Rate Of Thrombolysis Research Articles

Feasibility of low-dose infusion of alteplase for unsuccessful thrombolysis with urokinase in deep venous thrombosis.

The aim of the present study was to investigate whether the rescue of thrombolysis with the recombinant tissue plasminogen activator (rt-PA) alteplase was an effective and safe therapeutic option in patients who did not respond to urokinase. Between February 2016 and February 2017, 26 patients with deep venous thrombosis (DVT) underwent rescue thrombolysis with alteplase. Unsuccessful thrombolysis with urokinase was defined as a lack of improvement in the degree of thrombotic removal with a lysis rate <50% under one of the following three conditions: Two consecutive venography procedures, administration of >3 million units of total urokinase, or >7 days infusion duration. The thrombus score, lysis rate and post-thrombolysis safety of alteplase, following unsuccessful urokinase thrombolysis were all evaluated. At the end of the unsuccessful urokinase thrombolytic therapy, the mean duration of the perfusion was 6.09±1.60 days, and the mean total dose was (362.5±90.0) ×104 units. No significant difference was detected in the total thrombus score before (7.85±2.40) and at the completion (6.19±2.33) of urokinase thrombolysis (P>0.05). The mean duration of perfusion was 3.36±1.69 days, and the mean total infusion dose was 44.8±22.6 mg for the rescue thrombolysis with alteplase. The mean thrombus score decreased to 1.19±2.10 at the completion of rescue thrombolysis. The alteplase post-thrombolysis scores were significantly decreased compared with those of urokinase thrombolysis (P<0.05). There were 23 (88.5%) patients who achieved a successful lysis rate (grade II/III) following rescue thrombolysis with alteplase, and symptoms of swelling and pain in the affected limbs were significantly improved. Successful thrombolysis rates in patients in the acute (<14 days) and subacute (14-28 days) phases were high (93.3 and 81.8%, respectively; P>0.05). No symptomatic pulmonary embolism or major bleeding occurred during rescue thrombolysis, but minor bleeding complications occurred in 4 cases (15.4%). In conclusion, rescue thrombolysis with alteplase led to an effective and safe outcome in patients with DVT who did not respond to initial thrombolysis with urokinase, and may be a valid and easy alternative treatment option.

Intravenous thrombolytic therapy for acute ischemic stroke in Hubei, China: a survey of thrombolysis rate and barriers

BackgroundRates of thrombolysis in most countries are well below best practice benchmarks. We aimed to investigate thrombolysis utilization and its associated factors in acute ischemic stroke (AIS) patients in Hubei province, China, to assess neurologists’ experiences of the treatment, and to identify barriers against the treatment from perspective of AIS patients and neurologists.MethodsSurvey of 2096 AIS patients and 709 neurologists from 66 hospitals was conducted in Hubei province between 2014 and 2015. A multivariable logistic regression model was utilized to identify the factors associated with thrombolysis utilization and neurologists’ experiences with thrombolysis.ResultsOf the 2096 AIS patients, only 3.8% received thrombolysis. Of the 709 neurologists, 66.0% reported using thrombolysis for AIS patients. The main reasons for not using thrombolysis were late arrival of patients, fear of the risk of complications of thrombolysis, and light or quickly recovered stroke symptoms. The behavior and clinical characteristics of patients, including early admission to hospital (odds ratio [OR] = 5.81, 95% confidence intervals [CI] 3.31–10.20), using emergency medical services to be hospitalized (OR = 3.36, 95% CI 2.00–5.62), stroke history (OR = 0.53, 95% CI 0.28–0.99), and National Institute of Health Stroke Scale score < 4 (OR = 0.46, 95% CI 0.27–0.77) were shown to significantly affect the thrombolysis utilization in the multivariate model. In addition, hospital grade (OR = 2.84, 95% CI 1.84–4.37), education level (OR = 2.49, 95% CI 1.09–5.73), and working years (OR = 1.88, 95% CI 1.18–3.00) were strongly associated with neurologists’ experiences of thrombolysis.ConclusionsA very low proportion of AIS patients received thrombolysis in Hubei province, China. Considerable education programs and interventions were required regarding knowledge of stroke treatment for clinicians and proper behavior after stroke for AIS patients and their families.

