Use Of Intravenous Thrombolysis Research Articles

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 4.5hours. 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.

Persistent Inequities in Intravenous Thrombolysis for Acute Ischemic Stroke in the United States: Results From the Nationwide Inpatient Sample.

Despite its approval for acute ischemic stroke >25 years ago, intravenous thrombolysis (IVT) remains underused, with inequities by age, sex, race, ethnicity, and geography. Little is known about IVT rates by insurance status. We assessed temporal trends from 2002 to 2015 in IVT for acute ischemic stroke in the Nationwide Inpatient Sample using adjusted, survey-weighted logistic regression. We calculated odds ratios for IVT for each category in 2002 to 2008 (period 1) and 2009 to 2015 (period 2). IVT use for acute ischemic stroke increased from 1.0% in 2002 to 6.8% in 2015 (adjusted annual relative ratio, 1.15). Individuals aged ≥85 years had the most pronounced increase during 2002 to 2015 (adjusted annual relative ratio, 1.18) but were less likely to receive IVT compared with 18- to 44-year-olds in period 1 (adjusted odds ratio [aOR], 0.23) and period 2 (aOR, 0.36). Women were less likely than men to receive IVT, but the disparity narrowed over time (period 1: aOR, 0.81; period 2: aOR, 0.94). Inequities in IVT resolved for Hispanic individuals in period 2 (aOR, 0.96) but not for Black individuals (period 2: aOR, 0.81). The disparity in IVT for Medicare patients, compared with privately insured patients, lessened over time (period 1: aOR, 0.59; period 2: aOR, 0.75). Patients treated in rural hospitals remained less likely to receive IVT than in urban hospitals; a more dramatic increase in urbanity widened the inequity (period 2, urban nonteaching versus rural: aOR, 2.58, period 2, urban teaching versus rural: aOR, 3.90). IVT for acute ischemic stroke increased among adults. Despite some encouraging trends, the remaining disparities highlight the need for intensified efforts at addressing inequities.

Geographic differences in pharmacotherapy patterns and outcomes of acute ischemic stroke in China

BackgroundVast economic and healthcare status discrepancies exist among regions in China, contributing to different treatment patterns. This study was aimed to investigate the current status of pharmacotherapy for acute ischemic stroke (AIS) and outcomes in China and explore the geographic variation in stroke care.MethodsThis study was a multicenter prospective registry study, which collected the data of patients with AIS from 80 hospitals in 46 cities in 2015–2017 across China. Poor functional outcome defined as a modified Rankin Scale score of 3–6 was assessed at 3 and 12 months. Multivariate logistic regression was used.ResultsAmong 9973 eligible patients, the number of receiving intravenous thrombolysis (IVT), antiplatelet agents, anticoagulants, statin and human urinary kallidinogenase was 429 (4.3%), 9363 (93.9%), 1063 (10.7%), 6828 (74.7%) and 5112 (51.2%), respectively. Multivariable analysis showed IVT use in northeastern was significantly more frequent than in eastern region (OR = 3.17, 95% CI, 2.53–3.99), while the antiplatelets agents use were less frequent (OR = 0.46, 95%CI: 0.38–0.57). The proportions of poor outcomes at 3 and 12 months were 20.7% and 15.8%, respectively. Multivariate analysis showed AIS patients from northeastern and central region had significantly lower risk of poor outcome at month 3 and 12 than those from eastern region (all P < 0.05).ConclusionsThere was a low IVT use and a high antiplatelet agent and statin use for AIS in China. The pharmacotherapy and prognosis of AIS had variation by geographic region.Trial registrationThis study was registered with ClinicalTrials.gov (NCT02470624).

Abstract TMP92: Dementia and Cognitive Impairment in Stroke: A Systematic Review and Meta-Analysis of Reperfusion Treatment Outcomes

