Intravenous Thrombolysis Treatment Research Articles

Understanding Endothelial Dysfunction and Its Role in Ischemic Stroke After the Outbreak of Recanalization Therapies.

Despite recent advances in treatment options, stroke remains a highly prevalent and devastating condition with significant socioeconomic impact. Recanalization therapies, including intravenous thrombolysis and endovascular treatments, have revolutionized stroke management and prognosis, providing a promising framework for exploring new therapeutic strategies. Endothelial dysfunction plays a critical role in the pathophysiology, progression, and prognosis of stroke. This review aims to synthesize the current evidence regarding the involvement of the nitric oxide (NO)/endothelium pathway in ischemic stroke, with a particular focus on aging, response to recanalization therapies, and therapeutic approaches. While significant progress has been made in recent years in understanding the relationship between endothelial dysfunction and stroke, many uncertainties persist, and although treatments targeting this pathway are promising, they have yet to demonstrate clear clinical benefits.

A telemedicine-enabled intravenous thrombolytic treatment pathway for patients with hyperacute non-arteritic central retinal artery occlusion

PurposeTo describe the visual acuity (VA) outcomes from a telemedicine-enabled pathway allowing for rapid diagnosis and administration of intravenous (IV) thrombolytic treatment for non-arteritic central retinal artery occlusion (naCRAO) within 4.5 hours (4.5 h) of visual loss. DesignRetrospective observational case series. MethodsSetting: A large managed healthcare consortium.Patient Population: Eighty-five patients with naCRAO and vision loss for less than 4.5 h presenting between 2021 and 2023. Thirty-five patients received IV thrombolytic therapy and 50 patients were closely observed.Intervention: A collaborative telemedicine-enabled pathway employing fundus photography was previously established by Ophthalmology, Emergency Medicine, and Stroke services to rapidly evaluate and manage patients presenting with acute painless monocular vision loss and allow for administration of IV tenecteplase (0.25 mg/kg) for eligible consenting patients diagnosed with naCRAO within 4.5 h. Retrospective chart review was conducted to collect data on demographics, vascular risk factors, clinical features, VA outcomes, and adverse events. Comparison was made between patients who received intravenous thrombolysis and those who were observed.Main Outcome Measures: Improvement in VA of at least 0.3 logarithm of the minimum angle of resolution (logMAR) and/or from 20/200 or worse to 20/100 or better. ResultsA greater percentage of patients in the treated group had VA improvement of ≥0.3 logMAR (54.3 % vs 28 %, p = .014), and a greater percentage of patients in the untreated group had VA worsening of ≥0.3 logMAR (30 % vs 5.7 %, p = .006). Twice the percentage of treated versus untreated patients had improved VA from 20/200 or worse to 20/100 or better, but this difference was not statistically significant (20 % vs 10 %, p = .192). There was a significantly shorter mean time to treatment for those patients who had VA improvement from 20/200 or worse to 20/100 or better compared to those who did not (118 versus 171 min, p = .031). Two patients experienced intracranial bleeding after IV thrombolysis. ConclusionsThe evaluation and treatment of hyperacute naCRAO is possible on a large scale via an integrated telemedicine-enabled approach utilizing fundus photography. The use of IV thrombolytic was associated with better VA outcomes compared to observation alone. Prospective randomized controlled trials are needed to confirm these findings and determine optimal management.

Percheron Artery Stroke and Reperfusive therapies: A systematic review and meta-analysis

Background and AimsPercheron Artery Stroke, affecting bilateral paramedian thalamic structures, accounts for 0.1–0.4 % of all acute ischemic strokes. Little is known about disability or mortality outcomes in patients receiving intravenous thrombolysis (IVT) or endovascular treatment (EVT), therefore a systematic review was carried out. MethodsA systematic search of Pubmed, Embase and Scopus databases for all kind of studies regarding Percheron Artery Stroke was performed. The review is registered in INPLASY (202410059). In total, 1895 papers were screened; 197 studies were included, consisting exclusively in case reports, retrospective series and conference abstracts. Data from 448 patients were analyzed in logistic regression. ResultsBoth IVT (ORIVT = 3.08; 95 % CI 1.4 – 6.7; p = 0.005) and EVT (OREVT = 5.77; 95 % CI 1.69 – 19.7; p = 0.005) were associated with reduced disability, as well as exclusive thalamic involvement (OR = 3.24; CI 2.1 – 5.1; p < 0.001) and higher Glasgow Coma Scale score (GCS) on admission (OR = 1.2; 95 % CI 1.12 – 1.28; p < 0.001). GCS (OR = 0.73, 95 % CI 0.63 – 0.82; p < 0.001) and exclusive thalamic involvement (OR = 0.36; 95 % CI 0.16 – 0.74; p = 0.005) were associated with lesser mortality, while IVT displayed a non-significant trend towards reduced mortality (ORIVT = 0.13; 95 % CI 0.01 – 1.04; p = 0.056). ConclusionThe present work, albeit summarizing data coming from low quality sources, suggests an association between both EVT/IVT and better outcomes in paramedian bilateral thalamic strokes.

