Intravenous Tissue Plasminogen Activator Treatment Research Articles

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, >8.8 – ≤9.9, >9.9-≤10.8, >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 >9.9-≤10.8 compared to Groups 1 and 4. (p=0.002; p<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.

Factors predicting functional outcome after rtPA for patients with acute ischemic stroke

BackgroundAccurate outcome prediction for patients with acute ischemic stroke after intravenous recombinant tissue plasminogen activator (rtPA) treatment is essential for optimizing patients’ management. We aimed to identify factors associated with unfavorable outcomes following intravenous rtPA treatment. This study was carried out on 162 patients who presented with acute ischemic stroke within 4.5 h from onset of neurological symptoms and were eligible for intravenous rtPA. After exclusion of 48 patients, 114 patients were finally eligible for follow-up. After complete medical and neurological history, complete medical and neurological examination and brain image (CT and or MRI brain) were collected from the patients. patients eligible were included in the study. NIHS scale was assessed for all patients at time of admission, after 24 h, and follow-up for 3 months.ResultsAfter a 90-day follow-up period for 114 patients with acute ischemic stroke after rtPA, 35.8% had good outcome (MRS; 0–2), 18.5% had partial outcome (MRS; 3–4) and 12.5% had poor outcome (MRS; 5–6). Atrial fibrillation (AF), PH of stroke, stroke severity, and severity of symptom (NIHSS) score were significantly (P: 0.004, 0.001, 0.007 and 0.001) correlated with poor outcome after rtPA. Similarly, old age, high blood pressure at time of presentation, hypertension, and dyslipidemia were showed to carry poor outcome.ConclusionsAF, high NIHSS score, PH of stroke, previous stroke, hypertension, dyslipidemia, and high blood pressure on presentation were significantly correlated with poor functional outcome.

Abstract 276: CT versus MR based imaging for ischemic stroke triage: effect on workflow during contrast shortage

Introduction We assessed the feasibility and effectiveness of using magnetic resonance (MR) imaging as a substitute for computed tomography (CT) angiography and perfusion for triaging ischemic stroke patients during the national shortage of iodinated contrast medium between May 4th to July 17th 2022. Methods We compared the rates of intravenous tissue plasminogen activator treatment (IVT) and endovascular thrombectomy (EVT), changes in treatment times, and patient outcomes (defined by modified Rankin Scores (mRS) at discharge) before (4 months period) and after (3 months period) transitioning from CT angiography (CTA) and perfusion (CTP) to Fast MRI imaging. Results We analyzed 241 patients in the CT‐based group and 166 patients in the MR‐based group. EVT was performed on almost twice as many patients in the CTA/CTP group (12%) compared to the Fast MRI group (6.6%), but this difference was not statistically significant (p=0.07). Workflow processing time showed no significant difference, with similar time intervals for door‐to‐needle, door‐to‐interventioanal radiology suite, door‐to‐puncture, and door‐to‐first pass. However, the CTA/CTP group exhibited a trend towards faster overall times. Both groups had similar rates of mRS 0‐2 at discharge (41.9% vs 43%, p=0.82). Conclusion We observed a non‐significant reduction in the rate of EVT during the period of MRI substitution secondary to the iodinated contrast medium shortage, although treatment times and patient outcomes were similar.

Examination of Treatment Options According to Clinical Features and Radiological Findings in Wake-up Stroke

Aim: Wake-up stroke patients account for one-fifth of all ischemic stroke patients and they have been deprived of recanalization treatment as the onset of the stroke is not known. It has come into the focus of recent research that this treatment could be applied to particularly patients who are selected on a radiological basis. We aimed to examine clinical and demographic characteristics of wake-up strokes.
 Material and Methods: All ischemic stroke patients who presented to the emergency service throughout the night were analyzed. Patients with wake up stroke were recorded. The time of finding these patients, clinical features, treatment options and mortality status of these patients were examined. It was examined whether they received intravenous thrombolysis (IVT), endovascular therapy (EVT), or both as acute reperfusion therapy.
 Results: Age, gender, the last time when they were seen healthy, treatment start time, treatment types, clinical classification, comorbid diseases, and discharge status of 72 wake-up stroke patients were analyzed. It was found that the time of discovery of 51.4% (n=37) of the wake-up stroke patients was 06.00 am and afterwards. Of these patients, 15.3% (n=11) received intravenous tissue plasminogen activator and/or endovascular treatment. These patients’ hospital stay durations, intracerebral hemorrhage status following the procedure, NIHSS scores, angiography findings, and mortality rates were examined. Here, mortality rate was found to be significantly high especially in patients with high NIHSS score.
 Conclusion: Wake-up stroke is more common in the period close to the time of waking up in the morning. Recanylazation therapy should always be considered as an option in these patients.

Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients

IntroductionSeveral reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA. MethodsWe analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis. ResultsFive patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups. ConclusionApproximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.

Efficacy and Safety of Butylphthalide in Patients With Acute Ischemic Stroke

DL-3-n-butylphthalide (NBP) is a drug for treating acute ischemic stroke and may play a neuroprotective role by acting on multiple active targets. The efficacy of NBP in patients with acute ischemic stroke receiving reperfusion therapy remains unknown. To assess the efficacy and safety of NBP in patients with acute ischemic stroke receiving reperfusion therapy of intravenous thrombolysis and/or endovascular treatment. This multicenter, double-blind, placebo-controlled, parallel randomized clinical trial was conducted in 59 centers in China with 90-day follow-up. Of 1236 patients with acute ischemic stroke, 1216 patients 18 years and older diagnosed with acute ischemic stroke with a National Institutes of Health Stroke Scale score ranging from 4 to 25 who could start the trial drug within 6 hours from symptom onset and received either intravenous recombinant tissue plasminogen activator (rt-PA) or endovascular treatment or intravenous rt-PA bridging to endovascular treatment were enrolled, after excluding 20 patients who declined to participate or did not meet eligibility criteria. Data were collected from July 1, 2018, to May 22, 2022. Within 6 hours after symptom onset, patients were randomized to receive NBP or placebo in a 1:1 ratio. The primary efficacy outcome was the proportion of patients with a favorable outcome based on 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) thresholds of 0 to 2 points, depending on baseline stroke severity. Of 1216 enrolled patients, 827 (68.0%) were men, and the median (IQR) age was 66 (56-72) years. A total of 607 were randomly assigned to the butylphthalide group and 609 to the placebo group. A favorable functional outcome at 90 days occurred in 344 patients (56.7%) in the butylphthalide group and 268 patients (44.0%) in the placebo group (odds ratio, 1.70; 95% CI, 1.35-2.14; P < .001). Serious adverse events within 90 days occurred in 61 patients (10.1%) in the butylphthalide group and 73 patients (12.0%) in the placebo group. Among patients with acute ischemic stroke receiving intravenous thrombolysis and/or endovascular treatment, NBP was associated with a higher proportion of patients achieving a favorable functional outcome at 90 days compared with placebo. ClinicalTrials.gov Identifier: NCT03539445.

Specificity and sensitivity of the SeLECT score in predicting late seizures in patients undergoing intravenous thrombolytic treatment and the effect of diabetes mellitus and leukoaraiosis

Seizures after stroke can negatively affect the prognosis of ischemic stroke and cause a decrease in quality of life. The efficacy of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) treatment in acute ischemic stroke has been demonstrated in many studies, and IV rt-PA treatment has been increasingly used around the world. The SeLECT score is a useful score for the prediction of late seizures after stroke and includes the severity of stroke (Se), large artery atherosclerosis (L), early seizure (E), cortical involvement (C), and the territory of the middle cerebral artery (T). However, the specificity and sensitivity of the SeLECT score have not been studied in acute ischemic stroke patients that received IV rt-PA treatment. In the present study, we aimed to validate and develop the SeLECT score in acute ischemic stroke patients receiving IV rt-PA treatment. The present study included 157 patients who received IV thrombolytic treatment in our third-stage hospital. The 1-year seizure rates of the patients were detected. SeLECT scores were calculated. In our study, we found that the SeLECT score had low sensitivity but high specificity for predicting the likelihood of late seizure after stroke in patients administered IV rt-PA therapy. In addition to the SeLECT score, we found that the specificity and sensitivity were higher when we evaluated diabetes mellitus (DM) and leukoaraiosis. We found that DM was an independent risk factor for late seizures after stroke in a patient group receiving thrombolytic therapy, and late seizures after stroke were less frequent in patients with leukoaraiosis.

