Iv rtPA Research Articles

Analysis of influencing factors of early neurological improvement after intravenous rt-PA thrombolysis in acute anterior circulation ischemic stroke.

It has been widely reported that Early neurological improvement (ENI) after rt-PA intravenous thrombolysis contributes to a good long-term prognosis in patients experiencing acute ischemic stroke (AIS). However, which clinical factors influence after intravenous administration of recombinant tissue-type plasminogen activator (IV-rt PA) in AIS patients ENI is still unclear. This study aimed to evaluate the impact of influencing factors on the benefit of ENI after intravenous thrombolysis neurological improvement after IV-rt PA. The data of 73 patients with acute anterior circulation ischemic stroke who received intravenous thrombolysis with rt-PA in Chongqing University Jiangjin Hospital from January 2021 to July 2022 were retrospectively studied. According to the change rate of 24 h NISHH score, the research subjects were divided into the recovery group, the significant curative effect group, the curative effect group and the no curative effect group, the ENI after intravenous thrombolysis with rt-PA was defined as the improvement rate of National Institutes of Health Stroke Scale (NIHSS)score >46% at 24 h after IV-rt PA, and univariate factor analysis was used Clinical factors associated with ENI after intravenous thrombolysis. According to the 24-h NIHSS improvement rate of rt-PA intravenous thrombolysis in patients with acute anterior circulation ischemic stroke, 35 cases (47.95%) of the study population had ENI. There was no statistical difference between the improvement and non-improvement group in general demographic data, stroke TOAST classification, stroke risk factors (history of stroke, heart disease, hyperlipidemia, hypertension), and laboratory test data. There was a statistically significant difference in the random blood glucose levels between the two groups (p < 0.001, t = 3.511). The effect of rt-PA intravenous thrombolysis within the time window of patients with acute anterior circulation ischemic stroke is significant, but the ENI after thrombolysis is easily affected by the level of blood glucose; diabetes is the most important factor affecting the acute anterior circulation ischemic stroke patients Clinical factors of ENI after intravenous thrombolysis with rt-PA.

Outcome of thrombolysis with recombinant tissue plasminogen activator (rtPA) in a rural tertiary care center

Stroke is a leading cause of morbidity and mortality worldwide and there is a significant gap in the availability of standard of care in different regions especially in the rural areas. To assess the clinical profile and outcome of patients treated with iv rtPA at a rural tertiary care center. A prospective observational study of consecutive window period stroke patients treated with iv rtPA. Clinical, epidemiological, imaging parameters, outcome measures including baseline NIHSS, NIHSS at 1 hour, 24 hours, discharge and mRS [modified Rankin Score] at 1 and 3 months were entered in structured proforma. A total od 28 patients were thrombolysed with iv rtPA during the study period. Diabetes, Hypertension and smoking were the most common comorbidities. The mean arrival time in hospital was 151 minutes. The door to needle time was 68 minute. 22 had anterior circulation stroke and 6 with posterior circulation stroke. Mean NIHSS at arrival was 10.4. Mean NIHSS score at 24 hours was 10.1 and NIHSS at 7 days was 9.8. Major improvement as measured as a drop in NIHSS of 8 points was seen in 7 patients [25%]. The mean MRS at 1 month was 2.89 and at 3 months was 1.74. At 3 months follow up 10 out of 28 patients [35.7%] had major improvement characterized by mRS improvement of 3 from time of discharge or final mRS of 0 or 1. Thrombolysis with rtPA is safe and effective in rural setting.

GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate: evidence from the Chinese Stroke Center Alliance

BackgroundTimely delivery of intravenous tissue plasminogen activator (IV-rt PA) is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic. This paper...

