Intravenous Thrombolytic Therapy Research Articles

Intravenous thrombolysis versus dual antiplatelet therapy for patients with acute minor ischaemic stroke: a systematic review and meta-analysis.

The efficacy of intravenous thrombolysis (IVT) in patients with acute minor ischaemic stroke (AMIS) remains unclear. We performed a meta-analysis to compare the efficacy and safety of IVT and dual antiplatelet therapy (DAPT) in patients with AMIS. The Embase, Cochrane Library, PubMed, and Web of Science databases were searched up to 10 October, 2023. Prospective and retrospective studies comparing the clinical outcomes of IVT and DAPT were included. Odds ratios (ORs) and 95% confidence intervals (CIs) for early neurological deterioration (END), excellent and favourable functional outcomes, recurrent ischaemic stroke at 3months, mortality at 3months, and symptomatic intracranial haemorrhage (ICH) were pooled using a random-effects model. Of the five included studies, 6,340 patients were included. In patients with AMIS, IVT was not significantly associated with excellent and favourable functional outcomes, recurrent ischaemic stroke, or all-cause mortality at 3months compared to early DAPT. However, a higher risk of symptomatic ICH (OR, 9.31; 95% CI, 3.39-25.57) and END (OR, 2.75; 95% CI, 1.76-4.30) were observed with IVT. This meta-analysis indicated that IVT was not superior to DAPT in patients with AMIS, especially in those with nondisabling AIS. However, these findings should be interpreted with caution and have some limitations. Further, well-designed randomised controlled trials are warranted.

Meta-analysis of clinical and safety profiles after reperfusion therapy in acute posterior circulation strokes: insights and implications.

Posterior circulation stroke (PCS) accounts for approximately 20% of all acute ischemic strokes. The optimal reperfusion therapy for PCS management remains uncertain. To evaluate the prevalence and outcomes of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and bridging therapy in PCS patients. We conducted a meta-analysis of 19 studies examining reperfusion therapy outcomes in PCS patients, including 9765 individuals. We pooled prevalence data and assessed associations between reperfusion therapies and clinical, safety, and recanalization outcomes using random-effects models. The pooled prevalence of reperfusion therapies post-acute PCS was 39% for IVT, 54% for EVT, and 48% for bridging therapy. EVT was associated with significantly higher odds of favorable functional outcomes (modified Rankin Score [mRS] 0-3) at 90 days compared to standard medical therapy (odds ratio [OR] = 5.68; 95% confidence interval [CI]=2.07-15.59; P = 0.001). Conversely, bridging therapy was linked to reduced odds of favorable functional outcomes at 90 days compared to EVT (OR = 0.35; 95% CI=0.26-0.47; P < 0.001). Bridging therapy was also significantly associated with lower odds of good functional outcomes (mRS 0-2) (OR = 0.25; 95% CI=0.11-0.54; P < 0.001), reduced risk of symptomatic intracranial hemorrhage (OR = 0.26; 95% CI=0.07-0.68; P = 0.009), lower mortality (OR = 0.13; 95% CI=0.04-0.44; P = 0.001), and less successful recanalization (OR = 0.35; 95% CI=0.13-0.94; P = 0.038) relative to EVT. Our meta-analysis underscores the favorable outcomes associated with EVT in PCS cases. With notable reperfusion rates, understanding factors influencing PCS outcomes can inform patient selection and prognostic considerations.

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

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

Predictive value of monocyte-to-high-density lipoprotein-cholesterol ratio (MHR) for poor prognosis after intravenous thrombolytic therapy for acute ischaemic stroke