Stroke Factors Associated with Thrombolysis Use in Hospitals in Singapore and US: A Cross-Registry Comparative Study

Background and Objectives: This paper aims to describe and compare the characteristics of 2 stroke populations in Singapore and in St. Louis, USA, and to document thrombolysis rates and contrast factors associated with its uptake in both populations. Methods: The stroke populations described were from the Singapore Stroke Registry (SSR) in ­Singapore and the Cognitive Rehabilitation Research Group Stroke Registry (CRRGSR) in St. Louis, MO, USA. The registries were compared in terms of demographics and stroke risk factor history. Logistic regression was used to determine factors associated with thrombolysis uptake. Results: A total of 39,323 and 8,106 episodes were recorded in SSR and CRRGSR, respectively, from 2005 to 2012. Compared to CRRGSR, patients in SSR were older, male, and from the ethnic majority. Thrombolysis rates in SSR and CRRGSR were 2.5 and 8.2%, respectively, for the study period. History of ischemic heart disease or atrial fibrillation was associated with increased uptake in both populations, while history of stroke was associated with lower uptake. For SSR, younger age and males were associated with increased uptake, while having a history of smoking or diabetes was associated with decreased uptake. For CRRGSR, ethnic minority status was associated with decreased uptake. Conclusions: The comparison of stroke populations in Singapore and St Louis revealed distinct differences in clinicodemographics of the 2 groups. Thrombolysis uptake was driven by nonethnicity demographics in Singapore. Ethnicity was the only demographic driver of uptake in the CRRGSR population, highlighting the need to target ethnic minorities in increasing access to thrombolysis.

Imbalanced Regional Development of Acute Ischemic Stroke Care in Emergency Departments in China.

Objective Most patients of acute ischemic stroke (AIS) receive treatments in the department of emergency in China. We aimed to examine the status of AIS diagnosis and treatment and the impact of green pathway operation in different regions of China. Methods In this nationwide survey, information regarding the emergency care of AIS was collected from 451 hospitals in different regions of China, by interviewing 484 physicians from these hospitals. Structured questionnaire was used to explore the status of AIS care and impact of the green pathway. Results 445 hospitals from 18 provinces, 4 municipalities, and 3 ethnic autonomous regions in China were included in the present study. Overall, the proportion of door-to-needle time (DNT) less than 60 min was 66.08% in the enrolled hospitals (n = 298). Stratified by regions, the results suggested that hospitals located in East regions had shorter DNT time (P=0.036), and more proportion of rtPA (P < 0.001) than those in West regions. Further analysis suggested that hospitals with a green channel were more likely to shorten DNT and improve the proportion of rtPA (P < 0.01). Conclusion Considerable regional differences were observed in terms of DNT time and thrombolysis rates in the departments of emergency in China. Further studies are required to confirm the regional differences in AIS care in China.

100 Recent trends in stroke reperfusion in new zealand

IntroductionStroke reperfusion therapy improves patient outcomes. Here we describe recent trends in the stroke reperfusion intervention rates, treatment delays, and complications across New Zealand.MethodAll 20 DHBs enter acute stroke reperfusion treatment information into a compulsory, centralized, Ministry of Health (MoH) approved and funded Stroke Register. The data from 1/1/2018 through 30/9/18 was cleaned and analysed to explore trends in intervention rates, time delays, and complication rates.ResultsIn the nine-month study period there were a total of 544 (320 males, mean (SD) age 70.6 (14.5) years) patients thrombolysed and 193 patients underwent thrombectomy. For the January-June period, for which MoH stroke denominator rates were available, there was a thrombolysis rate of 10.4%. The overall median time (interquartile range, IQR) for onset-to-door was 76 minutes (48–118), door-to-computed tomography (CT) scan was 23 (15–36) minutes and CT-to-needle was 33 (20–51) minutes. The overall median (IQR) time delay from hospital arrival to thrombolysis was 59 (40–85) minutes and onset-to-needle median (IQR) time was 145 (110–196). There were a total of 26 (4.8%) symptomatic intracerebral haemorrhages (sICH) for the nine-month period. This compares with a thrombolysis rate of 9.85% and door-to-needle time median of 64 minutes in 2017.ConclusionThrombolysis rates in New Zealand continue to rise and now surpass the more recent 10% Ministry of Health target. The continued reduction in door-to-needle time is also an indication of continued service improvement resulting in better patient outcome. However, there are still to be opportunities for improvement.