Advancements in Imaging for the Diagnosis of Wake-up Stroke.

The concept of wake-up stroke (WUS) as a distinct subtype of acute ischaemic stroke, characterized by an uncertain onset time, traditionally resulted in the exclusion of patients from intravenous thrombolysis treatment. Advancements in neuroimaging have prompted a shift in the approach to intravenous thrombolysis treatment, moving away from a strict focus on the onset time window toward consideration of the tissue time window. This paradigm shift has expanded the opportunity for a larger cohort of patients with WUS to receive timely and effective treatment, ultimately leading to improved prognosis. This study reviews the WUS pathogenesis and the progress of various imaging diagnostic techniques to clarify the WUS onset time and select the optimal treatment plan.

Thrombolysis in wake-up stroke based on MRI mismatch

ObjectivesWake-up stroke (WUPS) patients can be selected to intravenous thrombolysis (IVT) treatment based on the Magnetic Resonance Imaging (MRI) mismatch concept. However, recent studies suggest the introduction of modified MRI mismatch criteria, allowing IVT in WUPS patients with a partial mismatch. Material and methodsWUPS patients treated with IVT in the NOR-TEST trial and consecutively thereafter at Stavanger University Hospital were included in this study. Patient selection for treatment was performed based on the clinical presentation and the MRI DWI/FLAIR mismatch criteria. MRI examinations were reassessed according to the modified DWI-FLAIR mismatch criteria, allowing partial mismatch. Improvement in NIHSS and mRS at 3 months were used to analyze clinical outcome, and the rate of intracranial hemorrhage (ICH) to analyze safety. Results78 WUPS patients were treated with IVT. Only 68 of these patients were independent pre-stroke and included in the clinical analysis. When reassessing the MRI examinations, 41 (60 %) were rated as DWI/ FLAIR mismatch, 14 (21 %) as partial mismatch and 13 (19 %) as match. The results show that the patient groups had a mRS score 0–1 at 3 months measured as primary outcome to respectively 27 (65.9 %), 11 (78.6 %) and 8 (61.5 %); (P = 0.629). The mismatch group showed the best clinical improvement (3-points NIHSS reduction, p = 0.005). No ICH was seen in any of the groups. ConclusionOur study extended the mismatch concept in clinical praxis to treat WUPS patients with partial mismatch, showing the best clinical outcome in the mismatch group.

Evaluating Thrombolysis Rates and Emergency Department Time Targets in Acute Ischemic Stroke: Need for Personalized Medicine.

In the era of personalized medicine, standard protocols regarding the management of acute ischemic stroke (AIS) focus on time targets alone without tailoring the protocol to the specific patient and hospital characteristics to increase IV thrombolysis rates and improve outcomes for these patients by considering organizational differences and patient-related factors that influence adherence to target times at the emergency department level. With this in mind, we evaluate the effect of achieving ED time targets from standard protocol and patient-related risk factors on the intravenous (IV) thrombolysis rate in patients with AIS in the therapeutic window. For our research, we enrolled people who arrived at the ED with signs of recent AIS with an onset of less than 4.5 h. Initially, 355 patients were included in the study, but through careful screening, only 258 were considered eligible to participate. Of the final group of 258 patients, only 46 received intravenous thrombolysis treatment. In our study, when we are analyzing ED times in patients admitted with stroke symptoms in the therapeutic window, we found statistically significantly decreased ED times for patients that performed IV thrombolysis compared to patients not performing as follows: a median of 100 min in onset-to-ED door time (p < 0.001), a door-to-physician time (ED doctor) of 4 min (p = 0.009), door-to-blood-samples of 5 min (p = 0.026), a door-to-CT time of 15.5 min (p = 0.009), and door-to-CT results of 37 min (p < 0.001). In addition, patients who received intravenous thrombolysis were found to be significantly older (p < 0.001), with lower height and weight (p < 0.001 for both) and lower Glasgow Coma Scale (GCS) scores (9 ± 4.94 vs. 13.85 ± 2.41, p < 0.001). The logistic regression analysis indicated that the onset-to-ED time (p < 0.001) and the door-to-physician time (p = 0.014) for emergency medicine physicians are significant predictors of the likelihood of administering thrombolysis. By analyzing the impact of comorbidities, we observed that dyslipidemia, chronic arterial hypertension, and diabetes mellitus are significant predictive factors for performing IV thrombolysis (the presence of dyslipidemia and diabetes mellitus are predictive factors for performing IV thrombolysis, while the presence of arterial hypertension is not). The ED time targets that significantly influenced IV thrombolysis in our study were the onset-to-ED door time and the time it takes for the ED doctor to assess the AIS patient (door-to-physician time). The IV thrombolysis rate for these patients was 17.83%, lower than expected despite achieving most ED time targets, with the presence of chronic arterial hypertension as a significant predictive patient-related factor for not performing it. Even though our reported hospital's thrombolysis rate is favorable compared to international reports, there is always room for improvement. Based on our study results, it is necessary that new protocols to customized standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right. Based on our study results, it is necessary that new protocols customize standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right.