Abstract 90: Butylphthalide Improves Functional Outcome In Patients With Acute Ischemic Stroke Receiving Intravenous Thrombolysis And/or Endovascular Treatment In Comparison To Placebo

Introduction: Butylphthalide is a cerebro-protection drug that was originally extracted from seeds of Apium graveolens. Pre-clinical experiments have shown the cerebro-protective effect of Butylphthalide in animal models of ischemia-reperfusion. This study evaluated whether Butylphthalide can improve the functional outcome in acute ischemic stroke patients who receive intravenous recombinant tissue plasminogen activator (rt-PA) and/or endovascular treatment (EVT) compared to placebo. Methods: In the randomized, double-blinded, placebo-controlled trial, we enrolled patients with acute ischemic stroke who received intravenous rt-PA and/or EVT in 59 centers. Patients were randomized in a 1:1 ratio to receive either Butylphthalide or placebo daily for 90 days, including 14 days of intravenous injections and 76 days of oral capsules. All trial personnel and patients were masked to treatment allocation. The primary outcome was an adjusted favorable outcome at 90 days after randomization, defined as a score of 0 on the modified Rankin Scale (mRS) in patients with a baseline score of 4-7 on the National Institutes of Health Stroke Scale (NIHSS); an mRS score of 0-1 in patients with a baseline NIHSS score of 8-14; and an mRS score of 0-2 in patients with a baseline NIHSS score of 15-25. Secondary outcomes included symptomatic intracranial hemorrhage, recurrent stroke and mortality. The analysis was done in the intention-to-treat population and in subgroups of age, sex, baseline NIHSS score, hypertension, and reperfusion treatment methods. This trial is registered with ClinicalTrials.gov, NCT03539445. Results: Between July 1, 2018 and 19 February, 2022, 1216 patients were enrolled, with 607 assigned to the butylphthalide group and 609 to the placebo group. The primary outcome of a favorable outcome on day 90 occurred in 344 patients (56.7%) in the butylphthalide group and 268 patients (44.0%) in the placebo group (OR, 1.70; 95% CI, 1.35 to 2.14; P &lt;0.001). Secondary outcomes were similar between groups. There was no evidence of treatment modification effect in the subgroups. Conclusions: In conclusion, Butylphthalide improved favorable clinical outcome compared with placebo in patients with acute ischemic stroke receiving intravenous rt-PA and/or EVT.

Complete Sudden Recanalization: There Is Hope Beyond the First Pass Effect

Background In the endovascular treatment of stroke, achieving complete recanalization in a minimum number of attempts is the main procedural objective. We aimed to explore the effect of the per pass recanalization pattern in patients with final complete recanalization. Methods We analyzed all patients admitted in our center from 2014 to 2022 with a terminal internal carotid artery or M1‐middle cerebral artery occlusion who received endovascular treatment and achieved complete recanalization (expanded thrombolysis in cerebral infarction 2c–3) in our center. Complete sudden recanalization (cSR) was considered when expanded thrombolysis in cerebral infarction improved from 0–1 to 2c–3 in a single pass as opposed to complete progressive recanalization when partial recanalization (2a or 2b) was observed after interim passes. Results Among the 400 included patients with final complete recanalization, 301 (75%) showed a cSR pattern. There were no differences in baseline demographic characteristics between patients with cSR and complete progressive recanalization, including intravenous tissue plasminogen activator treatment (42.2% versus 44.4%; P =0.69). The rate of terminal carotid artery occlusion (28.6% versus 44.4%; P =0.003), median number of passes (1 [interquartile range 1—2] versus 2 [2–3]; P &lt;0.001), and time from puncture to recanalization (27 [interquartile range 18–43] versus 46 [34–66] minutes; P &lt;0.001) were lower in cSR group. At 90 days cSR was an independent predictor of good functional outcome (57.8% versus 44.4%, adjusted odds ratio 1.72 [CI 95% 1.03–2.88]; P =0.038). The rate of favorable outcome did not decrease with additional passes as long as cSR was observed (cSR after pass 1: 57.6%, after pass 2: 55.6%, after &gt;2 passes: 63.6%; P =0.825). Conclusion Among stroke patients with a large vessel occlusion, the cSR pattern predicted favorable outcome independently of the number of thrombectomy passes.