Country-Wide Analysis of Systemic Factors Associated With Acute Ischemic Stroke Door to Needle Time.

Objective: Pre-hospital, in-hospital, and patient factors are associated with variation in door to needle (DTN) time in acute ischemic stroke (AIS). Publications are usually from large single centers or multicenter registries with less reporting on national results.Materials and methods: All AIS patients treated with intravenous tissue plasminogen activator (iv-tPA) over 4 years (2013–2016) in Northern Ireland were recorded prospectively, including patient demographics, pre-hospital care, thrombolysis rate, and DTN time. Logistic regression was performed to identify factors associated with DTN time.Results: One thousand two hundred and one patients from 10,556 stroke admissions (11.4%) were treated with iv-tPA. Median NIHSS was 10 (IQR 6-17). Median DTN time was 54 min (IQR 36-77) with 61% treated < 60 min from arrival at hospital. National thrombolysis numbers increased over time with improving DTN time (P = 0.002). Arrival method at hospital (ambulance OR 2.3 CI1.4-3.8) pre-alert from ambulance (pre-alert OR = 5.3 CI3.5-8.1) and time of day (out of hours, n = 650, OR 0.20 CI 0.22-0.38) all P < 0.001, were the independent factors in determining DTN time. Variation in DTN time between centers occurred but was unrelated to volume of stroke admissions.Conclusion: Ambulance transport with pre-hospital notification and time of day are associated with shorter DTN time on a national level. Most thrombolysis was delivered outside of normal working hours but these patients are more likely to experience treatment delays. Re-organization of stroke services at a whole system level with emphasis on pre-hospital care and design of stroke teams are required to improve quality and equitable care in AIS nationally.

Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP): study protocol for a randomised controlled trial

BackgroundSome studies have suggested that transdermal administration of glyceryl trinitrate (GTN; nitroglycerin) in the first few hours after symptom onset increases the chance of a favourable outcome after ischaemic stroke or intracerebral haemorrhage, possibly through an increase in intracranial collateral blood flow and a reduction in blood pressure. The Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP) aims to assess the effect of transdermal GTN, started within 3 h after stroke onset in the prehospital setting, on functional outcome at 90 days in patients with acute ischaemic stroke or intracerebral haemorrhage.MethodsMR ASAP is a phase III, multicentre, randomised, open-label clinical trial with a blinded outcome assessment. A total of 1400 adult patients with suspected stroke and a systolic blood pressure ≥ 140 mmHg will be randomised to transdermal GTN (5 mg/day), administered as a transdermal patch by paramedics in the prehospital setting within 3 h of stroke onset and continued for 24 h or to standard care. The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days, analysed with ordinal logistic regression. Secondary outcomes include blood pressure and collateral circulation at hospital admission, neurological deficit measured with the National Institutes of Health Stroke Scale at 24 h, and mortality and poor outcome (mRS score 3 to 6) at 90 days. This trial will be conducted in the Netherlands and will use a deferred consent procedure. The trial is part of the Collaboration for New Treatments of Acute Stroke (CONTRAST) programme.DiscussionMR ASAP will assess whether very early administration of GTN improves outcome after stroke in a setting where rates of intravenous thrombolysis and endovascular treatment for acute ischaemic stroke are high. The deferred consent procedure facilitates prompt GTN treatment and will prevent delay to revascularisation therapies. If early transdermal GTN treatment proves to be effective, this low-cost treatment can be readily implemented into daily clinical practice.Trial registrationISRCTN Registry, ISRCTN99503308. Registered on 2 January 2018.

