Rate Of Intravenous Thrombolysis Research Articles

Distribution and evolution of acute interventional ischemic stroke treatment in Germany from 2010 to 2016

BackgroundMechanical thrombectomy (MT) is a new evidence-based treatment option for large vessel occlusion in the anterior brain circulation. Using comprehensive administrative data from Germany, we analysed the nationwide development of intravenous thrombolysis (IVT) and MT in Germany between 2010 and 2016.MethodsWe considered all documented cases (n = 1,515,634) with a main diagnosis of the ICD-10-GM code I63 (ischemic stroke) and identified specific stroke recanalization therapy by using the corresponding Operating and Procedure Key for systemic thrombolysis and mechanical thrombectomy out of the DRG statistics. Regional analyses are based on data from the 413 German administrative districts and cities and the obligatory quality reports of all hospitals. We distinguished between rates of MT related to place of residence of patients and place of treatment.ResultsCoded ischemic strokes increased by 10.2% from 2010 (n = 206.688) to 2016 (n = 227.687). The rate of IVT increased from 8.9% in 2010 to 14.9% in 2016 and the rate of MT increased from 0.8% in 2010 to 4.7% in 2016 with a strong increase in 2015 and 2016. There was a high regional variability of MT according to place of residence of patients between 0 and 11.2% in 2016 with significant lower treatment rates in rural compared to urban areas (3.8 vs 5.4%). Mean age of patients treated with MT increased from 67.8 years in 2010 to 73.3 years in 2016 and almost reached the mean age of IVT treated patients (74.4 years). The number of hospitals coding MT increased from 91 to 193 from 2010 to 2016, but 80% of all MT procedures were performed in neurointerventional centers with ≥50 procedures/year in 2016.ConclusionsThe rate of IVT in patients with acute ischemic stroke in Germany continues to rise and has reached 14.9% nationwide. The increase of MT is even more pronounced and was triggered by the evidence after publication of the MT randomized trials. There is still a high regional variability with significant lower MT rates in rural areas.

Abstract WP387: Language Barrier Impacts Outcome From Acute Ischemic Stroke Without Effect on Receiving Intravenous Thrombolysis

Objectives: Early treatment is crucial for patients with acute ischemic stroke (AIS). Language barrier may delay evaluation and therapy. This study aimed to evaluate the impact of primary language on outcome in patients with AIS. Methods: This is a retrospective study of consecutive patients with AIS at our institution from January 1, 2013 to December 31, 2016. Data were collected from the electronic medical record and the Get With the Guidelines database. Patients were divided into three groups by primary language. Outcome measures include rate of intravenous thrombolysis (IVT), length of stay (LOS), functional outcome per modified Rankin scale (mRS), and mortality at hospital discharge. Statistical analysis was done by non-parametric testing with Kruskal-Wallis for multiple comparisons between groups and Chi-square analysis for comparison of proportions. Results: Among the 1,117 patients included within the study period, 189 received IVT. In this cohort, 759 patients spoke English, 194 spoke Spanish, and 164 spoke Other languages including Vietnamese, Arabic, and Mandarin. The severity of stroke per mean NIHSS on arrival was highest at 12 (95% CI, 10-13) in Other-language group, 9.1 (95% CI, 8.5-9.7, P <0.001) in English group and 8.6 (95% CI, 7.5-9.7, P =0.002) in Spanish group. There was no significant difference in the rate of receiving IVT among the 3 groups, with 16% in English and Spanish groups and 19.5% in Other-language group ( P =0.62). The Other language group has significantly longer LOS (6.7, 95% CI 5.6-7.8) than the Spanish (6.0, 95% CI 5.0-6.9) and English (5.2, 95% CI, 4.8-5.6, P <0.001) groups and worse outcomes with mean mRS 3.5 (95% CI, 3.2-3.7) at hospital discharge compared to English (2.9, 95% CI, 2.8-3.1, P =0.008) and Spanish (2.9, 95% CI, 2.7-3.2, P =0.02) groups, and lower rate of favorable outcome with mRS 0-2 (26.8%) compared to English (41.5%) and Spanish groups (38.7%) ( P =0.0022). Mortality was not significantly different between English (7.9%), Spanish (3.2%), and Other groups (7.9%, P =0.06). Conclusions: At our multiethnic cohort, primary language has no effect on acute stroke therapy with IVT. However, the non-English and non-Spanish speaking patients tended to have longer LOS and worse functional outcome.

Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis.

The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.

Acute basilar thrombosis: Recanalization following intravenous thrombolysis is dependent on thrombus length.

IntroductionWe investigated whether thrombus length measured in Computed Tomography Angiography (CTA) is predictive of the success rate of intravenous thrombolysis (IVT) in acute basilar occlusion and whether recanalization can be achieved by additional mechanical endovascular thrombectomy.MethodsIn 51 patients with acute basilar thrombosis thrombus length was measured on CTA images before intravenous thrombolysis (IVT) with rt-PA was started. After 114 minutes on average success of IVT was evaluated either by CTA or DSA. Patients with persistent basilar occlusion and no major brainstem infarction on CT underwent endovascular recanalization.Results87% of patients had no recanalization of basilar artery after IVT alone. The average thrombus length was 15 mm in patients with persistent basilar occlusion after IVT and 7 mm in patients with recanalization after IVT. Thrombi longer than 13 mm did not resolve after IVT alone and 80% of thrombi shorter than 13 mm did not resolve either. 41 patients were transferred to endovascular recanalization; endovascular therapy was performed successfully in 90% (37 / 41).ConclusionsRecanalization rates in acute basilar occlusion after IVT alone are low and dependent on thrombus length. Additional mechanical endovascular thrombectomy showed to be a very successful recanalization therapy.

Impact of "Stroke Code"-Rapid Response Team: An Attempt to Improve Intravenous Thrombolysis Rate and to Shorten Door-to-Needle Time in Acute Ischemic Stroke.

Objective:“Stroke code” (SC) implementation in hospitals can improve the rate of thrombolysis and the timeline in care of stroke patient.Materials and Methods:A prospective data of patients treated for acute ischemic stroke (AIS) after implementation of “SC” (post-SC era) were analyzed (2015–2016) and compared with the retrospective data of patients treated in the “pre-SC era.” Parameters such as symptom-to-door, door-to-physician, door-to-imaging, door-to-needle (DTN), and symptom-to-needle time were calculated. The severity of stroke was calculated using the National Institutes of Health Stroke Score (NIHSS) before and after treatment.Results:Patients presented with stroke symptoms in pre- and post-SC era (695 vs. 610) and, out of these, patients who came in window period constituted 148 (21%) and 210 (34%), respectively. Patients thrombolyzed in pre- and post-SC era were 44 (29.7%) and 65 (44.52%), respectively. Average DTN time was 104.95 min in pre-SC era and reduced to 67.28 min (P < 0.001) post-SC implementation. Percentage of patients thrombolyzed within DTN time ≤60 min in pre-SC era and SC era was 15.90% and 55.38%, respectively.Conclusion:Implementation of SC helped us to increase thrombolysis rate in AIS and decrease DTN time.

Diurnal Variation of Intravenous Thrombolysis Rates for Acute Ischemic Stroke and Associated Quality Performance Parameters.

Based on data from the Baden-Wuerttemberg stroke registry, we aimed to explore the diurnal variation of acute ischemic stroke (IS) care delivery. 92,530 IS patients were included, of whom 37,471 (40%) presented within an onset-to-door time ≤4.5 h. Daytime was stratified in 3-h time intervals and working vs. non-working hours. Stroke onset and hospital admission time, rate of door-to-neurological examination time ≤30 min, onset-/door-to-imaging time IV thrombolysis (IVT) rates, and onset-/door-to-needle time were determined. Multivariable regression models were used stratified by stroke onset and hospital admission time to assess the relationship between IVT rates, quality performance parameters, and daytime. The time interval 0:00 h to 3:00 h and working hours, respectively, were taken as reference. The IVT rate of the whole study population was strongly associated with the sleep-wake cycle. In patients presenting within the 4.5-h time window and potentially eligible for IVT stratification by hospital admission time identified two time intervals with lower IVT rates. First, between 3:01 h and 6:00 h (IVT rate 18%) and likely attributed to in-hospital delays with the lowest diurnal rate of door-to-neurological examination time ≤30 min and the longest door-to-needle time Second, between 6:01 h and 15:00 h (IVT rate 23-25%) compared to the late afternoon and evening hours (IVT rate 27-29%) due to a longer onset-to-imaging time and door-to-imaging time. No evidence for a compromised stroke service during non-working hours was observed. The analysis provides evidence that acute IS care is subject to diurnal variation which may affect stroke outcome. An optimization of IS care aiming at constantly high IVT rates over the course of the day therefore appears desirable.