The Effect of Atrial Fibrillation on Recanalization and Prognosis in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy and/or Intravenous Thrombolysis

ABSTRACT Background: Atrial fibrillation (AF) is the most common cause of cardioembolic ischemic strokes. It causes large-vessel occlusions and a poor prognosis. Regardless of ischemic stroke etiology, hyperacute therapy strategies are effective treatment modalities. Methods: Patients who were diagnosed as having AF were classified as AF (+) and others without AF were classified as AF (-). It is not clear which treatment should be preferred in patients with stroke who are AF (+). We studied demographic characteristics, recanalization rates, and clinical outcomes in acute patients with ischemic stroke with or without nonvalvular AF who underwent hyperacute treatments. Results: We detected that clinical findings were more severe and the NIHSS scores were significantly higher at admission inpatients who were AF (+). In our study, mechanical thrombectomy rates were high in patients who were AF (+), whereas intravenous tissue plasminogen activator treatment rates were higher in patients who were AF (-). Thrombolysis in cerebral infarction scores were similar in our patient groups. We found high rates of both symptomatic (PH 2) and asymptomatic hemorrhagic transformation in patients who were AF (+) in 24th-h cranial computed tomography. A positive correlation was found between symptom-admission, symptom-needle, and symptom-groin times and discharge-modified Rankin Scale scores regardless of the hyperacute treatments in all patient groups. Conclusion: As a result, physicians should focus on the diagnosis of AF, and appropriate anticoagulant treatment is important for primary prevention.

Prognostic factors for acute large vessel occlusion with NIHSS 5 or lower.

Intravenous recombinant tissue plasminogen activator (IV rt-PA) and endovascular treatment have been performed for severe large vessel occlusion (LVO) and the results have been reported at high levels of evidence. However, acute treatment for LVO with mild symptom remains controversial. We retrospectively examined prognostic factors for LVO with mild symptoms. We studied retrospectively the patients within 24 h of onset with large vessel occlusion with NIHSS score ??5. Outcomes were evaluated by modified Rankin Scale (mRS) at 90 days, with 0?2 defined as a good outcome and 3?6 as a poor outcome. Clinical characteristics of each case were examined. Participants comprised 76 patients. Of the 76 patients. ICA occlusion showed good outcome in 17?/?19 cases (90%), whereas MCA occlusion showed good outcome in 36?/?54 cases (67%). Among the 14 cases showing positive results for distal intraarterial signal (d-IAS), outcomes were good in 6 cases (43%). On the other hand, the 32 d-IAS-negative cases showed good outcome in 28 cases (88%). Outcomes were thus significantly poorer for d-IAS-positive cases. MCA occlusion is associated with poor prognosis, even with NIHSS score ??5, and d-IAS may provide a predictor. J. Med. Invest. 70 : 22-27, February, 2023.

Predictive accuracy of an ADC map for hemorrhagic transformation in acute ischemic stroke patients after successful recanalization with endovascular therapy.

BackgroundHemorrhagic transformation (HT) of acute ischemic stroke (AIS) is associated with poor outcome. Previous studies only reported the association of mean ischemic severity or total infarct volume with HT after endovascular therapy (EVT). We aimed to investigate the predictive value of preoperative apparent diffusion coefficient (ADC) map for HT by combinated ischemic severity and corresponding volume in AIS after successful recanalization with EVT.MethodsWe retrospectively analyzed 119 consecutive cases of AIS with large vessel occlusion of anterior circulation within 24 hours after symptom onset and successful recanalization after EVT. All cases had baseline magnetic resonance imaging (MRI), follow-up computed tomography (CT), and magnetic resonance angiography (MRA) or computed tomography angiography (CTA). Volumes of ADC <0.6×10−3, 0.5×10−3, 0.4×10−3, and 0.3×10−3 mm2/s, baseline characteristics and outcomes of patients with and without HT identified by European Collaborative Acute Stroke Study (ECASS) were compared. The optimal ADC and volume threshold for predicting HT were analyzed using receiver operating characteristic (ROC) curve, and multivariate logistic regression analysis were performed with clinical characteristics and volumes of optimal ADC threshold to determine risk factors for HT.ResultsAmong 119 patients, 42 patients had HT on follow-up CT, including 24 hemorrhagic infarct (HI) cases and 18 parenchymal hematoma (PH) cases. The optimal volumes were 6.46 mL with ADC <0.4×10−3 mm2/s for predicting both HT and PH, with a larger area under curve (AUC) of 83.3% for HT than that for PH of 80%. In logistic regression analysis, intravenous tissue plasminogen activator (IV tPA) treatment, atrial fibrillation, and volume of ADC <0.4×10−3 mm2/s were identified as independent predictors for HT and volume of ADC <0.4×10−3 mm2/s had the highest odds ratio (OR) value.ConclusionsThe combination of ischemic severity and corresponding volume in ADC map may predict HT after thrombectomy. In addition to the total infarct volume, volume with severe ischemia should be taken into consideration in preoperative patient selection.