Combining Intravenous Thrombolysis and Dual Antiplatelet Treatment in Patients With Minor Ischemic Stroke: A Propensity Matched Analysis of the READAPT Study Cohort.

The optimal treatment for acute minor ischemic stroke is still undefined. and options include dual antiplatelet treatment (DAPT), intravenous thrombolysis (IVT), or their combination. We aimed to investigate benefits and risks of combining IVT and DAPT versus DAPT alone in patients with MIS. This is a prespecified propensity score-matched analysis from a prospective multicentric real-world study (READAPT [Real-Life Study on Short-Term Dual Antiplatelet Treatment in Patients With Ischemic Stroke or Transient Ischemic Attack]). We included patients with MIS (National Institutes of Health Stroke Scale score at admission ≤5), without prestroke disability (modified Rankin scale [mRS] score ≤2). The primary outcomes were 90-day mRS score of 0 to 2 and ordinal mRS distribution. The secondary outcomes included 90-day risk of stroke and other vascular events and 24-hour early neurological improvement or deterioration (≥2-point National Institutes of Health Stroke Scale score decrease or increase from the baseline, respectively). From 1373 patients with MIS, 240 patients treated with IVT plus DAPT were matched with 427 patients treated with DAPT alone. At 90 days, IVT plus DAPT versus DAPT alone showed similar frequency of mRS 0 to 2 (risk difference, 2.3% [95% CI -2.0% to 6.7%]; P=0.295; risk ratio, 1.03 [95% CI 0.98-1.08]; P=0.312) but more favorable ordinal mRS scores distribution (odds ratio, 0.57 [95% CI 0.41-0.79]; P<0.001). Compared with patients treated with DAPT alone, those combining IVT and DAPT had higher 24-hour early neurological improvement (risk difference, 20.9% [95% CI 13.1%-28.6%]; risk ratio, 1.59 [95% CI 1.34-1.89]; both P<0.001) and lower 90-day risk of stroke and other vascular events (hazard ratio, 0.27 [95% CI 0.08-0.90]; P=0.034). There were no differences in safety outcomes. According to findings from this observational study, patients with MIS may benefit in terms of better functional outcome and lower risk of recurrent events from combining IVT and DAPT versus DAPT alone without safety concerns. URL: https://www.clinicaltrials.gov; Unique identifier: NCT05476081.

Management of patients with diffusion-weighted imaging-negative acute ischemic stroke: Retrospective analysis of 47 consecutive patients