Intravenous thrombolysis treatment compliance in patients with acute ischemic stroke in Zhengzhou University People’s Hospital

Objective To investigate the current status about the application of alteplase (rt-PA) for intravenous thrombolysis in acute ischemic stroke patients, and clarify the relevant factors affecting patients’ compliance of intravenous thrombolysis. Methods The acute ischemic stroke patients admitted in Department of Emergency, from January 2014 to December 2015 were recruited for study prospectively. After the patients with contraindications of thrombolysis were excluded, the eligible patients were divided into two groups, intravenous thrombolysis group (ITG) and non-intravenous thrombolysis group (NTG). Receiver operating characteristic curve(ROC)was used to determine the optimal cutoff point and the crucial NIHSS score of patients for decision on thrombolysis therapy. Results There were 230 patients with acute ischemic stroke occurred in the period of two years. Of 189 eligible patients, 33 refused the intravenous thrombolysis treatment (NTG) whereas 156 willing to take the intravenous thrombolysis treatment (ITG). The intravenous thrombolysis rate of eligible ischemic stroke patients reached to Henan Provincial People’s Hospital within the time window (4.5 hours) was 67.8% without contraindications. The results of the single-factor analysis for the patients of the two groups displayed that the differences in factors including age, baseline NIHSS score, limb weakness, hemiplegic paralysis, dysphasia, as well as dizziness were significant between two groups (t=2.578, P=0.047; U=157.221, P=0.000; χ2=26.702, P=0.000; χ2=9.069, P=0.003; χ2=7.381, P=0.007; χ2=28.636, P=0.000). The ROC analysis demonstrated the relationship between the baseline NIHSS score and the patients receiving intravenous thrombolysis. When NIHSS score<7, patients tended to refuse the treatment with intravenous thrombolysis (sensitivity 0.87, specificity 0.82). Among the patients receiving intravenous thrombolysis, the significant differences in intracranial hemorrhage rate, hospitalization mortality rate and 3-month mortality rate were not found between the patients with baseline NIHSS score≥7 and score<7 (1.9% vs. 3.9%, P= 0.662; 1.9% vs. 7.8%, P=0.168 and 3.8% vs. 11.7%, P=0.142, respectively). However a higher rate of favorable prognosis (3-month modified Rankin Scale score≤1) was observed in thrombolysis patients (75.5% vs. 41.7%, P=0.000). Conclusions Factors such as age, baseline NIHSS score, limb weakness, hemiplegic paralysis, dysphasia, as well as dizziness are supposed to be associated with patients’ compliance of intravenous thrombolysis. Key words: Brain infarction; Ischemic stroke; Tissue plasminogen activator; Thrombolysis

Temporal Trends in Intravenous Thrombolysis in Acute Ischemic Stroke: Experience from a Tertiary Care Center in India

Acute ischemic stroke (AIS) is a time-dependent treatable cause of morbidity and mortality. Despite the increasing stroke incidence in developing countries, parallel increasing stroke thrombolysis rates have not been documented. This study aims to determine trends in patient characteristics and rates of recombinant tissue plasminogen activator (rtPA) use in AIS patients in a tertiary care center in northern India. All AIS patients presenting within 8 hours of symptoms onset from January 2011 to December 2015 were enrolled and analyzed. A total of 867 AIS patients presented within 8 hours of symptoms onset. Out of 593 eligible patients, 189 (31.87%) underwent intravenous thrombolysis (IVT) with rtPA within 4.5 hours of the window period. Patients (undergoing) IVT had onset-to-door times of 2 hours or less (23.81%), 2-3 hours (33.86%), and 3.0-4.5 hours (42.33%). IVT rates in 2 hours or less of symptom onset increased from 22% to 25% and IVT rates in 2-3 hours increased from 38.9% to 43.8%. Door-to-computerized tomographic time (median 27 versus 11 minutes, P = .0001) and door-to-needle time (median 83 versus 67 minutes, P = .011) improved, with a significant improvement of computerized tomography imaging time within 25 minutes of arrival (from 50% to 78.4%, P = .014). Post-IVT symptomatic hemorrhage was noted in 5 patients (2.65%). The median National Institutes of Health Stroke Scale score at presentation was 11, whereas a favorable modified Rankin Scale score (0-1) at 3 months was seen in 39.68%. Encouraging trends in IVT over the years may be indicative of increasing community awareness of stroke and improving quality of stroke care in developing countries such as India.