Extended preclinical investigation of lactate for neuroprotection after ischemic stroke

Lactate has been shown to have beneficial effect both in experimental ischemia–reperfusion models and in human acute brain injury patients. To further investigate lactate’s neuroprotective action in experimental in vivo ischemic stroke models prior to its use in clinics, we tested (1) the outcome of lactate administration on permanent ischemia and (2) its compatibility with the only currently approved drug for the treatment of acute ischemic stroke, recombinant tissue plasminogen activator (rtPA), after ischemia–reperfusion. We intravenously injected mice with 1 µmol/g sodium l-lactate 1 h or 3 h after permanent middle cerebral artery occlusion (MCAO) and looked at its effect 24 h later. We show a beneficial effect of lactate when administered 1 h after ischemia onset, reducing the lesion size and improving neurological outcome. The weaker effect observed at 3 h could be due to differences in the metabolic profiles related to damage progression. Next, we administered 0.9 mg/kg of intravenous (iv) rtPA, followed by intracerebroventricular injection of 2 µL of 100 mmol/L sodium l-lactate to treat mice subjected to 35-min transient MCAO and compared the outcome (lesion size and behavior) of the combined treatment with that of single treatments. The administration of lactate after rtPA has positive influence on the functional outcome and attenuates the deleterious effects of rtPA, although not as strongly as lactate administered alone. The present work gives a lead for patient selection in future clinical studies of treatment with inexpensive and commonly available lactate in acute ischemic stroke, namely patients not treated with rtPA but mechanical thrombectomy alone or patients without recanalization therapy.

Strokectomy and Extensive Cisternal CSF Drain for Acute Management of Malignant Middle Cerebral Artery Infarction: Technical Note and Case Series.

Background and Purpose: Ischemic stroke is a major cause of death and disability worldwide. Large MCA stroke may evolve as malignant space occupying lesion and mortality rate reaches 80% despite maximal medical therapy. Early decompressive craniectomy is effective in reducing mortality and improving the functional outcome but is an extended and invasive surgical approach burdened with a significant complication rate. We report a surgical treatment based on partial strokectomy and basal cisterns opening with massive CSF drain.Materials and Methods: We retrospectively collected 15 cases of massive middle cerebral artery stroke treated with strokectomy between 2010 and 2017: nine males and six females, mean age 61.73 ± 9.5 years. The right side was affected in 66.7%. All patients show clinical deterioration despite standard medical therapy and indication for surgery was placed after collegiate evaluation by neurologists and neurosurgeons based on clinical and radiological data.Results: Surgical procedure was performed 24–96 h after the stroke onset. All the 15 patients survived the intervention, one patient died 20 days after the admission for massive lung embolism. Mean GCS and NIHSS at admission were 12.6 ± 1.18 (range 9–15) and 19.7 ± 2.3 (range 18–23), respectively. Mean mRS at 12 months was 3.6 ± 1.1 (range 2–6). Mean follow-up was 18.1 months (range 12–34). The outcome was evaluated as satisfactory (mRs ≤ 3) in 8 patients (53.3%). Mortality at 1 year was 6.7%. No patients developed hydrocephalus and 1 presented seizures. According to mRs outcome evaluation (mRs ≤ 3 vs. mRs ≥ 4) no quantitative variable resulted significantly different between the two groups, whereas the concomitant use of iv rTPA significantly differed (P < 0.05).Conclusion: Supratentorial strokectomy seems to be safe and could be a potential alternative to decompressive craniectomy for the acute management of malignant MCA stroke. Advantages of this approach could be low complication rate, avoidance of bone reconstruction procedure, and reduced occurrence of hydrocephalus or seizures. A co-operative multicentric, prospective pilot study will be necessary to validate this technical approach.