Background: Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) outcomes are unclear in patients with pre-stroke dementia or cognitive impairment. Although these individuals make up ~12% of acute stroke patients, they are often excluded from both stroke trials and routine care. This systematic review and meta-analysis explored reperfusion therapy outcomes in this population. Methods: Using the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines, this systematic review investigated studies on acute ischemic stroke patients with dementia or cognitive impairment treated with either IVT or EVT. Primary outcome was defined as favorable 90-day outcome (modified Rankin Scale (mRS) score 0-2). Secondary outcomes included 90-day mortality, radiographic intracranial hemorrhage (ICH) and symptomatic ICH (SICH). Results: 9 articles were included from 825 screened. 5 observational studies of IVT use in patients with (n=1078) and without dementia (n=2805) were selected for a meta-analysis. There were no significant differences in favourable 90-day mRS (adjusted OR 0.61, 95% CI 0.24 to 1.59), 90-day mortality (unadjusted OR of 1.19, 95% CI 0.86 to 1.64), ICH (unadjusted OR 1.32, 95% CI 0.79 to 2.19) and SICH (unadjusted OR of 0.94, 95% CI 0.70 to 1.25). EVT in dementia patients in one study found only increased odds of ICH (adjusted OR 1.57 95%CI 1.03 to 2.40). For patients with cognitive impairment, no significant association was found with assessed outcomes in a pooled analysis of 3 IVT studies and one EVT study found poorer 90-day mRS outcomes. Conclusions: This systematic review and meta-analysis suggests no considerable safety concerns for IVT or EVT use in patients with pre-existing dementia or cognitive impairment, compared to those without. Uncertainty remains in the efficacy of these therapies for these individuals. Rigorous, patient-caregiver informed design, and a more nuanced outcome approach are warranted for future studies. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

Impact of the pandemic and concomitant COVID-19 on the management and outcomes of middle cerebral artery strokes: a nationwide registry-based study

ObjectivesTo investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions.DesignRegistry-based study.SettingWe used the National Inpatient...

Abstract TMP44: Widening Sex Disparity in Thrombolysis Amid Worsening Stroke Care Quality in Korea

Introduction: The difference in the use of intravenous thrombolysis (IVT) between females and males has been recognized. Nevertheless, there has been a lack of comprehensive investigation into the sex disparity in South Korea, where the stroke care system has experienced a government-initiated reform recently. Method: A prospective, multicenter, nationwide stroke registry (CRCS-K) was utilized to analyze acute stroke admissions during the years 2008 to 2022. IVT candidates were defined as patients with an NIHSS score of 4 or greater and who arrived at the hospital within 4.5 hours from the time last known well. The stroke care quality was measured by the 90th percentile of door-to-needle (DTN) time for IVT. The joinpoint regression model was applied to detect changes in trends of IVT utilization among the candidates. Results: A total of 96,855 admissions, of which 43% were female, were recorded during the period. IVT candidates were identified to be 15,732 (16%). The proportion of IVT among the candidates showed an increasing trend after 2008 (Phase 1), followed by a notable decline from 2013 to 2016 (Phase 2) and no significant change afterward (Phase 3, Panel A). During Phase 2, a significant decrease in IVT utilization was observed with an annual percent change (APC) of -5.40, with a greater downward trend in females (APC, -8.71) compared to males (APC, -1.99, Panel B). The 90th percentile of DTN time improved during Phase 1 (APC, -10.28), and worsened after the year 2013 (APC, 4.82, Panel C). IVT utilization was comparable between sexes in Phase 1 (adjusted OR [95% CI], 0.88 [0.76 - 1.03]), but a significant difference was noted in Phase 2 (0.77 [0.66 - 0.91]) and in Phase 3 (0.82 [0.30 - 0.91]), after the year 2013. Conclusion: A sex disparity in the use of IVT for ischemic stroke was documented in South Korea. In line with the deterioration in the hyperacute stroke care quality, the gender disparities in the utilization of IVT were also worsening.

Abstract TP106: Intravenous Thrombolysis Door-to-Needle Times of English and Non-English Speaking Patients

Introduction: Language barriers between acute ischemic stroke patients and clinicians can create challenges in use of intravenous thrombolysis (IVT) as successful administration hinges on quick information gathering, shared decision making and consent with the patient and family. Our objectives were to compare IVT door-to-needle (DTN) times and consent between English and non-English speaking patients. Methods: We conducted a single institution retrospective chart analysis from 2018-2023 via manual data extraction of the electronic medical record to determine any disparities in quality metrics between English and non-English speakers treated with IVT. Standard time-based metrics were pulled from the AHA Get with the Guidelines registry. We included adult patients treated onsite, excluding telestroke encounters. We used standard descriptive statistics and a 2-paired t-test to compare treatment times. Results: We included 215 English speakers and 19 non-English speakers in our analysis. Consent was obtained in 92% (197/215) of English speakers and 90% (17/19) of non-English speakers, the remaining implied consent or consent was undocumented. Mean DTN times were 48.8 min and 48.2 min for English and non-English speakers, respectively, and differences were not statistically significant. Discussion: Previous studies have reported lower IVT use, longer DTN times and poorer clinical outcomes in patients who required an interpreter. However, others reported no difference in DTN times in non-English patients, attributing availability of translating services and diversity of healthcare providers. In our population, DTN times remained equally fast, but we remain unsure if our non-English speakers are appropriately consented, understanding their acute care. Future directions include improving consent documentation, and conducting qualitative interviews of English and non-English speakers who receive IVT. Our ultimate goal is to ensure quality of care for this vulnerable population.