IntroductionThe purpose of this study was to examine the relationship between monocyte-to-high-density lipoprotein-cholesterol ratio (MHR) and poor short-term 3-month and long-term 6-month prognosis after intravenous thrombolysis in patients with acute ischaemic stroke.Material and methodsBy retrospective analysis, 763 eligible patients with acute ischaemic stroke with intravenous thrombolysis were included in the study, and the general data and clinical laboratory examination results of the patients were collected. The relationship between MHR and poor prognosis at 3 and 6 months in patients with intravenous thrombolysis was derived by stepwise regression using the R language, followed by 1:1 propensity score matching to determine the MHR threshold and to investigate the relationship between high and low MHR values and poor prognosis.ResultsMHR level was found to predict the prognosis of intravenous thrombolysis patients with acute ischaemic stroke, and it was an effective predictor of poor prognosis at 3 and 6 months after intravenous thrombolysis. MHR has a threshold of 0.584. High MHR levels were strongly associated with a poor 3-month prognosis of intravenous thrombolysis in patients with acute ischaemic stroke (OR = 5.657; 95% CI: 4.124–7.762; p &lt; 0.001). High MHR level was closely associated with poor prognosis of acute ischaemic stroke patients with intravenous thrombolysis at 6 months (OR = 4.923; 95% CI: 3.603–6.726; p &lt; 0.001).ConclusionsMHR level is a valid predictor for poor prognosis at 3-6 months after intravenous thrombolysis in patients in acute ischaemic stroke.

Reperfusion therapies in patients with acute ischaemic stroke and atrial fibrillation: data on safety and effectiveness from a multi-centre cohort study.

Intravenous thrombolysis (IVT) and/or endovascular therapy (EVT) are currently considered best practices in acute stroke patients. Data regarding the efficacy and safety of reperfusion therapies in patients with atrial fibrillation (AF) are conflicting as regards haemorrhagic transformation, mortality, and functional outcome. This study sought to investigate for any differences, in terms of safety and effectiveness, between AF patients with acute ischaemic stroke (AIS) treated and untreated with reperfusion therapies. Data from two multicenter cohort studies (RAF and RAF-NOACs) on consecutive patients with AF and AIS were analyzed to compare patients treated and not treated with reperfusion therapies (IVT and/or EVT). Multivariable logistic regression analysis was performed to identify independent predictors for outcome events: 90-day good functional outcome and mortality. A propensity score matching (PSM) analysis compared treated and untreated patients. Overall, 441 (25.4%) were included in the reperfusion-treated group and 1,295 (74.6%) in the untreated group. The multivariable model suggested that reperfusion therapies were significantly associated with good functional outcome. Rates of mortality and disability were higher in patients not treated, especially in the case of higher NIHSS scores. In the PSM comparison, 173/250 patients (69.2%) who had received reperfusion therapies had good functional outcome at 90days, compared to 146/250 (58.4%) untreated patients (p = 0.009, OR: 1.60, 95% CI:1.11-2.31). Patients with AF and AIS treated with reperfusion therapies had a significantly higher rate of good functional outcome and lower rates of mortality compared to those patients with AF and AIS who had undergone conservative treatment.

Thrombus extraction in acute ischemic stroke: three years of experience at the regional vascular center

From a modern perspective, the key to successful treatment of ischemic stroke is early reperfusion with systemic thrombolytic therapy and thrombus extraction. Thrombectomy is the only reliable method of recanalization in patients with thrombosis of a large cerebral artery. Despite the fact that thrombus extraction has proven its effectiveness in the treatment of acute ischemic stroke in a number of large randomized trials, there are still issues that have not been fully studied, on which there are controversial opinions among specialists. For instance, there is different information about whether direct thrombectomy or thrombus extraction after systemic thrombolysis is more effective and safer. Moreover, in accordance with modern procedures for providing care to patients with acute cerebral circulatory disorders, patients admitted in the «therapeutic window» should receive intravenous thrombolytic therapy even if thrombectomy is planned. Based on the analysis of 164 thrombus extractions in patients with acute ischemic stroke admitted to the regional vascular center in 2020–2023, the results of direct thrombus extraction and staged reperfusion (systemic thrombolytic therapy + thrombectomy) were compared. It has been found that compared to direct thrombus extraction, staged reperfusion provides more frequent achievement of 2b-3 recanalization (71.83 % and 78.49 %, respectively), accompanied by lower mortality (45 % and 23.66 %, respectively) and more frequent achievement of Rankin 0–2 functional status at the time of discharge (48.72 % and 61.96 %, respectively). The worst results were observed among patients with vascular occlusion in the vertebrobasilar basin, at TICI 0-2a and the age of patients over 80 years.