Abstract TP18: Impact of Reperfusion Therapy on Short-Term Outcome in Patients With Mild Acute Ischemic Stroke

Purposes: The efficacy of reperfusion therapies (RT), including both intravenous recombinant tissue plasminogen activator (iv rt-PA) and any endovascular therapy (EVT) for mild acute ischemic stroke (AIS), is yet to be established. The present study aimed to evaluate the impact of RT on mild AIS patients outcome compared with non-RT. Methods: Of all 9775 AIS patients admitted in our hospital between 2006 and 2017, those patients with values of 0-1 on the modified Rankin Scale (mRS) prior to the onset of AIS and of ≤ 10 on the National Institute of Health Stroke Scale (NIHSS) just before the therapy was started were selected. Of these, RT patients and comparable non-RT patients were selected using propensity score matching. The RT group included patients with iv rt-PA and any EVT (local arterial infusion of Urokinase, percutaneous transluminal angioplasty, Merci retriever, Penumbra system, and any stent retriever). The primary outcome was mRS 0-1 at three months after the onset, which was defined as an excellent outcome. Subgroup analysis for patients with NIHSS ≤ 5, 6-10, small vessel occlusion (SVO), and non-SVO was also performed. Results: Of the selected 3089 patients, we constructed the 526 (263 each) propensity score-matched patients cohort. The propensity score-matched RT patients consisted of 135 solely iv rt-PA, 109 EVT, and 19 both. The non-RT patients had a median age of 72 compared to 73 years for the RT patients and the median NIHSS was 5 in both patient groups. The frequencies of excellent outcome in RT and non-RT patients did not differ significantly with 57.8 % and 52.1 %, respectively. The odds ratio and 95 % confidence interval (CI) of RT patients for an excellent outcome was 1.26 (0.89-1.78). In the subgroup analysis, odds ratios of patients with NIHSS ≤ 5, NIHSS 6-10, SVO, and non-SVO were 0.97 (0.61-1.56), 1.75 (1.01-3.03), 1.24 (0.57-2.70), and 1.27 (0.86-1.86), respectively. Conclusion: The present study found an excellent outcome of RT only in patients with NIHSS 6-10. Further studies may be warranted to investigate the efficacy of RT for patients with mildest AIS (NIHSS ≤ 5).

Abstract WP329: Time Dependent Recanalization and Outcomes in Transferred Stroke Patients With Large Vessel Occlusion (LVO) After IV rt-PA

Background: The time dependent benefit of rt-PA in acute stroke patients is established. However, only limited data exist on LVO outcomes post remote telemedicine administered rt-PA. We report the outcomes of such patients. Methods: A retrospective study of the CPMC stroke database was performed. Primary outcome measures were neurologic outcome at discharge, mortality, and TICI reperfusion scores of mechanical thrombectomy (MT) treated patients. The safety outcome measure was symptomatic hemorrhage rate (SICH; NIHSS &gt; 1 at ≤ 36hr). Results: From 1/2014-2/2018, 233 transferred rt-PA patients were identified. Median age was 73, and median NIHSS 6. Risk factors included hypertension (69%), dyslipidemia (43%), AF (27%), prior stroke/TIA (26%), CAD (26%), DM (24%), smoking (16%), and CHF (13%). The post rt-PA SICH rate was 4% and discharge mRS≤2 rate was 43%. Mortality rate was 11%, 43% required help at discharge, and 40% were discharged home. For the 61 patients who received rt-PA + MT, the SICH rate was 2% and mortality rate 12%. Median discharge NIHSS was 2 and mRS ≤2 rate was 19%. Of the 233 transferred patients, 40 had a pre rt-PA CTA with LVO available for review. For these patients, median time to scan was 76 min. Median time to repeat CTA at CPMC was 180 min. LVO was 80% anterior circulation, clot migration was seen in 5%, and &gt;90% of MT patients had AF. Post rt-PA recanalization rate was 12% (0% posterior circulation). MT after rt-PA was performed in 62% (TICI ≥ 2b 88%). Longer time to treatment trended towards poorer result and longer MT time. Average NIHSS dropped from 12 to 5 and average discharge mRS was 3. Conclusions: These data confirm that remote IV rt-PA followed by MT is safe and effective. Of LVO rt-PA patients 17% experienced full or partial recanalization suggesting repeat imaging is appropriate before initiating MT, possibly with the exception of posterior circulation strokes because of poor response to rt-PA. AF is common and may predict need for MT after rt-PA. A trend was observed towards improved TICI score and shorter recanalization time with a shorter latency between rt-PA and MT. These data support the use of stroke systems of care to ensure rapid triage and treatment of LVO patients.