Effect of COVID‐19 on Acute Ischemic Stroke Hospitalizations and Treatments: Population‐Level Experience

Background Several studies have reported changes in the volume and type of acute ischemic stroke (AIS) hospitalizations during the early stage of the COVID‐19 pandemic. However, population‐based assessments, which include lower volume centers and more comprehensive geographic areas, are limited. Here, we evaluate an entire state‐level experience during the first peak COVID pandemic and compare against a 1‐year prior historical period. Methods We conducted a retrospective population‐based study using the Texas Inpatient Public Use Data File, capturing all discharges from hospitals in the State of Texas, except federal hospitals. AIS admission volumes, patient characteristics, proportions of large vessel occlusion (LVO), admission rates to comprehensive stroke centers, use of intravenous tissue plasminogen activator and endovascular treatment, and patient outcomes were compared between April 1, 2019 and June 30, 2019 (historical control period) and April 1, 2020 and June 30, 2020 (pandemic period). Results A total of 9277 hospitalized AIS cases were identified during the pandemic period, a decrease of 12% (10 524) compared with the control period. Cases without LVO dropped by 15%, whereas LVO cases dropped by only 5%. There were no significant differences in age or race and ethnicity of patients. While admission rates to comprehensive stroke centers (39.6% versus 39.4%, P =0.81) and endovascular treatment use in LVO (17.0% versus 16.3%, P =0.45) were not different between the 2 periods, the use of intravenous tissue plasminogen activator (15.0% versus 13.6%, relative risk [RR], 0.90; 95% CI, 0.84–0.97; P =0.004) decreased. The percentage of patients who died or were discharged to hospice increased from 7.2% to 8.25% (RR, 1.17; 95% CI. 1.06–1.29; P =0.001). Conclusions This study from a statewide population‐level analysis confirms smaller hospital‐based cohorts observing decreasing numbers of milder AIS admissions, and lower use of thrombolysis. Although LVO admissions and endovascular treatment use were largely unchanged, these findings suggest missed treatment opportunities for patients with AIS in the pandemic.

Comparison of outcome of patients with acute minor ischaemic stroke treated with intravenous t-PA, DAPT or aspirin

BackgroundWhether to treat minor stroke with intravenous tissue plasminogen activator (t-PA) treatment or antiplatelet therapy is a dilemma. Our study aimed to explore whether intravenous t-PA treatment, dual antiplatelet therapy...

Prediction of Early Recanalization after Intravenous Thrombolysis in Patients with Large-Vessel Occlusion.

Background and Purpose We aimed to develop a model predicting early recanalization after intravenous tissue plasminogen activator (t-PA) treatment in large-vessel occlusion. Methods Using data from two different multicenter prospective cohorts, we determined the factors associated with early recanalization immediately after t-PA in stroke patients with large-vessel occlusion, and developed and validated a prediction model for early recanalization. Clot volume was semiautomatically measured on thin-section computed tomography using software, and the degree of collaterals was determined using the Tan score. Follow-up angiographic studies were performed immediately after t-PA treatment to assess early recanalization. Results Early recanalization, assessed 61.0±44.7 minutes after t-PA bolus, was achieved in 15.5% (15/97) in the derivation cohort and in 10.5% (8/76) in the validation cohort. Clot volume (odds ratio [OR], 0.979; 95% confidence interval [CI], 0.961 to 0.997; P=0.020) and good collaterals (OR, 6.129; 95% CI, 1.592 to 23.594; P=0.008) were significant factors associated with early recanalization. The area under the curve (AUC) of the model including clot volume was 0.819 (95% CI, 0.720 to 0.917) and 0.842 (95% CI, 0.746 to 0.938) in the derivation and validation cohorts, respectively. The AUC improved when good collaterals were added (derivation cohort: AUC, 0.876; 95% CI, 0.802 to 0.950; P=0.164; validation cohort: AUC, 0.949; 95% CI, 0.886 to 1.000; P=0.036). The integrated discrimination improvement also showed significantly improved prediction (0.097; 95% CI, 0.009 to 0.185; P=0.032). Conclusions The model using clot volume and collaterals predicted early recanalization after intravenous t-PA and had a high performance. This model may aid in determining the recanalization treatment strategy in stroke patients with large-vessel occlusion.

