signify skill) does not guarantee that the trained clinician has acquired the ability to effectively and readily execute as independent practitioners by the end of their training.5 A novel approach to enhance the learning experience and training of doctors to competently perform mechanical thrombectomy is metric-based virtual simulation training to proficiency.5 A group of senior interventional neuroradiologists and the ASSERT Center at University College Cork, in conjunction with industry partner Mentice AB (Gothenburg, Sweden), have pioneered this method to help prepare physicians …

Association between Systolic Blood Pressure after Thrombolysis and Early Neurological Improvement in Ischaemic Stroke Patients

Introduction This study aimed to evaluate the relationship between systolic blood pressures (SBPs) within 12 hours after intravenous recombinant tissue plasminogen activator (rtPA) treatment and early neurological outcomes. Methods This was a retrospective observational study of acute ischaemic stroke (AIS) patients who received intravenous rtPA administration. SBPs at the time of rtPA bolus and thereafter every hour were collected. The mean, standard deviation, and coefficient of variation values of SBP during the periods of 0-2 h, 2-6 h, and 6-12 h were calculated. The primary outcome was major neurologic improvement (MNI) at 24 hours after thrombolysis. Results Serial measures of SBPs revealed different 12-hour courses between the patients with and without MNI. The difference of SBP tendency was statistically significant (p=0.013). In univariate analysis, patients with MNI showed lower levels of mean SBPs during the periods of 2-6 h and 6-12 h (p=0.030 and p=0.005, respectively), and higher frequency of very early neurologic improvement (VENI) at the end of rtPA infusion (p&lt;0.001). In logistic regression analysis, VENI at 1 h, mean SBP value during 6-12 h, and atrial fibrillation were independently related to MNI at 24 h. Conclusions SBP level during the first 12 hours after intravenous rtPA treatment may be an important clinical factor that is associated with early neurological improvement of AIS patients.

Monte Carlo Simulation Modeling of a Regional Stroke Team's Use of Telemedicine.

The objective of this study was to evaluate operational policies that may improve the proportion of eligible stroke patients within a population who would receive intravenous recombinant tissue plasminogen activator (rt-PA) and minimize time to treatment in eligible patients. In the context of a regional stroke team, the authors examined the effects of staff location and telemedicine deployment policies on the timeliness of thrombolytic treatment, and estimated the efficacy and cost-effectiveness of six different policies. A process map comprising the steps from recognition of stroke symptoms to intravenous administration of rt-PA was constructed using data from published literature combined with expert opinion. Six scenarios were investigated: telemedicine deployment (none, all, or outer-ring hospitals only) and staff location (center of region or anywhere in region). Physician locations were randomly generated based on their zip codes of residence and work. The outcomes of interest were onset-to-treatment (OTT) time, door-to-needle (DTN) time, and the proportion of patients treated within 3hours. A Monte Carlo simulation of the stroke team care-delivery system was constructed based on a primary data set of 121 ischemic stroke patients who were potentially eligible for treatment with rt-PA. With the physician located randomly in the region, deploying telemedicine at all hospitals in the region (compared with partial or no telemedicine) would result in the highest rates of treatment within 3hours (80% vs. 75% vs. 70%) and the shortest OTT (148 vs. 164 vs. 176 minutes) and DTN (45 vs. 61 vs. 73 minutes) times. However, locating the on-call physician centrally coupled with partial telemedicine deployment (five of the 17 hospitals) would be most cost-effective with comparable eligibility and treatment times. Given the potential societal benefits, continued efforts to deploy telemedicine appear warranted. Aligning the incentives between those who would have to fund the up-front technology investments and those who will benefit over time from reduced ongoing health care expenses will be necessary to fully realize the benefits of telemedicine for stroke care.

Abstract 155: Rate, Clinical features, Safety Profile and Outcome of Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with Negative Brain Imaging