Outcomes after Thrombectomy in Belfast: Mothership and Drip-and-Ship in the Real World

Background: Mechanical thrombectomy has revolutionised the treatment of acute ischaemic stroke due to large vessel occlusion. It is well recognised that patients are more likely to benefit when reperfusion happens quickly, however, there is uncertainty as to how best to deliver this service. Objectives: To compare outcomes of patients in Northern ­Ireland who underwent thrombectomy via direct admission to the single endovascular centre (mothership [MS]) with those transferred from primary stroke centres (drip-and-ship [DS]). Methods: Analysis was conducted on the records of all patients who underwent thrombectomy from January 2014 to December 2017 inclusive. The primary outcome measure was 3 months functional independence (modified Rankin Score [mRS] 0–2). Secondary outcome measures were full recovery (mRS 0) at 3 months, symptomatic intracranial haemorrhage (sICH) rates and mortality rates. Results: Two hundred fourteen patients underwent thrombectomy (MS 124, DS 90). Patients in the MS group were older (median 73 vs. 70 years, p = 0.026), but there was no significant difference in baseline National Institutes of Health Stroke Scale (median 15 MS vs. 16.5 DS, p = 0.162) or thrombolysis rates (41.9% MS vs. 54.4% DS, p = 0.070) between the groups. Time from stroke onset to arrival at thrombectomy centre was shorter in the MS group (median 71 vs. 218 min, p < 0.001) but door to groin puncture time was shorter in the DS group (median 30 vs. 60 min, p < 0.001). There was no significant difference in 3 months functional independence (51.6% MS vs. 62.2% DS, p = 0.123), or in the secondary outcome measures of full recovery (21.8% MS vs. 12.2% DS, p = 0.071), sICH (MS 0.8%, DS 4.4%, p = 0.082) and mortality (MS 24.2%, DS 20.0%, p = 0.468). Conclusions: Our analysis showed similar outcomes after thrombectomy in the MS and DS groups. For patients potentially eligible for thrombectomy, rapid access to the endovascular centre is essential to optimise both the number of patients treated and the outcomes achieved.

Sonothrombolysis with magnetic microbubbles under a rotational magnetic field

Thrombosis is an extremely critical clinical condition where a clot forms inside a blood vessel which blocks the blood flow through the cardiovascular system. Previous sonothrombolysis methods using ultrasound and microbubbles (MBs) often have a relatively low lysis rate due to the low microbubbles concentration at clot region caused by blood flow in the vessel. To solve this problem, the magnetic microbubbles (MMBs) that can be retained by an outer magnetic field against blood flow are used in this study. Here we report the development of a new method using the rotational magnetic field to trap and vibrate magnetic microbubbles at target clot region and then using an intravascular forward-looking ultrasound transducer to activate them acoustically. In this study, we investigated the influence of different blood flow conditions, vessel occlusion conditions (partial and fully occluded), clot ages (fresh, retracted), ultrasound parameters (input voltage, duty cycle) and rotational magnetic field parameters (amplitude, frequency) on the thrombolysis rate. The results showed that the additional use of magnetic microbubbles significantly enhances in vitro lysis of blood clot.

Functional stroke outcomes after mobile stroke unit deployment \u2013 the revised protocol for the Berlin Prehospital Or Usual Delivery of acute stroke care (B_PROUD) part 2 study