Impact of Hospital Level on Stroke Outcomes in the Thrombolytic Therapy Era in Northeast Thailand: A Retrospective Study.

IntroductionStroke is a common neurological disease. Thrombolytic therapy has been shown to be beneficial in acute ischemic stroke. This treatment can be given in various hospital levels. This study aimed to evaluate the quality of acute ischemic stroke care among various hospital levels.MethodsData were randomly selected from the medical records that were sent to the National Health Security Office (NHSO) for reimbursement purposes between October 2015 and August 2016. Patient demographics, risk factors, stroke subtypes, stroke severity, quality of care indicators, and complications were recorded. Paired comparisons between two groups were carried out using the Bonferroni correction.ResultsA total of 947 patients, including 169 patients from community hospitals (CHs), 629 from regional hospitals (RHs), and 149 from tertiary hospitals (THs), were included in the final analysis. The CH group had a higher median age but lower median initial National Institutes of Health Stroke Scale (NIHSS) score than the RH and TH groups (median age = 70, 66, and 67 years, respectively, and initial NIHSS = 6, 8, and 9, respectively). The CH group had shorter onset-to-needle times for intravenous recombinant tissue plasminogen activator (rt-PA) treatment than the other two groups (147 vs. 178.5 and 180 min). After adjustment for baseline characteristics, stroke type, and stroke severity, the CH group was significantly associated with lower mortality and presence of complications. The adjusted odds ratios (95% confidence intervals) for the two factors were 0.13 (0.03, 0.67) and 0.59 (0.35, 0.99). None of the patients received endovascular therapy or non-thrombolytic interventional therapy.ConclusionCHs may have the potential for acute ischemic stroke care in the same way as RHs or THs, with faster rt-PA treatment, in northeast Thailand. However, further studies should be performed to evaluate appropriate patient characteristics for CHs.

Outcomes of intravenous thrombolytic therapy in cardioembolic strokes

Background/Aim: It is controversial whether intravenous recombinant tissue plasminogen activator (IV r-tPA) treatment outcomes in cardioembolic strokes differ from other types of strokes. This study aims to investigate the clinical data of patients with cardioembolic and large-vessel atherosclerosis who received IV r-tPA treatment and compare and discuss the results according to the literature. Methods: The data of the patients who were admitted within the first 4.5 hours following the onset of symptoms, diagnosed with acute ischemic stroke in the Neurology clinic of Kutahya Evliya Celebi Training and Research Hospital and underwent IV r-tPA were evaluated in this retrospective cohort study. Demographic data, clinical and functional results of patients were compared between the two groups (cardioembolic and large vessel atherosclerosis). Results: Eighty-five patients with ischemic stroke who received IV r-tPA treatment due to cardioembolism and large-vessel atherosclerosis were included in the study. There were 51 patients (60%) in the cardioembolic stroke group and 34 patients (40%) in the large vascular atherosclerotic group. There was no significant difference in terms of functional results between the groups (62.7% vs 44.1%; P=0.09). While symptomatic intracerebral hemorrhage was not detected in the large-vessel atherosclerosis group, it occurred in 3.9% of the cardioembolic stroke group. Conclusion: This study proved that functional and clinical results are similar between cardioembolic and large-vessel atherosclerosis patients who were treated with IV r-tPA treatment. Regardless of the etiology, all suitable patients with acute ischemic stroke should be treated with thrombolytic therapy.