Abstract TP386: From Zero to Stroke Elite Gold Plus in Three Years

Background and Purposes: Geisinger Community Medical Center is located in Scranton, Pennsylvania. We serve six counties with a population of 700,000. Due to the Scranton aging population, the incidence of stroke is 1.3 x the national average. We began our stroke program in March 2011 and grew to one of the best stroke programs in this region. Here, we describe our strategies leading to our success. Subjects and Methods: To achieve our goal ,beside employing routine strategies such as ongoing hospital-wide education and monthly stroke meetings; we took the following intuitive steps: 1. Recruited a stroke program coordinator who was a RN with a post-graduate degree, certified in neurological nursing and rehab counseling with substantial experience in working in a trauma unit 2. Consistent presence of the stroke coordinator in the ER and an office on the stroke floor. 3. Developed a collegial relationship with all team members 4. Bottom-up approach to gain the trust and support of nursing staff and administration 5. Consistent real-time chart review of neurology / neurosurgery consults and scanning the emergency department patients’ list . 6. Develop an organized Feedback / Performance Improvement in stroke care. 7. Weekly Rehabilitation Collaboration Meeting. 8. Kept the ER medical service highly engaged in our stroke program by having regular meetings and offering on-site education and feedback 9. Recruited a Nurse Navigator and a Data Analyst. Results: Geisinger Community Medical Center became a Joint Commission designated Primary Stroke Center and obtained a Gold Plus status in 2013. Since then, the number of treated stroke patients has increased to greater than 550. We have met the American Heart and Stroke Association and Joint Commission criteria for over 90% (95%CI: 87.5-92.5) compliance for eight stroke core measures. Our intravenous thrombolysis rate significantly increased to 12.6% (95%CI: 9.8-15.4). We achieved Honor- Roll Elite award for decreasing Door to Needle time below 60 minutes in 2015. Conclusions: Our experience indicates a few simple strategies, can make a big difference in stroke care in community hospitals. A fledgling stroke center can rise from Zero to Gold Plus with Elite Status with careful planning, coordination and caring.

Abstract WP305: Uniting Hospital Leaders in a Competitive Region to Improve Intravenous Thrombolysis Rates: Analysis of the SETRAC Stroke Registry

Uniting Hospital Leaders in a Competitive Region To Improve Intravenous Thrombolysis Treatment Rates: Analysis of the SETRAC Stroke Registry Background: The Southeast Texas Regional Advisory Council (SETRAC) convenes representatives from area hospitals belonging to different health systems to discuss how to improve the delivery of stroke care in a nine county area that includes Houston, Texas. In 2014, area hospitals agreed to focus upon improving tissue plasminogen activator (tPA) administration rates in the area. Hypothesis: By sharing stroke metrics in a blinded fashion on a consistent basis, tPA administration rates will improve. The theory was tested by tracking the following metrics: a. percent of ischemic stroke patients receiving tPA. b. percent of treated patients receiving tPA within 60 minutes of arrival at the hospital. Methods: SETRAC aligned regional metrics with stroke treatment and timing metrics in Get With The Guidelines®-Stroke beginning in Q3 2014. SETRAC compiled and shared this data with stroke coordinators and hospital administrators on a quarterly basis. Bar graphs were utilized for benchmarking hospitals in a blinded fashion. Linear tests were performed to validate increases in the percent of patients treated with tPA and the percent of patients treated within 60 minutes of arrival at the hospital. Results from hospitals that consistently reported data for each of the six quarters were included in the analysis. Results: Twenty-six area hospitals reported 10,396 ischemic stroke patients between Q3 2014 through Q4 2015. In that time, tPA administration increased from 10.3% in Q3 2014 to 12.0% in Q4 2015 (p&lt;0.001). Further, tPA administration within 60 minutes of arrival in emergency room increased from 55.3% in Q3 2014 to 66.7% in Q4 2015 (p&lt;0.001). In conclusion, following the uniting of hospital leaders and utilizing nationally aligned stroke metrics, a higher percentage of ischemic stroke patients received tPA. Of those that received tPA, an improvement in the timeliness of administration was also realized.

Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke.

In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States.

Increase in national intravenous thrombolysis rates for ischaemic stroke between 2005 and 2012: is bigger better?

BackgroundIntravenous thrombolytic therapy after ischaemic stroke significantly reduces mortality and morbidity. Actual thrombolysis rates are disappointingly low in many western countries. It has been suggested that higher patient volume is related to shorter door-to-needle-time (DNT) and increased thrombolysis rates. We address a twofold research question: a) What are trends in national thrombolysis rates and door-to-needle times in the Netherlands between 2005–2012? and b) Is there a relationship between stroke patient volume per hospital, thrombolysis rates and DNT?MethodsWe used data from the Stroke Knowledge Network Netherlands dataset. Information on volume, intravenous thrombolysis rates, and admission characteristics per hospital is acquired through yearly surveys, in up to 65 hospitals between January 2005 and December 2012. We used linear regression to determine a possible relationship between hospital stroke admission volume, hospital thrombolysis rates and mean hospital DNT, adjusted for patient characteristics.ResultsInformation on 121.887 stroke admissions was available, ranging from 7.393 admissions in 2005 to 24.067 admissions in 2012. Mean national thrombolysis rate increased from 6.4 % in 2005 to 14.6 % in 2012. Patient characteristics (mean age, gender, type of stroke) remained stable. Mean DNT decreased from 72.7 min in 2005 to 41.4 min in 2012. Volume of stroke admissions was not an independent predictor for mean thrombolysis rate nor for mean DNT.ConclusionIntravenous thrombolysis rates in the Netherlands more than doubled between 2005 and 2012, in parallel with a large decline in mean DNT. We found no convincing evidence for a relationship between stroke patient volume per hospital and thrombolysis rate or DNT.

Stent-Retriever Thrombectomy for Acute Anterior Ischemic Stroke with Tandem Occlusion: A Systematic Review and Meta-Analysis.

To assess the efficacy and safety profile of stent-retriever thrombectomy (SRT) in acute anterior ischemic stroke patients with tandem occlusion. Using the MEDLINE database, we conducted a systematic review and meta-analysis of all studies that included patients with acute ischemic stroke attributable to tandem occlusion who received treatment with SRT between November 2010 and May 2015. The literature search identified 11 previous studies involving a total of 237 subjects out of whom 193 (81.4%) were treated with acute stent placement for the extracranial internal carotid artery occlusion. Mean initial NIHSS score was 17, and median time from onset to recanalization was 283.5min. Mean intravenous thrombolysis rate was 63.8%. In the meta-analysis, the recanalization rate reached 81% (95% CI, 73-89). Meta-analysis of clinical outcomes showed a pooled estimate of 44% (95% CI, 33-55; 10 studies) for favourable outcome, 13% (95% CI, 8-20; 10 studies) for mortality, and 7% (95% CI, 2-13; eight studies) for symptomatic intracranial haemorrhage. SRT with emergency carotid stenting is associated with acceptable safety and efficacy in acute anterior stroke patients with tandem occlusion compared to natural history. However, the best modality to treat proximal stenosis is based on an individual case basis. • Stent retriever thrombectomy of tandem occlusion is efficient and safe. • Emergent carotid stenting during thrombectomy increase symptomatic intracranial haemorrhage without impact mortality. • Thrombectomy of tandem anterior circulation occlusion may be the first therapeutic option.