Acute ischemic stroke with a diagnosis of Marfan syndrome: A report of 3 cases in multifaceted settings.

Marfan syndrome (MFS), which is a dominantly inherited connective tissue disease resulting from a mutation in the FBN1 gene, exhibits variable manifestations affecting the cardiovascular, musculoskeletal, ophthalmologic, and pulmonary systems. Notably, neurologic deficiency, which involves ischemic or hemorrhagic stroke, is a rare but severe manifestation. The safety of rt-PA treatment for ischemic stroke caused by MFS is still under discussion. In the current report, we discuss 3 atypical MFS cases presented as acute ischemic stroke, compared to those exhibiting cardiovascular and musculoskeletal abnormalities. Three patients were diagnosed with acute ischemic stroke accompanied by MFS based on clinical manifestations, imaging examinations, and genetic testings. The first case underwent intravenous thrombolytic therapy with rt-PA, the second case received antiplatelet therapy, and the third case received anticoagulant therapy and perfusion therapy. The neurologic deficiency of all three patients showed improvement upon discharge, and there were no symptoms of recurrence observed during the follow-up period. MFS is a rare etiology in young people with embolic stroke of undetermined source. Physicians should take MFS into consideration when they observe the characteristic symptoms during a consultation. The potential pathogenesis of ischemic stroke secondary to MFS may include cardio-embolism, arterial dissection, and hypoperfusion. Although intravenous thrombolysis is a promising therapy to treat acute ischemic stroke, further examinations should be conducted to rule out contraindications in patients with a suspicion of MFS.

Comparison of radiological and clinical characteristics of COVID-19 positive and negative ischemic stroke patients undergoing revascularization: A single-centre Turkish study

ObjectiveWe aimed to compare the radiological and clinical characteristics of COVID-19-positive and -negative acute ischemic stroke (AIS) patients who underwent revascularization and to evaluate whether COVID-19 has an effect on revascularization and outcome in AIS patients with COVID-19 infection. MethodsConsecutive COVID-19 positive and negative AIS patients who underwent intravenous thrombolysis and/or endovascular therapy in our hospital between March 2020 and February 2022 were included in this study. Our study is retrospective and 23 COVID-19 positive patients and 108 COVID-19 negative patients were compared in terms of radiological and clinical characteristics. ResultsHypertension was lower in the COVID-19 positive ischemic stroke group (p=0.029). Admission NIHSS score was higher in COVID-19 positive patients (p=0.041). ASPECTS was found to be lower in COVID-19 positive ischemic stroke patients (p=0.019). The rate of hyperdense artery sign differed between groups (p=0.014) and was higher in the COVID-19 positive ischemic stroke group. The incidence of multi-vessel occlusion was found to be significantly higher in the COVID-19-positive ischemic stroke group (p=0.002). In terms of prognostic features, only the 3-month good outcome rate was statistically significantly lower in the COVID-19-positive ischemic stroke group (p=0.011). ConclusionThis study found that radiologically, COVID-19 may be associated with lower ASPECTS in ischemic stroke patients receiving revascularization treatment and may predispose to multivessel occlusion and hyperdense artery sign. Clinically, COVID-19 may be associated with a more severe initial presentation and worse prognosis at 3 months in ischemic stroke patients undergoing revascularization, but may not affect long-term mortality.

Analysis of Safety and Efficacy of the Early Initiation of Antithrombotic Secondary Prevention in Patients Treated with Intravenous Thrombolysis for Acute Ischemic Stroke.