BackgroundFew studies with a limited number of patients focused on the outcomes of patients with diffusion-weighted imaging (DWI)-negative acute ischemic stroke (AIS) after intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). MethodsThis retrospective observational, single-center study included all consecutive patients admitted for AIS involving the anterior circulation and treated with IVT and/or EVT between January 1, 2015 and December 31, 2023. The collected data were used to identify the characteristics of patients with negative DWI and to compare outcomes in patients with negative and positive DWI. ResultsAmong the 1210 patients included, 47 (3.9 %) had negative (DWI-negative group) and 1163 had increased DWI signal (DWI-positive group). In the DWI-negative group, the mean age was 69 years (SD=19.4), 55.3 % were men, and 27 (57.4 %) had a large vessel occlusion. Thirty eight (80.9 %) were treated with IVT alone, 7 (14.9 %) with EVT alone, and 2 (4.3 %) with both. Fluid attenuated inversion recovery (FLAIR) sequences were the most sensitive to detect predictive factors of cerebral ischemia, such as vessel thrombosis and the spaghetti sign that were found in 68.1 % and 83 %, of patients, respectively. Oxyhemoglobin-sensitive (T2*) and susceptibility-weighted angiography (SWAN) sequences were less sensitive: vessel thrombosis and the brush sign were detected in 55.3 % and 19.1 % of patients, respectively. Comparison of the two DWI groups showed that M2 occlusion was more frequent (31.9 % vs 13 %, p<0.001) and M1 occlusion rarer (19.1 % vs 36 %, p<0.02) in the DWI-negative than DWI-positive group. At admission, the median National Institutes of Health Stroke Scale score was lower in the DWI-negative than DWI-positive group (2 vs 6, p=0.0001), but the median symptom onset-to-MRI time was similar in both groups (108 vs 111 min, p=0.88). ConclusionsIn patients with DWI-negative AIS, symptoms are less severe. Large vessel occlusions, notably in the M2 segment, are more distal at the expense of the M1 segment of MCA. The spaghetti sign remains the most predictive feature of AIS that should be specifically searched in the absence of DWI lesions.

Assessment of Thrombectomy versus Combined Thrombolysis and Thrombectomy in Patients with Acute Ischemic Stroke and Medium Vessel Occlusion.

Background The combination of intravenous thrombolysis (IVT) with mechanical thrombectomy (MT) may have clinical benefits for patients with medium vessel occlusion. Purpose To examine whether MT combined with IVT is associated with different outcomes than MT alone in patients with acute ischemic stroke (AIS) and medium vessel occlusion. Materials and Methods This retrospective study included consecutive adult patients with AIS and medium vessel occlusion treated with MT or MT with IVT at 37 academic centers in North America, Asia, and Europe. Data were collected from September 2017 to July 2021. Propensity score matching was performed to reduce confounding. Univariable and multivariable logistic regression analyses were performed to test the association between the addition of IVT treatment and different functional and safety outcomes. Results After propensity score matching, 670 patients (median age, 75 years [IQR, 64-82 years]; 356 female) were included in the analysis; 335 underwent MT alone and 335 underwent MT with IVT. Median onset to puncture (350 vs 210 minutes, P < .001) and onset to recanalization (397 vs 273 minutes, P < .001) times were higher in the MT group than the MT with IVT group, respectively. In the univariable regression analysis, the addition of IVT was associated with higher odds of a modified Rankin Scale (mRS) score 0-2 (odds ratio [OR], 1.44; 95% CI: 1.06, 1.96; P = .019); however, this association was not observed in the multivariable analysis (OR, 1.37; 95% CI: 0.99, 1.89; P = .054). In the multivariable analysis, the addition of IVT also showed no evidence of an association with the odds of first-pass effect (OR, 1.27; 95% CI: 0.9, 1.79; P = .17), Thrombolysis in Cerebral Infarction grades 2b-3 (OR, 1.64; 95% CI: 0.99, 2.73; P = .055), mRS scores 0-1 (OR, 1.27; 95% CI: 0.91, 1.76; P = .16), mortality (OR, 0.78; 95% CI: 0.49, 1.24; P = .29), or intracranial hemorrhage (OR, 1.25; 95% CI: 0.88, 1.76; P = .21). Conclusion Adjunctive IVT may not provide benefit to MT in patients with AIS caused by distal and medium vessel occlusion. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Wojak in this issue.

Impact of demographic and clinical factors on in-hospital delays in acute ischemic stroke treatment.

Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear. This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed. Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups. Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

European stroke organisation and European society for minimally invasive neurological therapy guideline on acute management of basilar artery occlusion.