INTRODUCTION: The exigent time demand for intravenous (IV) r-tPA administration in acute ischemic stroke (AIS) may not give the necessary time for thorough evaluation in patients presenting with AIS symptoms. As a result, IV thrombolysis of transient ischemic attack (TIA) or conditions mimicking stroke but with a subsequent different diagnosis might occur. In addition, IV r-tPA may sufficiently resolve ischemia such that subsequent brain diffusion weighted MR imaging (DWI-MRI) is negative in some patients. It would be expected that brain CT scan and the more sensitive DWI-MRI would be negative in all these cases. We sought to determine the rate, clinical characteristics, safety profile and outcome of brain imaging-negative patients treated with IV r-tPA for AIS in our large volume stroke center. METHODS: We retrospectively reviewed the medical records and brain imaging of patients who received IV rtPA for AIS within 4.5 hours of symptom onset from January 2006 to April 2014 at our center. A subset of patients with absence of acute infarct/ischemia on their follow- up brain imaging were identified. We recorded age, admission NIH stroke scale (NIHSS), discharge NIHSS, discharge modified Rankin Score (mRS), symptom onset to treatment time, clinical manifestations, discharge diagnosis and evidence of intracranial hemorrhage (ICH) on follow up images for these patients. RESULTS: A total of 637 patients received IV thrombolysis in our center during a 9.4 years period. Thirty seven (5.8%) were found to have no evidence of acute ischemia/infarct on their follow up imaging. DWI-MRI was available for 31 patients. Mean age was 65.2 ± 14, mean admission NIHSS was 8 and mean discharge NIHSS was 0. The mean time of symptom onset to IV thrombolysis was 2.5 hours. Twenty two (59%) had TIA or averted stroke and the rest had non-vascular stroke mimics. The most common stroke mimics were complicated migraine, seizure disorder and psychogenic disorders. No patient developed ICH on follow up brain imaging. All patients were functionally independent on discharge, mRS 0-1. CONCLUSION: IV thrombolysis is generally safe in patients with suspected AIS who have a follow -up negative brain imaging and delaying IV r-tPA administration in cases of doubt is not appropriate.

Value of early decompressive hemicraniectomy in patients with malignant infarction in the middle cerebral artery region treated with intravenous rt-PA: A retrospective analysis of six patients

Abstract Background Malignant middle cerebral artery (MCA) infarction accounts for ≤10% of ischemic strokes, and is associated with 80% mortality. Decompressive hemicraniectomy is the most effective intervention to improve survival. The aim of this paper is to report on the outcomes of combined therapy with alteplase (rt-PA) and decompressive hemicraniectomy in patients with malignant MCA infarction. Methods 215 patients who suffered an ischemic stroke were treated with rt-PA between 2009 and 2012. Malignant MCA infarction with space-occupying edema was diagnosed clinically with the National Institute of Health Stroke Scale (NIHSS) when the score was ≥16, including the score ≥1 for the level of consciousness (1a). Patients ≤62 years agreed to undergo hemicraniectomy procedure. Risk factors, condition of patients, time from the beginning of the stroke to the intravenous application (IV) of rt-PA, and to surgery, 30-days, 3-months, and 1-year mortality, and functional outcome using the modified Rankin scale (mRs) were analyzed. A favorable functional outcome was defined as a mRs score ≤3. Results Malignant MCA infarction with space-occupying edema developed in six (2.3%) patients, out of whom two were female. The mean NIHSS on admission was 15.8 points. Four patients had clinical manifestations of edema on day one, and two on day two. The NIHSS score was >15 when the patients qualified for hemicraniectomy. CT scans showed massive brain swelling, and in two patients also secondary hemorrhagic transformation before hemicraniectomy. One patient died from the brain edema on day 11, following hemicraniectomy and, one died suddenly on day 40, from heart-related problems. The four remaining patients survived in good condition (2–3 points on mRs). Conclusion Decompressive hemicraniectomy in malignant – MCA infarction – following intravenous administration of rt-PA has proved to be safe for all patients treated in this way. It appears that a hemicraniectomy performed after an earlier rt-PA treatment has contributed to the favorable functional outcome in our patients who have survived 1 year and longer after the procedure. Secondary hemorrhagic transformation after rt-PA before surgery should not be a contraindication for decompressive hemicraniectomy. Decompressive hemicraniectomy should be performed promptly when malignant brain edema develops, before herniation occurs. The procedure can be performed in every neurosurgery hospital ward.

Abstract T P261: Non-Contrast Head CT Prior to Comprehensive Neurological Evaluation Reduces Door to Needle Times for Administration of Intravenous rtPA