Abstract 82: Endovascular Therapy Eligibility in the Advent of DAWN and DEFUSE-3 Results

Introduction: We previously estimated that, among 2297 ischemic stroke patients in our 1.3 million metropolitan population in 2010, 159 were potentially IV rtPA (IVT)- and 29 were endovascular (EVT)-eligible based on AHA Class I, Level A guideline criteria; this projected to 31,000 IVT and 5600 EVT-eligible patients in the US annually. Given recent DAWN and DEFUSE 3 results suggesting EVT benefit beyond 6 hours to 24 hours, we aim to estimate the number of additional EVT-eligible patients in our region. Methods: We ascertained all hospitalized AIS patients ≥18 years old in 2010 using ICD-9 codes 430-436 within Greater Cincinnati/Northern Kentucky (GCNK) population; all cases were physician-reviewed. GCNK patients were considered potentially DAWN-eligible if ≥18 years, presenting within 5 to 23 hours from onset, and with a baseline NIHSS ≥10, prestroke mRS 0-1, platelets ≥50k, glucose 51-399 mg/dL, INR ≤3.0 and creatinine ≤3.0. Based on single-center (Pittsburgh) data, an eligibility proportion of 22% for both large vessel occlusion (LVO) and clinical-imaging-mismatch (CIM) was then applied. Additional patients eligible by only DEFUSE 3 criteria were identified within the GCNK population by including NIHSS 6-9, prestroke mRS 2, and an upper age of 90 years among patients presenting within 5 to 15 hours. Based on single-center (Bern) data, LVO rates by NIHSS score were applied. Based on DEFUSE 3 screening estimates, a 50% target mismatch (TTM) rate was then applied. Results: Among 2297 ischemic stroke patients hospitalized in our region, 34 were potentially DAWN-eligible, including 8 estimated to meet LVO and CIM criteria, and 19 additional patients were DEFUSE 3-eligible, including 4 estimated to meet LVO and TMM criteria. Conclusion: The 6-24 hour EVT treatment window may increase EVT eligibility by approximately 40% in the GCNK metropolitan region annually, although this estimate is limited by small sample sizes and inferences. Estimates will be updated as further data become available by the time of presentation of this abstract.

The effect of metabolic syndrome and obesity on outcomes of acute ischemic stroke patients treated with systemic thrombolysis

Metabolic syndrome (MetS) is associated with increased risk of ischemic stroke; while central obesity has controversial effects on ischemic stroke. We investigated effects of MetS and obesity on clinical courses and outcomes of patients treated with intravenous recombinant tissue-type plasminogen activator (iv rt-PA). 319 patients treated with intravenous thrombolysis were included to our study. Metabolic syndrome was determined if ≥3 of following criteria are present: elevated waist circumference; elevated triglycerides; reduced high density-lipoprotein cholesterol (HDL-C); elevated blood pressure; elevated fasting glucose. Obesity was defined as BMI≥30. Clinical features at baseline, 24th hour and 3rd month were examined. Computed tomography (CT) findings for ASPECT scores and hemorrhagic transformation were analyzed. 182 patients were MetS+; they were older (p=0.035), had similar ASPECT scores (p=0.477) and NIHSS scores (p=0.167) at admission; had significantly higher NIHSS scores at 24th hour (p<0.001) and worse outcome at 3rd month (p<0.001). Logistic regression analysis showed that either MetS, obesity or age were not independent predictors of poor outcome. Obese patients (n:72) had slight but significantly lower NIHSS scores at admission (p=0.049) compared to non-obese patients; meanwhile there was no significant difference between NIHSS scores at 24th hour (p=0.736) and 3rd month mRS scores (p=0.145). Hemorrhagic transformation and mortality rates were not affected with MetS or obesity. MetS is not an independent factor on clinical outcome but its presence may have a relationship with poor outcome; but obesity was not found to have any significant role on clinical course and outcome of patients treated with iv rt-PA.