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Safety and efficacy of tirofiban combined with intravenous thrombolysis and endovascular treatment in acute large vessel occlusion stroke

ObjectiveThis study assesses the safety and efficacy of tirofiban for patients with large vessel occlusion stroke after intravenous thrombolysis. MethodsThis study data was from SUSTAIN, DEVT, and RESCUE BT trials. According to whether the use of tirofiban who underwent endovascular treatment and preceding intravenous thrombolysis was divided into the tirofiban group and the no-tirofiban group. The safety outcomes were symptomatic intracranial hemorrhage, any intracranial hemorrhage within 48 h, and 3-month mortality. The efficacy outcome was defined as a score of 0–2 on the modified Rankin Scale scores at 3 months. ResultsA total of 372 patients with intravenous thrombolysis were included in these SUSTAIN, DEVT, and RESCUE BT trials. Adjusted multivariate analysis showed that tirofiban with intravenous thrombolysis was not associated with symptomatic intracranial hemorrhage (aOR, 0.87; 95 % CI, 0.49–1.57; P=0.65), any intracranial hemorrhage within 48 h (aOR, 1.00; 95 % CI, 0.60–1.66; P=1.00), 3-month mortality (aOR, 1.10; 95 % CI, 0.56–2.19; P=0.78) and 3-month modified Rankin Scale scores 0–2 (aOR, 0.72; 95 % CI, 0.42–1.25; P=0.25) in patients with acute large vessel occlusion. In the subgroup analysis, we found that tirofiban was not recommended for females (aOR, 0.34; 95 % CI, 0.12–0.93), baseline Alberta Stroke Program Early CT Score≤9 (aOR, 0.37; 95 % CI, 0.18–0.76), and cardiogenic embolism (aOR, 0.36; 95 % CI, 0.14–0.97). ConclusionTirofiban combined with intravenous thrombolysis in patients with acute large vessel occlusion may be safe. Further studies need to confirm the effectiveness of tirofiban after intravenous thrombolysis in different stroke etiology.

The use of a pre-hospital questionnaire expedited the acute management of patients with ischemic stroke in a comprehensive stroke center

BackgroundDelays in intravenous thrombolysis (IVT) treatment for acute ischemic stroke decrease the benefit of treatment. Difficulties determining a patient's clinical eligibility for IVT is a frequent cause of treatment delays. ObjectiveWe aimed to assess the effectiveness of the "PROVIDENCE" datasheet, a pre- hospital assessment of contraindications for IVT use applied by emergency medical services personnel. MethodsWe performed a single-center cohort study comparing IVT decision and treatment times between patients with PROVIDENCE datasheets and those without. Patients were eligible if they were over 18 years old and presented to our comprehensive stroke center from the field with stroke-like symptoms with onset within 4.5 hours. ResultsWe identified 465 records and included 166 records in our final analysis (54 in the study group and 112 in the control group). A subgroup of 85 patients received IVT (30 in the study group patients and 55 in the control group). The PROVIDENCE datasheet was associated with a faster median time by five minutes from the patient's initial presentation at the emergency department to the final decision regarding IVT eligibility (p = 0.032) and a faster time between the first encounter with a neurology provider and the decision regarding IVT administration by six minutes (p = 0.002) for the entire sample. In the subgroup that received IVT, the PROVIDENCE datasheet decreased the median decision time by seven minutes (p = 0.044) There was no significant difference in door-to-needle times between groups. ConclusionUsing the PROVIDENCE datasheet, first responders can quickly identify potential contraindications for IVT treatment in patients with stroke-like symptoms. This tool expedited decision-making and led to faster IVT administration process at a comprehensive stroke center.

The prognostic value of combined uric acid and neutrophil-to-lymphocyte ratio in acute ischemic stroke patients treated with intravenous thrombolysis

BackgroundSerum uric acid (UA) and the neutrophil-to-lymphocyte ratio (NLR) have been reported to be associated with outcomes in acute ischemic stroke (AIS). However, whether UA is related to the prognosis of AIS patients undergoing intravenous thrombolysis (IVT) remains inconclusive. We sought to explore the combined effect of UA and NLR on the prognosis of AIS treated with IVT.MethodsA total of 555 AIS patients receiving IVT treatment were enrolled. Patients were categorized into four groups according to the levels of UA and NLR: LNNU (low NLR and normal UA), LNHU (low NLR and high UA), HNNU (high NLR and normal UA), and HNHU (high NLR and high UA). Multivariable logistic regression analysis was used to evaluate the value of serum UA level and NLR in predicting prognosis. The primary outcomes were major disability (modified Rankin scale (mRS) score 3–5) and death within 3 months.ResultsAfter multivariate adjustment, a high NLR (≥ 3.94) increased the risk of 3-month death or major disability (OR, 2.23; 95% CI, 1.42 to 3.55, p < 0.001). However, there was no statistically significant association between a high UA level (≥ 313.00 µmol/L) and clinical outcome. HNHU was associated with a 5.09-fold increase in the risk of death (OR, 5.09; 95% CI, 1.31–19.83; P value = 0.019) and a 1.98-fold increase in the risk of major disability (OR, 1.98; 95% CI 1.07–3.68; P value = 0.030) in comparison to LNNU.ConclusionsHigh serum UA levels combined with high NLR were independently associated with 3-month death and major disability in AIS patients after IVT.