Minimum intravenous thrombolysis utilization rates in acute ischemic stroke to achieve population effects on disability: A discrete-event simulation model

BackgroundThe only pharmacological treatment with proven cost-effectiveness in reducing acute ischemic stroke (AIS) associated disability is intravenous thrombolysis with recombinant tissue plasminogen activator but it's utilization rate is still low in most of the world. We estimated the minimum thrombolysis utilization rate needed to decrease the prevalence of stroke-related disability at a population level by using a discrete-event simulation model. MethodsThe model included efficacy according to time to treatment up to 4.5h, and four scenarios for the utilization of intravenous thrombolysis in eligible patients with AIS: a) 2%; b) 12% c) 25% and d) 40%. We calculated the prevalence of AIS related disability in each scenario, using population based data. The simulation was performed from 2002 to 2017 using the ARENA software. ResultsA 2% utilization rate yielded a prevalence of disability of 359.1 per 100,000. Increasing thrombolysis to 12% avoided 779 disabled patients. If the utilization rate was increased to 25%, 1783 disabled patients would be avoided. The maximum scenario of 40% decreased disability to 335.7 per 100,000, avoiding 17% of AIS-related disability. ConclusionThe current utilization rate of intravenous thrombolysis of 2% has minimal population impact. Increasing the rate of utilization to more than 12% is the minimum to have a significant population effect on disability and should be a public policy aim.

Abstract WP238: Thrombolytic Use in Stroke Mimics via Telestroke

Background: It has been established that safety and outcomes of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) is similar to those presenting to stroke centers. Little is known on the accuracy of TS diagnosis among those receiving IVT. We sought to compare the rate of stroke mimic (SM) patients receiving IVT in our TS network to those who present to our comprehensive stroke center (CSC). Methods: Consecutive patients receiving IVT between August 2014 and June 2015 were identified at our CSC and TS network. The rates of SM patients in each cohort were calculated. Outcomes measured included rates of symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU). Results: During the study period, 132 patients (mean age 71±15 years, 49% women) receiving IVT were included in the analysis (75 CSC, 57 TS). Rates of SM patients receiving IVT were similar (CSC 12% vs TS 7%, p=0.39). One stroke patient developed sICH, and three other stroke patients experienced in-hospital mortality; neither outcome was found in the SM cohort. Discharge to home or ARU was similar between stroke (76.5%) and SM (76.9%) patients (p=1). Patients with SMs had significantly higher diagnoses of migraine (p=0.045) and psychiatric disorders (p=0.0002) compared to stroke patients. Conclusion: The rate of IVT among SM patients via TS is low and similar to those who present directly to a stroke center. Continued efforts should be made to further minimize IVT in SM patients despite the low rate of complications.

Mobile health: new technologies, new modes and new era.

Mobile health: new technologies, new modes and new era.

Brain Imaging Using Mobile CT: Current Status and Future Prospects.

Computed tomography (CT) is an invaluable tool in the diagnosis of many clinical conditions. Several advancements in biomedical engineering have achieved increase in speed, improvements in low-contrast detectability and image quality, and lower radiation. Portable or mobile CT constituted one such important advancement. It is especially useful in evaluating critically ill, intensive care unit patients by scanning them at bedside. A paradigm shift in utilization of mobile CT was its installation in ambulances for the management of acute stroke. Given the time sensitive nature of acute ischemic stroke, Mobile stroke units (MSU) were developed in Germany consisting of an ambulance equipped with a CT scanner, point of care laboratory system, along with teleradiological support. In a radical reconfiguration of stroke care, the MSU would bring the CT scanner to the stroke patient, without waiting for the patient at the emergency room. Two separate MSU projects in Saarland and Berlin demonstrated the safety and feasibility of this concept for prehospital stroke care, showing increased rate of intravenous thrombolysis and significant reduction in time to treatment compared to conventional care. MSU also improved the triage of patients to appropriate and specialized hospitals. Although multiple issues remain yet unanswered with the MSU concept including clinical outcome and cost-effectiveness, the MSU venture is visionary and enables delivery of life-saving and enhancing treatment for ischemic and hemorrhagic stroke. In this review, we discuss the development of mobile CT and its applications, with specific focus on its use in MSUs along with our institution's MSU experience.

Intravenous thrombolysis for acute ischaemic stroke in the elderly: data from the Baden-Wuerttemberg stroke registry.