Background and Objectives: Current guidelines and the alteplase product insert recommend that antithrombotic therapy be avoided within 24 h of intravenous thrombolytic therapy with rt-PA in acute ischemic stroke. Therefore, the rate of stroke recurrence is unclear in terms of early neurological deterioration, which we could prevent with the early administration of antithrombotic therapy. We do not know the effect of early antithrombotic therapy after intravenous thrombolysis with rt-PA in acute stroke on the outcome in patients after 90 days either. Design: Prospective monocentric observational cohort study. Methods: Data were collected from consecutive patients treated with alteplase for acute ischemic stroke between January 2015 and January 2023. We examined functional outcome at 90 days, including the risk of symptomatic intracranial hemorrhage and mortality rate as safety indicators and stroke recurrence events in both early and standard antithrombotic therapy at 24 h after intravenous thrombolysis. Results: A total of 489 patients were included, of which 278 (56.9%) were men. Of these, 407 (83.2%) patients received early antithrombotic therapy. No symptomatic intracranial hemorrhage occurred in any participants. There was a significantly higher number of patients with an excellent outcome (mRS 0-1) in early antithrombotic treatment (211 (53.1%) versus 28 (34.6%) in standard antithrombotic treatment (p = 0.002, OR 0.47, 95% CI: 0.28-0.76). Conclusions: Early antithrombotic treatment after intravenous therapy in patients with acute ischemic stroke revealed no safety concerns compared with standard antithrombotic therapy and resulted in a significantly higher proportion of patients with an excellent functional outcome.

Correlations of 2 Novel Inflammation Indexes With the Risk for Early Neurological Deterioration in Acute Ischemic Stroke Patients After Intravenous Thrombolytic Therapy.

Elevation of the systemic immune inflammation (SII) index and system inflammation response index (SIRI) is known to be associated with higher risk of stroke and all-cause death. However, no study has reported their correlation with early neurological deterioration (END) following recombinant tissue-type plasminogen activator (IV-rtPA) in acute ischemic stroke patients. The aim of this study was to explore the correlation of SII and SIRI with the risk of END after IV-rtPA. Included in this study were 466 consecutive patients treated with IV-rtPA. SII and SIRI were calculated according to blood cell counts before IV-rtPA. Patients were divided into 3 groups based on trisectional quantiles according to SII and SIRI values. The risk of END was assessed by multivariate regression. The overall discriminative ability of SII and SIRI in predicting END was assessed by receiver operating characteristic curve analysis. Of the 466 included patients, 62 (13.3%) were identified as having END. Compared with the first tertile of SII, multivariable regression analysis demonstrated that patients were more likely to have END (odds ratio 2.54; 95% CI: 1.23-5.23) and poor outcome at 90 days (odds ratio 2.02; 95% CI: 1.06-3.86) in third tertile after adjustment for potential confounders. In addition, a cutoff value of 591.63 for SII was detected in predicting post-thrombolysis END with a sensitivity of 58.1% and a specificity of 64.6% (area under the curve 0.61; 95% CI: 0.54-0.69). Higher SII but not SIRI may prove to be a predictor for high risk of END and a poor functional outcome at 90 days after IV-rtPA.

Impaired endogenous fibrinolysis status: a potential prognostic predictor in ischemic stroke.

Stroke confers a severe global healthcare burden, hence exploring risk factors for stroke occurrence and prognosis is important for stroke prevention and post-stroke management strategies. Endogenous fibrinolysis is a spontaneous physiological protective mechanism that dissolves thrombus to maintain vascular patency. Recently, impaired endogenous fibrinolysis has been considered as a potential novel cardiovascular risk factor, but its link with ischaemic stroke in the past has been underappreciated. In this review, we summarize the latest mechanisms of endogenous fibrinolysis, review the current evidence and data on endogenous fibrinolysis in ischemic stroke. It includes the structure of thrombus in ischemic stroke patients, the effect of fibrin structure on the endogenous fibrinolytic efficiency, and the association between intravenous thrombolytic therapy and endogenous fibrinolysis in ischemic stroke. It also includes the single factors (tissue plasminogen activator, urokinase plasminogen activator, plasminogen activator inhibitor-1, thrombin activatable fibrinolysis inhibitor, complement component 3, complement component 5, alpha-2-antiplasmin, plasmin-alpha-2-antiplasmin complex, and lipoprotein[a]), and the global assessments of endogenous fibrinolysis status (thromboelastography, rotational thromboelastometry, and global thrombosis test), and their potential as predictors to identify occurrence or unfavorable functional outcomes of ischemic stroke. All of these assessments present advantages and limitations, and we suggest that the global thrombosis test may be more appropriate for detecting impaired endogenous fibrinolysis status in ischemic stroke patients.