BackgroundStudies investigating the Mobile Stroke Unit (MSU) concept have shown increased thrombolysis rates, reduced alarm-to-treatment times and improved prehospital triage. Yet, so far, there is no definite scientific proof of better functional outcome after MSU deployment compared to regular ambulances.MethodsWe provide a revised protocol for the second part of the B_PROUD trial as organization of the MSU dispatch did not meet the anticipated standards in the first part. B_PROUD is a pragmatic, prospective study comparing functional outcomes of treatment candidates with or without MSU care. Treatment candidates are defined as patients with a final diagnosis of ischemic stroke or transient ischemic attack, onset-to-dispatch-times ≤4 h, disabling symptoms not resolved at time of ambulance arrival, and the ability to ambulate prior to the qualifying event. These patients are included if their emergency call prompted a stroke alarm at the dispatch center during MSU operation hours (7 am–11 pm, Monday-Sunday) and if the emergency is located within the MSU operation area in Berlin, Germany. The intervention group consists of patients who are cared for by the MSU. When the MSU is already in operation for another emergency, MSU dispatches are handled by regular ambulances (about 45%). These dispatches create the control group. Blinded stroke physicians assess the modified Rankin Scale (mRS) score in recorded structured interviews 3 months after stroke. The primary outcome is the degree of disability and death over the full range of the mRS. As a change to the previously published protocol and only pertinent in case of more than 9% lost-to-follow-up, a co-primary outcome was introduced consisting of the proportions of death, new institutional care or severe disability in patients with additional use of information from registration offices.PerspectiveThe results will inform parties involved in acute stroke care organization on the effectiveness of the MSU concept.Trial registrationThe protocol is registered in (NCT03931616) and has been approved by the ethical review committee of the Charité – University Medicine Berlin (EA4/109/15) on September 2, 2015. The study protocol of B_PROUD part 1 had been published in the International Journal of Stroke as “Berlin Prehospital Or Usual Delivery of acute stroke care (B_PROUD) – study protocol” (doi: https://doi.org/10.1177/1747493017700152) on March 22, 2017 [1] previous to first patient’s registration.

P.035 Impact of a telestroke system on acute ischemic stroke patient outcomes and thrombolysis rates

Background: Telestroke can improve ischemic stroke patient outcomes by improving access to physicians specialized in stroke care and increasing the rate of thrombolysis. The aim of this study to assess the effect of the newly implemented Telestroke service on ischemic stroke patient outcomes in New Brunswick, Canada, a province with a high rural population. Methods: By means of a retrospective chart review, data for 366 adult acute ischemic stroke patients (Telestroke = 15.3%; non-Telestroke = 84.7%) were collected from emergency departmentsspanning five sites in the province. Outcomes included home discharge rates, complications (i.e., hemorrhage,angioedema), mortality, rate of thrombolysis and time to treatment. Results: No significant differences emerged for home discharge rates, complications, mortality or door-to-needle time. Telestroke patients had a significantly greater rate of thrombolysis treatment (51.8% vs 6.1%) and significantly less door-to-CT time (M= 27.63 min vs M= 100.78 min) compared to the non-Telestroke group. Conclusions: Overall, both groups had similar outcomes with some trends toward improvements for patients utilizing Telestroke.

Efficacy of Catheter-directed Thrombolysis on Post-burn Deep Venous Thrombosis of Lower Extremity.

To observe the clinical effect of catheter-directed thrombolysis on deep venous thrombosis (DVT) of lower extremity after burn. An observational study. Invasive Technology Department, Binzhou City Center Hospital, China, from January 2015 to November 2017. Eighty-two patients with lower extremity DVT after burn were selected as the study object. All patients received catheter-directed thrombolysis and the clinical efficacy was evaluated. The blood coagulation parameters including plasma prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and fibrin original (FIB) and inflammatory response factors including interleukin (IL)-6, C-reactive protein (CRP) and D-dimer were compared before and after treatment. All interventional surgeries that the patients received were successful. The effective rate of catheter-directed thrombolysis was 98.78% (81 cases). After 6 days of treatment, compared with that before treatment, serum PT, APTT and TT were up-regulated (all p <0.001) and FIB was down-regulated (p <0.001). After 6 days of treatment, the levels of serum IL-6, CRP and D-dimer were lower than those before treatment (all p <0.001). No visceral hemorrhage occurred after 1 week of treatment. Catheter-directed thrombolysis of patients with lower extremity DVT after burn produces a good effect. It can improve the coagulation function and reduce the level of inflammatory response factors in patients with high safety.