Abstract TMP13: Prehospital Stroke Scales Are Non-Inferior to NIHSS in Prediction of Intravenous Thrombolysis Use in a Large Telestroke Network

Introduction: Recent studies report similar outcomes with antiplatelet drugs and intravenous thrombolysis (IVT) in patients with minor nondisabling ischemic stroke. These patients still meet emergent triage criteria and can increase the burden on stroke systems through prehospital stroke activation. Prehospital large vessel occlusion (LVO) scales can improve triage of LVO patients but have not been evaluated as tools to predict IVT administration. We sought to determine if common LVO scales can predict IVT use in a large academic telestroke practice. Methods: This retrospective study included all video telestroke consults performed in a large academic telestroke network from 2019-2020. Patients were excluded if they were on anticoagulation, presented beyond 4.5 hours from last known well, or family declined IVT due to goals of care. We recorded presenting NIHSS and IVT recommendations. NIHSS was used to calculate 7 LVO scales (RACE, G-FAST, FAST-ED, VAN, PASS, 3I-SS, and C-STAT). Scale performance was assessed by calculating area under curve (AUC) and compared to NIHSS total score using the DeLong test. Youden cutpoint was established for each scale and subsequently used to calculate sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. Results: A total of 513 patients were included; 205/513 (40%) were recommended IVT. Median (IQR) NIHSS was 1 (0-3) in non-IVT patients and 6 (4-11) in IVT patients. The RACE and G-FAST scales were noninferior to the NIHSS in predicting IVT recommendation (Table 1). Conclusion: The RACE and G-FAST scales may be useful triage tools to identify patients needing emergent stroke evaluation for consideration of IVT.

Abstract TP102: Pre-Hospital Obtention of Vital Information for Decision Enforcement in Cerebrovascular Emergencies: The PROVIDENCE Study

Background: Difficulties determining an acute ischemic stroke patient's eligibility for intravenous thrombolysis (IVT) treatment is a frequent cause of delays. Objective: To assess the effectiveness of the "PROVIDENCE" datasheet, a pre-assessment of contraindications for IVT use applied by emergency medical services personnel in the field. Methods: This is a quasi-experimental study to evaluate the efficacy of the PROVIDENCE datasheet used by first responders. Participants were eligible if they were over 18 years old and presented to our center from the field with stroke-like symptoms with onset within 4.5 h. Results: We identified 465 records and included 166 records in our final analysis (54 in the study group and 112 in the control group). Eighty-five of the 166 patients received IVT (30 in the study group patients and 55 in the control group). The PROVIDENCE datasheet showed a noticeable median improvement in corrected time by five minutes from the patient's initial presentation at the emergency department to the final decision regarding IVT eligibility (p = 0.032). Additionally, the time between the first encounter with a neurology provider and the decision regarding IVT administration saw a median improvement of six minutes (p = 0.002) for the entire sample. In the subgroup that received IVT, the PROVIDENCE datasheet decreased by seven minutes (p = 0.044) the median time between the first encounter by the neurology provider and the decision regarding the administration of IVT. All other comparisons were not significant. However, the PROVIDENCE datasheet decreased the door-to-needle time by 6.5 minutes compared to the control group. Conclusion: Using 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.

Hemiplegia in acute ischemic stroke: A comprehensive review of case studies and the role of intravenous thrombolysis and mechanical thrombectomy.

Acute ischemic stroke is a significant health concern worldwide, often leading to long-term disability and decreased quality of life. Rapid and appropriate treatment is crucial for achieving optimal outcomes in these patients. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are two commonly used interventions for acute ischemic stroke, but their effectiveness in improving neurological symptoms and functional outcomes in patients with hemiplegia remains uncertain. The aim of this work was to evaluate the impact of IVT and MT within a 4.5-h time frame on patients with acute ischemic stroke and hemiplegia. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies that assessed the impact of IVT and MT within 4.5-h on hemiplegia in patients with an acute ischemic strokewere included. Data were extracted and analyzed to determine the overall effects of these interventions. Most included case reports indicate positive outcomes in terms of neurological symptom improvement and functional recovery in patients with hemiplegia after receiving IVT and MT within the specified time frame. However, the heterogeneity among the patients and the limited use of IVT due to contraindications posed challenges in determining the most effective treatment option. The findings from the included studies demonstrate that both interventions led to a decrease in National Institutes of Health Stroke Scalescores, indicating an improvement in neurological symptoms. The results highlight the beneficial effects of early thrombolytic interventions and MT on the neurological status and functional outcomes of patients with an acute ischemic stroke.

Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction?

Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT. The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture. Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709). In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.

Effect of Intravenous Thrombolysis Prior to Mechanical Thrombectomy According to the Location of M1 Occlusion.

The additive effects of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remain unclear. We aimed to investigate the efficacy and safety of IVT prior to MT depending on the location of M1 occlusion. We reviewed the cases of patients who underwent MT for emergent large-vessel occlusion of the M1 segment. Baseline characteristics as well as clinical and periprocedural variables were compared according to the location of M1 occlusion (i.e., proximal and distal M1 occlusion). The main outcome was the achievement of functional independence (modified Rankin Scale score, 0-2) at 3 months after stroke. The main outcomes were compared between the proximal and distal groups based on the use of IVT before MT. Among 271 patients (proximal occlusion, 44.6%; distal occlusion, 55.4%), 33.9% (41/121) with proximal occlusion and 24.7% (37/150) with distal occlusion underwent IVT prior to MT. Largeartery atherosclerosis was more common in patients with proximal M1 occlusion; cardioembolism was more common in those with distal M1 occlusion. In patients with proximal M1 occlusion, there was no association between IVT before MT and functional independence. In contrast, there was a significant association between the use of IVT prior to MT (odds ratio=5.30, 95% confidence interval=1.56-18.05, P=0.007) and functional independence in patients with distal M1 occlusion. IVT before MT was associated with improved functional outcomes in patients with M1 occlusion, especially in those with distal M1 occlusion but not in those with proximal M1 occlusion.

Reperfusion therapies for ischemic stroke in dementia and cognitive impairment: A systematic review and meta-analysis.

Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations. Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0-2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH). Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24-1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86-1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79-2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70-1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03-2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3-6). These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis.

Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Abstract 15530: Intravenous Thrombolysis in Patients With Ischemic Stroke on Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis

Introduction: Current guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who are on direct oral anticoagulants (DOAC). However, studies found conflicting results regarding IVT safety and functional outcomes among patients receiving DOACs. Hypothesis: Herein, we aim to investigate this association through a systematic review and meta-analysis. Methods: A comprehensive literature search was performed in PubMed, Embase, Scopus, and the Web of Science. Studies were included if they compared the outcomes of patients receiving DOACs and those without recent use of DOACs. Random-effect meta-analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) for comparison of modified Rankin Score (mRS) 0-2, all-cause mortality, and symptomatic intracranial hemorrhage (sICH). Results: A total of five studies were included among which 3,408 received DOACs and 244,033 did not. Random-effect meta-analysis revealed that the functional neurological outcome (mRS 0-2) was significantly lower in patients that received DOACs (OR 0.71, 95% CI 0.62-0.81, p&lt;0.01). However, this difference was no longer significant in the subgroup analysis of 90 days mRS 0-2 (OR 0.71, 95% 0.46-1.11, p=0.14). Regarding all-cause mortality, patients on DOAC had a higher overall mortality rate (1.26, 95% CI 1.07-1.48, p=0.01). Nevertheless, this was not true for subgroups of in-hospital and 90-days mortality, which were both insignificant. Finally, sICH did not differ between the groups (OR 0.99, 95% CI 0.70-1.39, p=0.93). Conclusions: Our results demonstrated that the use of IVT in selected patients on DOACs with stroke might be beneficial and not associated with increased risk as there was no difference between the groups in terms of sICH.

Higher Procedural Volumes are Associated with Faster Treatment Times, Better Functional Outcomes, and Lower Mortality in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke.

We aimed to characterize the association of hospital procedural volumes with outcomes among acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). This was a retrospective, observational cohort study using data prospectively collected from January 1, 2016, to December 31, 2019, in the Get With The Guidelines-Stroke registry. Participants were derived from a cohort of 60,727 AIS patients treated with EVT within 24 hours at 626 hospitals. The primary cohort excluded patients with pretreatment NIHSS <6, onset-to-treatment time >6 hours, and inter-hospital transfers. There were two secondary cohorts: (1) EVT metrics cohort: excluded patients with missing data on time from door-to-arterial-puncture; (2) Intravenous thrombolysis (IVT) metrics cohort: only included patients receiving IVT ≤4.5 hours of onset. The primary cohort (mean±SD age, 70.7 ±14.8 years; 51.2% female; median [IQR] baseline NIHSS 18.0 [13-22]; IVT use, 70.2%) comprised 21,209 patients across 595 hospitals. The EVT metrics cohort and IVT metrics cohort comprised 47,262 and 16,889 patients across 408 and 601 hospitals, respectively. Higher procedural volumes were significantly associated with higher odds (expressed as adjusted odds ratio [95% confidence interval] for every 10-case-increase in volume) of discharge to home (1.03[1.02-1.04]), functional independence at discharge (1.02[1.01-1.04]), and lower rates of in-hospital mortality (0.96[0.95-0.98]). All secondary measures were also associated with procedural volumes. Among AIS patients primarily presenting to EVT capable hospitals (excluding those transferred from one facility to another and those suffering in-hospital strokes), EVT at hospitals with higher procedural volumes was associated with faster treatment times, better discharge outcomes, and lower rates of in-hospital mortality. This article is protected by copyright. All rights reserved.