Abstract 1158: Antiplatelet Therapy Versus Intravenous Thrombolysis For Mild Nondisabling Acute Ischemic Stroke: A Living Systematic Review And Meta-analysis

Background: Previous studies have shown contradictory results between early application of antiplatelet therapy and intravenous thrombolysis (IVT) for mild nondisabling (defined as NIHSS score of 0 to 5) acute ischemic stroke (AIS). Objective: To compare the benefits and risks of antiplatelet therapy and IVT in patients with mild nondisabling AIS. Methods: A systematic search of MEDLINE, Embase, and Cochrane Library was conducted from database inception until July 26, 2023, without language restriction. Randomized clinical trials (RCTs) or observational studies were selected. The primary outcomes were 90-day functional outcomes, measured by the modified Rankin Scale (mRS) score. The protocol has been registered before data collection (PROSPERO CRD42023447862). Results: Two RCTs and four observational studies with relatively low risk of bias that enrolled 3975 patients were analyzed (2454 in antiplatelet therapy and 1521 in IVT therapy). There were no significant differences between antiplatelet therapy and IVT in 90-day functional outcomes (mRS 0-1, odds ratio [OR], 1.08 [95% CI, 0.73-1.58]; mRS 0-2, OR, 1.04 [95% CI, 0.63-1.73]), death (OR, 0.64 [95% CI, 0.19-2.13]), and stroke recurrence (OR, 0.71 [95% CI, 0.28-1.79]). Antiplatelet therapy was associated with a reduced risk of sICH compared with IVT (OR, 0.20 [95% CI, 0.06-0.69]). Conclusions: Among patients with mild nondisabling AIS, compared with IVT, early application of antiplatelet therapy was not significantly associated with improved functional outcomes, reduced mortality, or stroke recurrence, but was significantly associated with a reduced risk of sICH. Regular updates will provide the best available evidence as new researches are published.

Cross‐Sectional Imaging Modalities in Correlation to the Thrombolysis in Cerebral Infarction Score: The Next Frontier in Adjunctive Endovascular Stroke Therapy

The expanded Thrombolysis in Cerebral Infarction (eTICI) scale is the default method to measure reperfusion success of endovascular treatment for acute ischemic stroke. It is an estimate of the percentage of the vascular territory affected by the initial occlusion, or target downstream territory (TDT), that is reperfused after the intervention. Traditionally, the size of the TDT is determined on the preinterventional catheter angiography images by delineating the antegrade capillary deficit caused by the catheter angiography target occlusion. As such, the current definition of eTICI grading is only suitable to estimate the efficacy of reperfusion strategies occurring after the baseline catheter angiogram. However, reperfusion therapy for acute ischemic stroke due to large vessel occlusion often encompasses intravenous thrombolysis therapy started prior to endovascular treatment but after cross‐sectional vascular imaging (computed tomography or magnetic resonance imaging) used to determine eligibility for endovascular treatment. The inherent shortcomings of the current eTICI scale to quantify preinterventional perfusion changes are discussed. We then argue that depending on the timing of the studied intervention – either between cross‐sectional imaging and endovascular treatment or after first intracranial catheter angiography – the TDT used to determine the eTICI grade should be based on the occlusion as seen on admission cross‐sectional vascular imaging or prethrombectomy catheter angiography, respectively. We propose a new conceptual framework to grade reperfusion based on the TDT derived from the occlusion seen on cross‐sectional vascular imaging: the cross‐sectional eTICI. Last, we discuss how this definition of the TDT more reliably measures preinterventional reperfusion and establishes homogenous definitions of embolization and infarctions in new territories.