Direct Medical Cost for Acute Ischemic Stroke Patients in Vietnam

Ischemic stroke is one of the leading causes of global disease burden. Vietnam, among other low- and middle-income countries, bears nearly 90% of the ischemic stroke burden. This study was a cost-of-illness study conducted from the healthcare system perspective to estimate the direct medical costs and associated factors for acute ischemic stroke patients at Bach Mai Hospital, a major hospital in Hanoi, Vietnam. A total of 500 eligible patients with acute ischemic stroke at the Neurology Department of Bach Mai Hospital from July 2021 to December 2021 were included. Patient characteristics and treatment information were collected via medical records and patient interviews. The majority of the patients were men (65.8%), with a mean age of 65.3 years. The average direct medical cost per patient was 10.5 ± 7.3 million Vietnam Dong (~454.2 ± 313.8 US dollars). The cost of hospital beds accounted for most of the total cost (34.6%), followed by medications and infusion fluid costs (27%) and diagnostic imaging (12.6%). Factors significantly associated with higher direct medical costs were the duration of stay, stroke severity, complications, number of comorbidities, and intravenous thrombolysis treatment. The study highlighted the need for a reduction in the duration of hospital stay and an improvement in onset-to-hospital arrival time.

Combined intravenous and intra-arterial thrombolysis in hyperacute cerebral ischemia without significant corresponding vascular occlusion/stenosis: A Preliminary investigation

ObjectiveIn this study, we assessed the efficacy and safety of various thrombolytic treatment protocols in patients with hyperacute cerebral infarction. MethodsPatients diagnosed with acute ischemic stroke within 6 h of symptom onset and with brain computer tomography angiography confirming the absence of major vessel stenosis or occlusion were eligible for this study. The enrolled patients were subsequently randomized into two groups: all the groups received the standard intravenous thrombolysis treatment with rt-PA (0.9 mg/kg), and the experimental group underwent sequential intra-arterial thrombolysis treatment with alteplase (0.3 mg/kg, with a maximum dose of 22 mg), administered directly into the target vessel via a microcatheter. Both groups were closely monitored for changes in their National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin scale score, hemorrhage rate, all-cause mortality rate, and the rate of favorable outcomes at 90 ± 7 days. ResultsNinety-four participants were enrolled in this study, with both the control and experimental groups initiating intravenous injection of rt-PA at a median time of 29 min. For the experimental group, the median time for arterial puncture was 123 min. Baseline data for both groups were similar (P > 0.05). Hemorrhagic transformation occurred in 24.47 % (23 patients), with a lower intracranial hemorrhage rate observed in the experimental group compared to the control group (15.2 % vs 33.3 %, P < 0.05). Asymptomatic hemorrhage rates were 8.7 % for the experimental group and 12.5 % for the control group, with no hemorrhage detected in other locations. Post-treatment median NIHSS scores were lower in the experimental group than in the control group (7 vs 9, P < 0.05), but short-term NIHSS scores were similar (P > 0.05). A higher proportion of patients in the experimental group achieved favorable outcomes compared to the control group (87.0 % vs 43.8 %, P < 0.05). ConclusionIn patients with acute ischemic stroke with an onset time of ≤6 h and no major intracranial vessel occlusion, combining rt-PA intravenous thrombolysis with intra-arterial thrombolysis via a microcatheter might yield superior functional outcomes.

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.

Impact of dementia status on intravenous thrombolysis and endovascular treatment for acute ischemic stroke: Retrospective study

IntroductionIndividuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia. MethodA retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching. ResultsAltogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes. DiscussionOur results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care.

Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial

Background Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients’ performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown. Objective To investigate the effect of EM on AIS treated with IVT or MT.| Methods We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge. Main Outcomes Measures The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center. Results Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.

RE-OPEN: Randomised trial of biosimilar TNK versus TPA during endovascular therapy for acute ischaemic stroke due to large vessel occlusions

RationaleRapid and timely treatment with intravenous thrombolysis and endovascular treatment (EVT) in patients with acute ischaemic stroke (AIS) and large vessel occlusion (LVO) significantly improves patient outcomes. Bridging therapy is...