Stroke risk factors and treatment variables in rural and urban Austria: An analysis of the Austrian Stroke Unit Registry.

Background and objectivesDifferences in stroke risk factors and treatment variables between rural and urban regions in Austria were analyzed retrospectively as European data on this topic are scarce.Research design and methodsWe performed statistical analysis using group comparisons and time series analysis of data of the Austrian Stroke Unit Registry between 2005 and 2016. 87411 patients were divided into three groups (rural, intermediate, urban) according to the degree of urbanisation classification of the European Commission/Eurostat.ResultsPatients in the rural group were significantly younger, more often female, had a lower pre-stroke disability, and were more frequently transported by an emergency physician. Vascular risk factors were significantly higher in urban patients, leading to a higher rate of microangiopathic etiology. Onset-to-door (ODT) and Onset-to-treatment times were significantly higher in the rural group, but ODTs decreased over time. Door-to-needle times and time to first vascular imaging were significantly lower in the rural group. Intravenous thrombolysis and rehabilitation rates were lower in urban patients.Discussion and implicationsContrary to previous literature predominantly from outside of Europe, vascular risk factors were higher in Austrian urban patients. Further, rural patients had higher intravenous thrombolysis and rehabilitation rates maybe because of lower pre-stroke disability. ODTs in rural patients were generally higher, but they decreased over time, which might be a consequence of better education of the public in noticing early stroke signs, better transportation and education of emergency medical personnel, better advance notification to the receiving hospital and implementation of Stroke Units in rural areas.

Thrombolysis Versus Primary Percutaneous Coronary Intervention For ST-segment Elevation Myocardial Infarction In Elderly Patients

Only few studies reported the outcomes of thrombolysis among elderly patients with ST-segment elevation myocardial infarction (STEMI), which results in a controversial benefit-risk ratio and a lower usage rate of thrombolysis in this population. The aim of the present study was to compare efficacy and safety of thrombolysis therapy with primary percutaneous coronary intervention (p-PCI) in patients aged ≥ 70 years old. Data from 2841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either thrombolysis therapy ( N = 269) or p-PCI ( N = 2572), were analyzed. The primary endpoint was in-hospital major adverse cardio-vascular events (MACE) defined as the composite of all-cause mortality, non-fatal MI, stroke and definite stent thrombosis (ST). Secondary endpoints included all-cause death, BARC 3 or 5 major bleeding, net adverse clinical events (NACE) and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the thrombolysis ( N = 247) and pPCI ( N = 958) groups, (11.3% vs. 9.0% respectively, OR: 1.25, 95% CI: 0.81–1.94; P = 0.31). Secondary endpoints were comparable between groups at the exception of a significant difference for the development of Killip class III or IV heart failure in favor of the thrombolysis group (3.3% vs. 9.3%, OR: 0.38, 95% CI: 0.18–0.79; P = 0.01) (Fig 1). Thrombolysis may be a safe and effective strategy in selected elderly patients, which may reduce the development of severe heart failure without a higher major bleeding rate.

Long-term cardiovascular prognosis after rotational atherectomy in hemodialysis patients: Data from the J2T multicenter registry

BackgroundHemodialysis (HD) patients have heavy calcium deposits in their stenotic coronary arteries and worse post-percutaneous coronary intervention (PCI) prognoses than those who do not undergo HD. Rotational atherectomy (RA) facilitates PCI success in severely calcified lesions. We aimed to identify clinical and procedural characteristics that predict HD patients' long-term prognoses after PCI that included RA in the drug-eluting stent (DES) era. MethodsThis study included 302 patients who underwent regular HD from J2T Multicenter Registry database of 1090 consecutive patients who underwent RA to treat de novo calcified lesions at three university hospitals between 2004 and 2015. The primary endpoint was cardiovascular (CV) death. ResultsDuring the 5-year observation period, 59 CV deaths (19.5%) occurred. The CV death group and non-CV death group had comparable profiles except significantly lower left ventricular ejection fraction, higher brain natriuretic peptide (BNP), lower rate of RA burr upsizing, and lower rate of final thrombolysis in myocardial infarction (TIMI) 3 flow achievement in the CV death group. Cox regression analysis revealed that increasing ablation burr size (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.13–0.81), final TIMI 3 flow (HR: 0.07; 95% CI: 0.02–0.28), lower BNP level, and optimal medication were independently associated with better CV mortality in HD patients. ConclusionIn the DES era, oral medications at the time of PCI and stepwise calcium ablation were associated with improved long-term CV mortality in HD patients who are scheduled to undergo RA to treat severely calcified coronary artery stenoses, as therapeutic strategies.