Analysis of the effect of comprehensive physical and mental nursing for patients with acute cerebral infarction in intravenous thrombolytic therapy.

To evaluate the efficacy of comprehensive physical and mental nursing for patients with acute cerebral infarction (ACI) undergoing intravenous thrombolytic therapy and its impact on patients' quality of life and psychological state. A total of 200 patients with ACI, admitted to our hospital between December 2018 and December 2019, were included in the study. They were randomly assigned to either the control group or the experimental group using a random number table. The control group received routine care (basic care such as monitoring vital signs, assisting with daily activities, administering medications, and providing comfort measures), while the experimental group received comprehensive physical and mental nursing (physical care, phsycological surpport, education and conceling). Various parameters including quality of life index (QLI) scores, mental status scale in non-psychiatric settings (MSSNS) scores, self-rating anxiety scale (SAS) scores, self-rating depression scale (SDS) scores, National Institute of Health Stroke Scale (NIHSS) scores, changes in hemodynamic indicators, and incidence of adverse events during intravenous thrombolysis were compared between the two groups. The experimental group had higher QLI scores and lower MSSNS, SAS, SDS, and NIHSS scores compared to the control group (p = 0.33, 0.22, 0.35, 0.26, 0.042). The experimental group also exhibited a lower incidence of adverse reactions during intravenous thrombolysis (p = 0.02). Comprehensive physical and mental nursing for patients with ACI undergoing intravenous thrombolysis improves nursing efficacy, nursing satisfaction, quality of life, and patients' psychological state. These findings highlight the importance of implementing holistic nursing interventions to optimize patient outcomes in ACI management.

Thrombolysis treatment and multi- disciplinary management of central retinal artery occlusion in comparison with traditional ophthalmological treatment options

<p>The management of central retinal artery occlusion (CRAO) has long been conservative therapy with limited efficacy carried out in ophthalmology departments together with etiolo&shy;gi&shy;cal investigations lacking a standardised protocol. However, CRAO is analogous to ischemic central nervous system stroke and is associated with increased stroke risk, thus, systemic thrombolysis treatment and multidisciplinary management can be beneficial. Since May 2022, at Semmelweis University CRAO patients diagnosed within 4.5 hours are given intravenous thrombolysis therapy and undergo etiologic workup based on current stroke protocols. Here we report our experience with the multidisciplinary, protocol-based management of CRAO in comparison with former non-protocol based ophthalmological conservative treatment.</p>. <p>We reviewed CRAO patients&rsquo; data treated conservatively and with paracentesis within 6 hours at the Department of Ophthalmology between 2013 and 2022 including changes in visual acuity, neurolo&shy;gical and cardiovascular findings compared to those in the thrombolysis project.&nbsp;</p>. <p>Of the 78 patients receiving non-protocol care, visual improvement was seen in 37% with natural course, 47% with conservative treatment and 47% with paracentesis. Four patients had significant carotid stenosis (2 underwent endarterectomy), 1 carotid dissection, 6 cardioembolism and 1 giant cell arteritis. Of the 4 patients within 4,5 hours, 3 gave their consent to the clinical trial and were treated with thrombolysis and underwent a full etiological assessment.&nbsp;<br>2 pa&shy;tients had improved visual acuity, 2 pa&shy;tients had significant carotid stenosis and underwent endarterectomy, 1 patient was started on anticoagulation for newly diagnosed atrial fibrillation.</p>. <p>CRAO patients presenting within 4,5 hours are rare and more patients are needed in our study to establish the efficacy of thrombolysis. However uniform protocollized evaluation helps identifying embolic sources thus, avoiding further and potentially more serious thromboembolic events.</p>.

Blood Pressure Variability in Acute Stroke: A Narrative Review.