Cystatin C is a potential predictor of unfavorable outcomes for cerebral ischemia with intravenous tissue plasminogen activator treatment: A multicenter prospective nested case–control study

The aim of this study was to explore whether cystatin C (CysC) could be used as a potential predictor of clinical outcomes in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV-tPA). We performed an observational study including a retrospective analysis of data from 125 AIS patients with intravenous thrombolysis. General linear models were applied to compare CysC levels between groups with different outcomes; logistic regression analysis and receiver-operating characteristic curves were adopted to identify the association between CysC and the therapeutic effects. Compared with the "good and sustained benefit" (GSB) outcome group (defined as ≥4-point reduction in National Institutes of Health Stroke Scale or a score of 0-1 at 24h and 7days) and the "good functional outcome" (GFO) group (modified Rankin Scale score 0-2 at 90days), serum CysC baseline levels were increased in the non-GSB and non-GFO groups. Logistic regression analysis found that CysC was an independent negative prognostic factor for GSB (odds ratio[OR]0.010; p=0.005) and GFO (OR 0.011; p=0.021) after adjustment for potential influencing factors. Receiver-operating characteristic curves showed the CysC-involved combined models provided credible efficacy for predicting post-90-day favorable clinical outcome (area under the curve0.86; p<0.001). Elevated serum CysC is independently associated with unfavorable clinical outcomes after IV-tPA therapy in AIS. Our findings provide new insights into discovering potential mediators for neuropathological process or treatment in stroke.

Pathophysiology of Ischemic Stroke: Role of Oxidative Stress.

Stroke is the second leading cause of mortality and the major cause of adult physical disability worldwide. The currently available treatment to recanalize the blood flow in acute ischemic stroke is intravenous administration of tissue plasminogen activator (t-PA) and endovascular treatment. Nevertheless, those treatments have the disadvantage that reperfusion leads to a highly harmful reactive oxygen species (ROS) production, generating oxidative stress (OS), which is responsible for most of the ischemia-reperfusion injury and thus causing brain tissue damage. In addition, OS can lead brain cells to apoptosis, autophagy and necrosis. The aims of this review are to provide an updated overview of the role of OS in brain IRI, providing some bases for therapeutic interventions based on counteracting the OS-related mechanism of injury and thus suggesting novel possible strategies in the prevention of IRI after stroke.

A 2-point difference of NIHSS as a predictor of acute ischemic stroke outcome at 3 months after thrombolytic therapy

ObjectiveA good functional response at 24 h from an intravenous recombinant tissue plasminogen activator (rtPA) treatment is associated with 3-month ischemic stroke outcome. The criterion for 24 -h neurological improvement is varied from 4 to 8 point the National Institutes of Health Stroke Scale (NIHSS) score reduction. This study aimed to evaluate the smaller difference of the NIHSS at 2 points on long term functional status. Patients and methodsThe inclusion criteria were adult patients diagnosed as acute ischemic stroke and received the rtPA treatment. There were two stroke outcomes comprised of immediate 24 -hs and 3 month long term outcomes. Favorable 24 -h outcome defined by improvement of the NIHSS at 24 h after the rtPA treatment at least 2 points or equal to 0. At 3 months, the outcome was evaluated by using the modified Rankin scale (mRS). The mRS of 0–1 and 2–6 defined as favorable and poor outcome, respectively. Factors associated with poor outcomes at 24 h and 3 months after the rtPA treatment were calculated by logistic regression analysis. ResultsThere were 618 patients met the study criteria. Of those, 403 patients (65.2 %) received the rtPA treatment at the tertiary care hospital. At 24 h after the rtPA treatment, 163 patients (26.38 %) had poor outcome. After adjusted, age and atrial fibrillation had adjusted odds ratios (95 % confidence interval) for poor outcome at 24 h after the rtPA treatment of 1.026 (1.009, 1.043) and 1.725 (1.119, 2.658). At 3 months after the rtPA treatment, the poor outcome at 24 h after rtPA treatment had the highest adjusted odds ratio at 42.876 (95 % confidence interval of 21.500, 85.501). ConclusionsThe NIHSS differences of 2 points at 24 -h after the rtPA treatment from baseline may be an additional tool to predict the 3-month functional outcome of acute ischemic stroke patients.