Coronary Angiography Complicated by Acute Ischaemic Stroke and the Use of Thrombolysis: a Cardiology Perspective and Narrative Review of Current Literature.

Coronary angiography-associated acute ischaemic stroke (CAAIS) is an uncommon event but is associated with significant mortality and morbidity. The incidence of CAAIS has increased with a rise in the volume of coronary angiography (CA) and percutaneous coronary intervention (PCI) performed. Intravenous thrombolysis (IVT) is utilized in the general management of acute ischaemic stroke; however, it is associated with a higher risk of intracranial hemorrhage (ICH). As CA or PCI is performed more often in an aging population or high-risk patients that also carry an increased risk of ICH, it is vital to minimize additional complications from the treatment of CAAIS. This article aims to review the pathophysiological mechanisms for CAAIS, clarify the current evidence regarding IVT use in this setting, and thus assist cardiologists in the management of CAAIS. The pathophysiology for CAAIS may be different from acute ischaemic stroke in the general population. Embolic phenomena from dislodgement of calcium or other debris during manipulation of instrumentation during CA or PCI are likely mechanisms. This may contribute to altered thrombus composition, which affects the efficacy of IVT as suggested in recent studies. Furthermore, IVT in the management of CAAIS has not been evaluated specifically. The utilization of IVT should be carefully considered in CAAIS given a paucity of evidence demonstrating safety and efficacy in this setting. A multidisciplinary pathway that emphasizes the involvement of cardiologists in the treatment decision-making process would aid in thoughtful risk-benefit evaluation for IVT use in CAAIS and reduce adverse patient outcomes. Future studies to assess the impact of this pathway on CAAIS outcomes would be beneficial.

Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions (S24.003)

Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions (S24.003)

Ability of patients with acute ischemic stroke to recall given information on intravenous thrombolysis: Results of a prospective multicenter study.

Intravenous thrombolysis (IVT) is an on label treatment for selected patients with acute ischemic stroke (AIS). As major bleeding or allergic shock may occur, the need to ensure patients' informed consent for IVT is a matter of debate. Prospective investigator-initiated multi-center observational study to assess the ability of AIS patients to recall information, provided by a physician during a standardized educational talk (SET) on IVT use. The recall of 20 pre-defined items was assessed in AIS after 60-90 min (n = 93) or 23-25 h (n = 40) after SET. About 40 patients with subacute stroke, 40 non-stroke patients, and 23 relatives of AIS patients served as controls, and were surveyed 60-90 min after SET. Within 60-90 min after SET, AIS patients (median age 70 years, 31% female, median NIHSS score on admission 3 points) who were considered capable to provide informed consent recalled 55% (IQR 40%-66.7%) of the provided SET items. In multivariable linear regression analysis recapitulation by AIS patients was associated with their educational level (β = 6.497, p < 0.001), self-reported excitement level (β = 1.879, p = 0.011) and NIHSS score on admission (β = -1.186, p = 0.001). Patients with subacute stroke (70 years, 40% female, median NIHSS = 2) recalled 70% (IQR 55.7%-83.6%), non-stroke patients (75 years, 40% female) 70% (IQR 60%-78.7%), and AIS relatives (58 years, 83% female) 70% (IQR 60%-85%). Compared to subacute stroke patients, AIS patients less often recalled the frequency of IVT-related bleeding (21% vs 43%), allergic shock (15% vs 39%), and bleeding-related morbidity and mortality (44% vs 78%). AIS patients recalled 50% (IQR 42.3%-67.5%) of the provided items 23-25 h after SET. AIS patients eligible for IVT remember about half of all SET-items after 60-90 min or 23-25 h, respectively. The fact that the recapitulation of IVT-associated risks is particularly poor should be given special consideration.

Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants

International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.