The management of blood pressure variability (BPV) in acute stroke presents a complex challenge with profound implications for patient outcomes. This narrative review examines the role of BPV across various stages of acute stroke care, highlighting its impact on treatment strategies and prognostic considerations. In the prehospital setting, while guidelines lack specific recommendations for BP management, emerging evidence suggests a potential link between BPV and outcomes. Among ischaemic stroke patients who are ineligible for reperfusion therapies, BPV independently influences functional outcomes, emphasising the need for individualised approaches to BP control. During intravenous thrombolysis and endovascular therapy, the intricate interplay between BP levels, recanalisation status, and BPV is evident. Striking a balance between aggressive BP lowering and avoiding hypoperfusion-related complications is essential. Intracerebral haemorrhage management is further complicated by BPV, which emerges as a predictor of mortality and disability, necessitating nuanced BP management strategies. Finally, among patients with acute subarachnoid haemorrhage, increased BPV may be correlated with a rebleeding risk and worse outcomes, emphasizing the need for BPV monitoring in this population. Integration of BPV assessment into clinical practice and research protocols is crucial for refining treatment strategies that are tailored to individual patient needs. Future studies should explore novel interventions targeting BPV modulation to optimise stroke care outcomes.

Safety and Feasibility of a “Fast‐Track” Monitoring Protocol for Patients Treated With Intravenous Thrombolytic Therapy

Background Our health care systems continue to face significant strain due to chronically taxed intensive care resources. A subgroup of patients following thrombolytic stroke may not require prolonged intensive monitoring, alleviating some burden. Here, we describe the safety, feasibility, and utility of a Fast‐Track Protocol (FTP) for early deescalation of high‐acuity monitoring. Methods We compared a prospective cohort of patients on the FTP at our stroke centers from April 2020 to February 2022 to a similar retrospective cohort. Those who presented with a National Institutes of Health Stroke Scale &lt;10 and without large‐vessel occlusion or flow‐limiting stenosis, intravenous antihypertensive use, and any hemodynamic or respiratory concerns were eligible. Primary outcomes included early neurologic deterioration, defined as worsening of National Institutes of Health Stroke Scale score of ≥4 points at 24 hours, parenchymal hemorrhage, and symptomatic intracranial hemorrhage. Results Of 574 patients undergoing thrombolysis, 119 (21%) were eligible for the FTP. A total of 100 (88%) were included for analysis. The median±interquartile range hospitalization was 2.0±1.6 days. None of the 4 cases of early neurologic deterioration were due to hemorrhage. No symptomatic intracranial hemorrhages occurred, and no patients on the FTP were transferred back to the intensive care unit. Median±interquartile range 90‐day modified Rankin scale score was 1±1. Conclusion FTP is a safe and feasible strategy to triage intensive care unit patients and decrease unnecessary intensive care unit monitoring. This is important in a postpandemic era as intensive care unit resources continue to fluctuate. Future studies are needed to establish the optimal level of monitoring in patients following thrombolysis.

The systemic inflammation score is a prognostic factor for patients with ischemic stroke who have not undergone intravenous thrombolysis or endovascular thrombectomy therapy

BackgroundThe systemic inflammation score (SIS) has been utilised as a representative biomarker for evaluating nutritional and inflammation status. However, the predictive value of SIS has not been reported in patients with acute ischemic stroke (AIS). We aimed to evaluate whether SIS is associated with prognosis in stroke. MethodsA total of 4801 patients with AIS were included in the study. The primary outcome was a modified Rankin Scale score>2 at the 3-month follow-up. A total of 4801 patients were randomly allocated into training (n=3361) and validation cohorts (n=1440) at a ratio of 7:3. Model performance was validated using the receiver operating characteristic (ROC) curve and calibration curve. Additionally, a comparison was made between the nomogram and the THRIVE score in regards to their respective predictive capabilities. ResultsOverall, 1091(32.5%) patients in the training cohort and 446 (31.0%) patients in the validation cohort experienced an unfavorable outcome. The multivariate logistic regression analysis revealed that a high SIS, age, NIHSS, diabetes and prior stroke were associated with unfavorable outcome. Our nomogram was developed based on the variables mentioned above. The area under the curve (AUC) of the training set and the validation set are 0.702 and 0.708, respectively, indicating that the model has modest agreement and discrimination. The results of AUC, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) showed that nomogram had significantly higher predictive value than THRIVE scores (all P<0.001). However, unlike the THRIVE publication, all patients who had undergone intravenous thrombolysis or endovascular thrombectomy therapy were excluded in our study. In consequence, our derived THRIVE scores cannot be compared to those in the original THRIVE study. ConclusionThe SIS exhibits potential as a simple prognostic biomarker, and the nomogram, which utilizes the SIS, may serve as a valuable tool for clinicians in the early identification of patients at heightened risk for unfavorable outcomes.