Budget Impact Analysis (BIA) Of Mechanical Thrombectomy In Acute Phase Of Ischemic Stroke (AIS)

To estimate financial consequences of reimbursement of mechanical thrombectomy (MT) using a stent retriever in patients with AIS in Poland. Analysis was performed from two perspectives: public payer and public payer + patient in 2-year time horizon (2017-2018). Two scenarios were considered: with and without reimbursement of MT. Target population was defined as patients with AIS eligible for MT who are contraindicated to intravenous tissue plasminogen activator (IV-rt PA) or are treated with IV rt-PA (and MT is added). Size of target population and market share for MT were estimated by compilation of following sources: National Health Found stats on Diagnosis Related Groups (DRG), data from stroke clinical center and clinical expert opinion. Cost data, treatment effectiveness and mortality were also included and data were input in accordance with economic analysis. One-way sensitivity analysis was performed for the key input parameters. All estimations were done with constructed Excel model. Total number of target population is 8,748 in 2017 and 9,792 in 2018. This include all patients treated with IV-rt PA and those with contraindications for IV-rt PA but eligible for MT. In scenario without MT total annual expenditures in 1st and 2nd year will be 151.2 mPLN and 192.1 mPLN from public payer perspective (152.2 mPLN and 195.4 mPLN from public payer + patient). In scenario with MT reimbursement estimated number of patients treated with MT will be 514 in 2017 and 1,150 in 2018. This will result with increase in total expenditures by 22.5 mPLN and 50.3 mPLN in 1st and 2nd year of analysis regardless of perspective. Positive decision of reimbursement of mechanical thrombectomy, using a stent retriever, will bring additional cost incurred by public payer or public payer and patients.

Abstract TP24: Trends in Iv r-tpa and Thrombectomy Treatment Rates Before and After the LVO RCT’s in a Regional Tele-stroke Network

The presentation of endovascular stroke trials at international stroke conference was a land mark event in acute stroke therapy. This study aims to analyze the rates of utilization of IV r-tPA, with or without mechanical thrombectomy before and after the 2015 International Stroke Conference (ISC) in a large regional tele-stroke network. Methods: A systematic review of prospective telestroke and procedure database was performed for 18 months prior and 18 months post conference. There were three groups included in the analysis. The first group consisted ischemic stroke patients presented within 12 hours of onset including inpatient events, transfers from primary centers and rural clinics. The second group consisted of patients who received IV r-tPA, and the third group consisted of patients who received IV r-tPA and/or underwent mechanical thrombectomy for a demonstrated LVO. Results: A total of 2628 consecutive ischemic stroke events presented within 12 hours of onset were evaluated. In the pre-ISC conference group, there were 1135 ischemic stroke patients. IV r-tPA was given 535 times(47.1%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 42 times(3.7%). In the post-ISC conference group, there were 1493 ischemic stroke patients. IV r-tPA was given 642 times(43%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 132 times(8.84%). The Chi Square statistical test was performed comparing these groups. When comparing the rate of IV r-tPA usage, there was a significant decrease from the pre-ISC conference group to the post-ISC conference group (P= 0.04). When comparing the rate of mechanical thrombectomy performed, there was a significant increase of greater than double the percentage of thrombectomy procedures performed in the post conference group compared to the preconference group (p&lt; 0.001). Conclusion: There was a significant decrease in IV r-tPA usage but a greater than double the increase in the thrombectomy rate . This may be secondary to increased awareness of benefit of thrombectomy at referral centers. Slightly lower rates of IV r-tPA usage may be secondary to an increase in transfers of patients outside of the 0-4.5 hr window but were deemed candidates for thrombectomy.