Background: American Heart Association/American Stroke Association recommends treatment of eligible acute ischemic stroke patients with intravenous rtPA &lt;60 minutes from emergency department arrival. Purpose: A quality improvement project was designed to reduce the door to needle times for intravenous rtPA administration at Mayo Clinic Florida. We hypothesized that workflow changes in emergency department evaluation of suspected stroke patients would decrease door to needle times. The goal was to treat &gt;75% of patients eligible for IV t-PA within 60 minutes of ED arrival. Methods: We utilized LEAN methods to develop a project charter, identify stakeholders, and visually map the emergency department clinical workflow. Prior to project initiation, suspected stroke patients were taken upon arrival to an exam room for clinical evaluation followed by transport to the CT scanner and return to the exam room for decision-making and rtPA administration. The clinical workflow was changed to obtain patient weight immediately upon arrival, abbreviated patient assessment and lab draws outside of the CT scanner in a holding bay and performing CT scanning prior to transport to an examination room for decision making and rtPA administration. Results: In a 12 month period preceding project initiation, 29 patients were treated with rtPA, 55 % were treated &lt;60 minutes of emergency department arrival. In the 11 month period following implementation of CT scanning prior to neurological evaluation, 57 patients were treated with rtPA, 80 % were treated in &lt;60 minutes of emergency department arrival. The mean door to needle time was reduced from 66 minutes to 46 minutes following the clinical workflow change. No patients experienced clinical deterioration at the time of CT scanning. Conclusions: Non-contrast head CT scan be safely performed prior to comprehensive neurological evaluation and reduces door-to-needle times for intravenous rtPA administration in eligible stroke patients. Validated process improvement paradigms such as LEAN have the potential to reduce door to needle times and improve patient outcomes.

Combined Intra-Arterial and Intra-Venous rt-PA Administration to Patients Selected Using SMART Criteria and CT Perfusion Is Safe and Effective (P06.258)

Combined Intra-Arterial and Intra-Venous rt-PA Administration to Patients Selected Using SMART Criteria and CT Perfusion Is Safe and Effective (P06.258)

Thrombolysis on Ischemic Stroke Patients with Decreased Level of Consciousness within 4.5 h

Few reports concerned on recombinant tissue plasminogen activator (rt-PA) treatment in stroke patients with decreased consciousness. This study assesses the efficacy and safety of intravenous rt-PA administration within 4.5 h in stroke patients with decreased consciousness. A total of 136 stroke patients with decreased consciousness, who received or not rt-PA intravenously within 4.5 h after stroke onset from Jiangsu province of China from 2009 to 2012, were reviewed retrospectively. Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS), intracranial hemorrhage rate, and mortality were used to determine patient outcome when discharged. A 3-month outcome was calculated by modified Rankin Scale (mRS) with score 0 to 1 considered favorable outcome. Baseline characteristics of two groups were similar. When discharged, no significant differences were observed regarding NIHSS score (P = 0.994) or GCS score (P = 0.591) between groups. After 3 months, 22.8% patients in rt-PA group had favorable outcome as compared with 7.5% patients in control group (P = 0.014). Treatment with rt-PA did not significantly increase incidence of hemorrhage (P = 0.494) or mortality (P = 0.169). Intravenous rt-PA administration within 4.5 h after onset of symptoms benefited stroke patients with abnormal consciousness.

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

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

Alteplase for Acute Ischemic Stroke. Experience in an Emergency Department of a Community Hospital

Background: Intravenous administration of recombinant tissue plasminogen activator (rt-PA) remains the most beneficial proven intervention for emergency treatment of stroke. Objective: To assess the implementation of the “Stroke code” in routine clinical care at our Emergency Department (ED) from November 2005 to March 2009 and to describe the clinical outcome of patients who received treatment with intravenous rt-PA. Methods: The aim of the “Stroke code” is the early recognition of selected patients with a suspected stroke who may be treated with thrombolysis therapy, implemented in our hospital in November 2005. Prehospital emergency medical services, ED, Critical Care, Radiology, and Neurology departments are implicated. Inclusion criteria for intravenous administration of rt-PA (0.9 mg/Kg) were: age 18 years or greater, measurable neurological deficit, NIHSS (National Institutes of Health Stroke Scale) > 4 and < 25, onset of symptoms < 3 h before beginning treatment, computed tomography (CT) scan without a multilobar infarction (hypodensity > 1/3 cerebral hemisphere). Results: There were 120 “Stroke codes” activated from November 2005 to March 2009. rt-PA was administered in 52 patients (43.3%), 33 patients were males and 19 females. Mean age was 63.6 years. APACHE II (Acute Physiology and Chronic Health Evaluation II) (admission) = 9.1 ± 3.2 points. Intensive care unit length of stay was 3.8 ± 1.6 days; 78.8% of patients had vascular risk factor; 26.9% were with aspirin at stroke onset. Post-treatment study imaging was performed 48 h after thrombolysis: 6 patients developed in CT hemorrhagic infarct type 1 (asymptomatic small petechiae along the margins of the infarct). Two patients died due to cerebral infarction with cerebral edema. Median NIHSS scores were 13.4 points at admission and 9.8, 8.3, and 7 at 2, 24, and 48 h after treatment, respectively. Conclusions: The ED plays an important role in the early recognition of selected patients with a suspected stroke for administration of rt-PA. rt-PA improved clinical outcomes and is safe in patients with acute ischemic stroke.