Association between baseline hemoglobin level and early neurological deterioration after intravenous thrombolysis in patients with acute ischemic stroke.

To investigate the association between baseline hemoglobin level and early neurologic deterioration (END) after intravenous thrombolysis in patients with acute ischemic stroke (AIS). Data of AIS patients who received intravenous thrombolytic therapy at multiple hospitals across the country between January 2017 and July 2020 were collected from the online database Acute Stroke Patients for Stroke Management Quality Evaluation (CASE-Ⅱ, NCT04487340). Binary logistic regression analysis was used to study the factors affecting the occurrence of END after intravenous thrombolytic therapy, and the correlation between baseline hemoglobin level and END was investigated by limiting cubic spline curve analysis. A total of 8162 patients were included. Patients with END had lower baseline hemoglobin levels (136 and 140 g/L, P<0.01) and higher rates of anemia (24.2% and 16.9%, P<0.01) compared with non-END patients. Binary logistic regression analysis showed that baseline hemoglobin level (OR=0.995, 95%CI: 0.991-0.999, P<0.05) and anemia (OR=1.238, 95%CI: 1.055-1.454, P<0.01) were independently correlated with the occurrence of END after intravenous thrombolysis in AIS patients. Restricted cubic spline regression showed that there was a U-shaped relationship between hemoglobin level and the risk of END after intravenous thrombolysis in AIS patients (P<0.01), although this relationship was only significant in male patients (P<0.05) and not in female patients (P>0.05). There is a correlation between baseline hemoglobin level and the risk of END in AIS patients after intravenous thrombolysis, especially in male patients, in whom both lower and higher hemoglobin level may increase the risk of END.

Abstract WP179: Clinical Outcomes in Acute Stroke in Patients Undergoing Emergency Intracranial Stenting Receiving IV Thrombolysis

Background: Stent-retriever thrombectomy is the first-line therapy for acute stroke with intracranial large vessel occlusion. In cases of stent-retriever thrombectomy failure, rescue stent angioplasty might be the sole option for achieving permanent recanalization. This study aims to evaluate the safety of combined intracranial vessel stent placement and thrombolysis. Methods: We conducted a retrospective analysis of patients with large vessel occlusion who underwent rescue stent angioplasty after stent-retriever thrombectomy between 2012 and 2023 in 8 neurovascular centers. We defined two binary outcomes: (1) functional clinical outcome (modified Rankin Scale 0-2) and (2) early symptomatic intracerebral hemorrhage (sICH). Clinical outcomes were assessed using uni- and multivariable logistic regression models. Results: A total of 216 patients were included, with target vessels located within the anterior circulation (133; 63.4%) and posterior circulation (79; 36.6%). Among patients who underwent emergency intracranial stenting, 66 (30.6%) received intravenous thrombolytic treatment. In multivariate logistic regression analysis, adjusted for age, gender, baseline NIHSS, target vessel, time to recanalization, number of passes including, and type of antiplatelet therapy, intravenous thrombolytic therapy was not associated with symptomatic ICH (odds ratio (OR) 1.05, 95% confidence interval (CI) 0.27-4.14, p=0.9502), but it was associated with a functional clinical outcome at 90 days (OR 3.39, 95% CI 1.11-10.43, p=0.0325). Conclusions: The use of rescue stent angioplasty can be considered after unsuccessful stent-retriever thrombectomy, along with intravenous thrombolytic therapy. Patients receiving intravenous thrombolytic therapy before the procedure exhibited higher rates of good functional outcomes.