Abstract WMP85: Target Stroke Implementation: Best Practice Strategies Cut Thrombolysis Time to &lt;30 minutes in a 1,550 Bed Academic Urban County Hospital

Introduction: Thrombolytic window for acute ischemic stroke is brief and crucial. The AHA/ASA Target: Stroke Best Practice Strategies (TSBPS) aim to help hospitals improve thrombolysis door-to-needle (DTN) time. We assessed long-term efficacy of TSBPS to reduce DTN in a tertiary care hospital. Methods: We initiated a quality improvement program across one regional academic medical center (1,550 beds, 900 annual stroke admissions) that serves a multi-ethnic population by establishing a multidisciplinary DTN committee to assess causes of delayed DTN and implement focused TSBPS. Strategies included stroke team pre-admission notification, direct transfer to CT scanner, storing and administering IV rt-PA at CT scanner, and immediate stakeholder feedback. Door-to-CT, DTN, CT to IV rt-PA and door-to-groin (DTG) times were analyzed prospectively in consecutive IV rt-PA treated patients over 27 months pre-implementation and 13 months post-implementation. Results: A total of 148 patients were included in the pre-implementation and 126 patients in the post-implementation group. The two groups had similar demographics, comorbidities, anticoagulation status, pre-thrombolysis hypertension treatment, stroke severity (median NIHSS 11 (6-18) vs. 11 (5-17), p= 0.483), arrival by EMS (96% vs. 97%, p=0.708), and arrival after hours. Post implementation, reductions in treatment times were observed for median DTN (IQR) 59 (52-80) to 28.5 (20-41) min (p&lt;0.001), door-to-CT time 17 (14-21) to 16 (12-19) min (p=0.016), CT-to-IV rt-PA time 43 (31-59) to 13 (6-23) min (p&lt;0.001), and DTG time 164 (136-188) min (n=37) to 86 (63-103) min (n=51) (p&lt;0.001). Overall monthly IV r-tPA administration increased post-implementation (5.5 vs. 9.8, p&lt;0.001). Rate of symptomatic intracranial hemorrhage (2.7% vs. 3.2%, p=0.817) and treatment of stroke mimics (9% vs. 13%, p=0.311) were similar pre- and post-implementation. Conclusions: In this study, delay in IV rt-PA administration was predominantly related to prolonged CT to IVrt-PA time. DTN committee implementation is a simple, low-cost intervention, that significantly reduced DTN and DTG with persistent effect and no increase in symptomatic intracranial hemorrhage or stroke mimic treatment rate.

Abstract TP286: A Literature Review of Cost-effectiveness of Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke

Introduction: Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed. Objectives: We conducted a literature review of the cost-effectiveness studies about IV rtPA. Methods: A literature search was conducted using PubMed, MEDLINE, and EconLit, with the key words stroke, cost, economic benefit, saving, cost-effectiveness, tissue plasminogen activator, and rtPA. The review is limited to original research articles published during 1995–2014 in English-language peer-reviewed journals. Results: We found 15 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 1 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective. Conclusions: The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.

Abstract WP7: A Projection of Endovascular Therapy Eligibility in the United States: A Population-based Analysis

Introduction: After five randomized trials in 2015 demonstrating benefit, endovascular therapy (EVT) is the new standard of care for selected acute ischemic stroke (AIS) patients. Stroke systems must rapidly adapt to provide this time-sensitive therapy to eligible patients. Objective: To estimate the number of EVT-eligible AIS patients in the US annually using Class I and IIa eligibility criteria from the 6/2015 AHA/ASA guideline update. Methods: We ascertained all hospitalized AIS patients ≥18 years old in 2010 using ICD-9 codes 430-436 within the 1.3 million Greater Cincinnati/Northern Kentucky (GCNK) population. Two groups were selected: (1) IV rtPA (IVT)-eligible: arrival ≤3.5 hours from onset and no standard contraindications, and (2) IVT-ineligible but potentially EVT-eligible: arrival ≤5 hours from onset, NIHSS ≥6, platelets ≥50k, and INR ≤3.0. For each group, we estimated the rate of large-vessel occlusion (LVO) by baseline NIHSS using a 2,152-patient prospective database at University of Bern. Other criteria included prestroke mRS 0-1 and ASPECTS ≥6 (estimated 75% prevalence). We also considered expanded eligibility of mRS 0-3 and ASPECTS ≥5 (estimated 85% prevalence). Regional rates were age/race/sex-adjusted to 2010 US census data. Results: Regional eligibility for IVT and EVT among 2297 AIS patients is shown in the Figure. Projecting to the US, 30,607 patients would be IVT-eligible, and 5582 patients would be EVT-eligible annually. Expanded EVT eligibility would lead to 18,094 EVT-eligible patients nationally. Conclusion: Within the GCNK population, 1.0% of AIS patients (including 11.3% of IVT-eligible patients) are EVT-eligible based on Class I and IIa AHA/ASA recommendations. We project 5582 EVT-eligible patients in the US annually, and up to 18,094 using expanded eligibility. Estimates are limited by the use of cohort-based LVO and ASPECTS rates, and the projection of urban GCNK region arrival time patterns to the broader US population.