In Europe intravenous thrombolysis (IVT) for ischaemic stroke is still not approved for patients aged >80 years. However, elderly patients are frequently treated based on individual decision making. In a retrospective observational study a consecutive and prospective stroke registry in southwest Germany was analysed. The data registry collected 101,349 patients with ischaemic stroke hospitalized from January 2008 to December 2012. Of these, 38,575 (38%) were aged 80 years and older and 10 286 (10.1%) underwent IVT. Favourable outcome at discharge was defined as modified Rankin Scale (mRS) ≤1 or not worse than prior to stroke. Multiple logistic regression models stratified by 10-year age groups were used to assess the relationship between IVT and mRS at discharge, adjusted for patient characteristics, admitting facility and length of hospital stay. The highest IVT rate was 15% in patients aged <50 years, with a continuous decline down to 8% in patients aged ≥90 years. Adjusted odds ratios and 95% confidence intervals for patients 80-89 years of age were 2.20 (1.95-2.47) (P < 0.0001) and 1.25 (0.88-1.78) (P = 0.21) for patients >90 years of age, compared to patients of the same age decade not treated with IVT. The evidence from routine hospital care in southwest Germany indicates that IVT is an effective treatment also for aged patients with ischaemic stroke in an age range between 80 and 89 years. Although no clear evidence for the effectiveness of IVT beyond 90 years was found, treatment should also be carefully considered in these patients. High age should not discourage from treatment.

Safety and outcomes of intravenous thrombolysis in dissection-related ischemic stroke: an international multicenter study and comprehensive meta-analysis of reported case series.

The safety and efficacy of intravenous thrombolysis (IVT) in dissection-related ischemic stroke (DRIS) has not been established. We sought to determine safety and recovery rates of IVT in DRIS using prospective, international, multicenter data and by conducting a comprehensive meta-analysis of reported case series. We analyzed consecutive DRIS patients treated with IVT according to national guidelines during a 5-year period at six tertiary-care stroke centers, and also conducted a comprehensive review and meta-analysis of all available case series reporting safety outcomes in DRIS treated with IVT according to PRISMA guidelines. A total of 39 DRIS patients (mean age 60 ± 18 years; 59% men; median NIHSS 13 points, IQR 9-17) received IVT in our multicenter study. Symptomatic intracranial hemorrhage (sICH), in-hospital mortality, complete recanalization, favorable functional outcome (FFO; mRS-score of 0-1) and functional independence (FI; mRS-score of 0-2) were 0% (adjusted Wald 95% CI 0-8%), 10% (3-24%), 55% (40-70%), 61% (45-74%) and 68% (52-81%). The pooled sICH and mortality rates in meta-analysis including 10 case series (234 IVT-DRIS patients) were 2% (0-5%) and 4% (0-8%). The pooled recanalization, FFO and FI rates were 45% (26-67%), 41% (29-54%) and 61% (48-72%), respectively. Substantial heterogeneity was only found for FFO (I(2) = 61%; p = 0.006). Subsequent meta-regression analysis identified baseline NIHSS and dissection in the posterior circulation as independent predictors of FFO (p < 0.05), accounting for FFO variance across different studies. Our prospective, international data coupled with comprehensive meta-analysis results underscore IVT safety in DRIS, while further independent validation is required in larger observational registries or RCTs.

Exploring the impact of intravenous thrombolysis on length of stay for acute ischemic stroke: a retrospective cohort study.

BackgroundUnderstanding the factors that influence the hospital length of stay (LOS) for patients with stroke will help in discharge planning and stroke unit management. We explored how intravenous thrombolysis (IVT) affects LOS in an acute-care hospital setting.MethodsWe analyzed adult patients with ischemic stroke who presented within 48 h of onset from a hospital-based stroke registry. The relationship between IVT and prolonged LOS (LOS ≥ 7 days) was studied by both multivariate logistic regression and the classification and regression tree (CART) analyses.ResultsAmong the study population of 3054 patients, 1110 presented within 4.5 h. The median LOS (interquartile range) was 7 (4 to 11) days, and 1619 patients had prolonged LOS. Multivariate logistic regression revealed that IVT (odds ratio, 0.53; 95 % confidence interval 0.38–0.74) was an independent factor that reduced the risk of prolonged LOS, whereas age, National Institutes of Health Stroke Scale (NIHSS) score, diabetes mellitus, and leukocytosis at admission predicted prolonged LOS. CART analysis identified 4 variables (NIHSS score, IVT, leukocytosis at admission, and age) as important factors to partition the patients into six subgroups. The patient subgroup that had an NIHSS score of 5 to 7 and received IVT had the lowest probability (19 %) of prolonged LOS.ConclusionsIVT reduced the risk of prolonged LOS in patients with acute ischemic stroke. Measures to increase the rate of IVT are encouraged.