Higher Insulin Resistance Level is Associated with Worse Clinical Response in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis.

Insulin resistance is linked to atherosclerotic cardiovascular diseases and stroke. We investigated whether there is a relationship between insulin resistance and clinical findings and outcomes of acute ischemic stroke patients treated with intravenous thrombolysis. In our study, 180 acute ischemic stroke non-diabetic patients treated with intravenous recombinant tissue-type plasminogen activator (iv rt-PA) were evaluated for insulin resistance assessed by homeostasis model assessment insulin resistance (HOMA-IR). The threshold for HOMA-IR was determined as 2.7. Patients were grouped as HOMA-IR > 2.7 and HOMA-IR ≤ 2.7. Clinical features at baseline, 24th hour, and 3rd month were examined. Computed tomography (CT) findings for hemorrhagic transformation were also assessed. Patients with HOMA-IR > 2.7 had significantly higher National Institutes of Health Stroke Scale (NIHSS) scores at 24th hour (p = 0.005) and higher modified Rankin Scale (mRS) scores at 3rd month (p = 0.011). Logistic regression analysis displayed that the presence of HOMA-IR > 2.7 increases the likelihood of poor outcome 2.93 times (confidence interval [CI] 1.001-1.079) (p = 0.003). There was no statistically significant difference between baseline clinical features, hemorrhagic transformation (p = 1.000), and mortality (p = 0.350) rates. Insulin resistance at higher levels seems to be associated with poor clinical courses and outcomes in patients who received iv rt-PA.

Drip-and-Ship Thrombolytic Therapy Supported by the Telestroke System for Acute Ischemic Stroke Patients Living in Medically Under-served Areas.

There are a few stroke specialists in medically under-served areas in Japan. Consequently, in remote area patients may not receive thrombolysis with intravenous recombinant tissue plasminogen activator (iv rt-PA), the standard treatment for acute ischemic stroke. Using a mobile telestroke support system (TSS) that accesses the internet via a smart phone, we implemented iv rt-PA infusion therapy under a drip-and-ship protocol to treat the stroke patients in medically under-served areas. The physicians at the Tokushima Prefectural Kaifu Hospital (TPKH), located in rural Japan, can relay CT or MRI scans and other patient data via their smart phone to off-site stroke specialists. In the course of 34 months, we used the TSS in 321 emergencies. A total of 9 of 188 (4.8%) with acute ischemic stroke, received iv rt-PA infusion therapy using a mobile TSS; in 5 among these (55.6%), we obtained partial or complete recanalization of occluded arteries. None suffered post-treatment hemorrhage and their average NIH stroke score fell from 14.6 at the time of admission to 6.8 at 24 h post-infusion. The drip-and-ship protocol contributed to the safe and effective treatment of the stroke patients living in medically under-served rural areas.

Cerebral microhemorrhage: update for the practicing neurologist

Cerebral microhaemorrhages (CMHs) are small dot like lesions appearing as hyposignal on gradient echo T2* MR sequences. The development of specific MR sequences raised the interest in this radiological construct that is meant to represent a specific underlying microscopic pathology: perivascular collections of hemosiderin deposits. Those lesions, which were considered as rare and silent before, are becoming frequent and clinically meaningful. Cerebral microhaemorrhages are interesting biomarkers both from diagnostic and prognostic perspectives. Indeed, deep CMHs may suggest deep perforating vasculopathy while the presence of lobar CMHs is suggestive of cerebral amyloid angiopathy. These radiological biomarkers are becoming surrogate markers for clinical trials and they may eventually help tailoring therapeutic strategies to prevent ICH recurrences and functional decline. In the setting of ischaemic strokes, CMHs might influence the benefit-risk ratio of long term anticoagulation. In the acute phase, when the administration of iv rtpa is discussed, CMHs might trigger anxiety for the neurologist on duty… In Alzheimer’s disease, CMHs are of special interest as they may have a crucial role in the pathophysiology of AD. Moreover, they may affect clinical course of the disease and may have therapeutic implications. Moreover, the predictive power of BMBs for future cognitive impairment is currently explored both in stroke but also in population-based settings (in so called “healthy” cohorts).

Technical standards for the interventional treatment of acute ischemic stroke

Acute ischemic stroke is the leading cause of acquired disability and its treatment is still a major challenge. For more than a decade, various mechanical devices have been developed for the recanalization of proximal artery occlusions in acute ischemic stroke but most of them have been approved for clinical use, only on the basis of uncontrolled case series. Intravenous thrombolysis with recombinant tissue-specific plasminogen activator administered (iv rtPA) within 4.5h of symptom onset is so far the only approved medicinal treatment in the acute phase of cerebral infarction. With the introduction of stent retrievers, mechanical thrombectomy has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with iv rtPA and best medical treatment alone in multiple randomized clinical trials in select patients with acute ischemic stroke and proximal artery occlusions. This review discusses the evolution of endovascular stroke therapy followed by a discussion of the current technical standards of mechanical thrombectomy that have to be considered during endovascular stroke therapy and the updated treatment recommendations of the ESO Karolinska stroke update.

Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience.

BackgroundAlthough initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials.PurposeTo examine the utility of mechanical thrombectomy based on patient outcomes.Material and MethodsAll stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination.ResultsMean NIHSS on presentation was 18.2 (range, 6–31), and 13.3 (range, 3–30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization.ConclusionOur study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.

Abstract T P39: Serial Alberta Stroke Program Early Ct Score (aspects) Is A Superior Predictor Of Outcomes With Iv Rtpa

Background and purpose: The Alberta stroke program early computed tomography score (ASPECTS) on baseline imaging is known predictor of outcomes for acute ischemic stroke (AIS) patients. We looked at the change in ASPECTS at the baseline CT and 24hr CT in AIS patients treated with IV rTPA to determine if it can help predict 3 month functional outcomes. Methods: Consecutive AIS patients receiving IV-tPA within 4.5 hours of symptom-onset during 2010-2013 and underwent pre-treatment and day-2 CT were included ASPECTS at the baseline CT and 24hr CT were independently scored in all anterior circulation stroke patients who underwent IV rTPA within 4.5 hours of onset. ASPECTS at baseline, 24hrs and the serial change were analyzed. Results: 210 consecutive AIS patients were included. ROC curves for ASPECTS on the initial CT scan for MRS 0-1 was AUC 0.613, 95% CI 0.536-0.690, p=0.005, while ROC curves for ASPECTS on the 24hr CT scan for MRS0-1 was AUC 0.763 95% CI 0.699 - 0.828, p &lt;0.001. ASPECTS on the 24hr CT was statistically significantly better able to predict outcomes compared to the initial CT (z= -2.936, p = 0.001). 28 out of 210 patients had an increase in ASPECTS by &gt;3 with a 3-fold risk of worse outcomes (OR 3.572 95%CI 1.393- 9.156, p=0.08). Conclusion: ASPECT scores on 24hr CT have better prognostic ability compared to the baseline scan. Serial ASPECT scores are a viable surrogate predictor in AIS patients treated with IV rTPA.