Measuring thrombolysis in a static model to assess ultrasound protocol efficacy

Over the years, EKOS has developed an efficacy measure called Lysis Enhancement Factor (LEF) to evaluate the performance of prototype ultrasound catheters and acoustic protocols. LEF is defined as the percent increase in the rate of lysis compared to tPA alone as measured in our simple clot model consisting of a plasma clot in a static tube. The amount of thrombolysis can be measured by determining the change in fibrin weight compared to control clots. The LEF is expressed as a percent change in the thrombolysis rate compared to lytic control. When the EkoSonic catheter was initially launched, the in vitro LEF was about 50% using a constant amplitude pulsed ultrasound protocol with an average power of 2.7 W per transducer group. Later, the MACH4 ultrasound protocol was introduced with an LEF of about 70%. This protocol had a higher average power (3.5W) and consisted of variable pulse amplitudes, which were randomly sequenced. Further investigations with the clot model lead to the development of the currently marketed MACH4e protocol with an LEF of about 90% but with variable amplitude pulses, which cycle up and down. The clot model and LEF are being used to further develop EKOS’ technologies.

Short-term versus long-term triple antithrombotic therapy for patients with coronary stents and requiring oral anticoagulation: a meta-analysis of randomized clinical trials.

The cornerstone therapy for patients with coronary stents is dual antiplatelet therapy (DAPT). In 5-10% of these patients, oral anticoagulation (OAC) is clearly indicated in addition to DAPT. However, the optimal duration of this triple antithrombotic therapy (TAT) remains uncertain. Scientific databases and websites were searched for randomized clinical trials (RCTs). RCTs were included if patients undergoing coronary stent placements with additional indications of chronic OAC were randomly assigned to either short-term TAT or long-term TAT. Short-term TAT was defined as no more than 6 weeks of TAT, and long-term TAT was defined as 6-12 months of TAT RESULTS: Using data from three RCTs and 1883 patients, short-term TAT was associated with decreased rates of major adverse cardiovascular events, cardiac mortality, all-cause mortality, and any-bleeding events compared to long-term TAT, but similar rates of myocardial infarction, stroke, stent thrombosis, and thrombolysis in myocardial infarction major bleeding. Furthermore, in subgroup analysis, short-term TAT was associated with decreased rates of major adverse cardiovascular events, cardiac mortality, all-cause mortality, and any-bleeding compared to 12-month TAT, but similar rates compared to 6-month TAT. In patients who require chronic OAC therapy and undergo coronary stent placement, short-term TAT was associated with better efficacy and safety outcomes compared to long-term TAT.

Abstract WP387: Language Barrier Impacts Outcome From Acute Ischemic Stroke Without Effect on Receiving Intravenous Thrombolysis

Objectives: Early treatment is crucial for patients with acute ischemic stroke (AIS). Language barrier may delay evaluation and therapy. This study aimed to evaluate the impact of primary language on outcome in patients with AIS. Methods: This is a retrospective study of consecutive patients with AIS at our institution from January 1, 2013 to December 31, 2016. Data were collected from the electronic medical record and the Get With the Guidelines database. Patients were divided into three groups by primary language. Outcome measures include rate of intravenous thrombolysis (IVT), length of stay (LOS), functional outcome per modified Rankin scale (mRS), and mortality at hospital discharge. Statistical analysis was done by non-parametric testing with Kruskal-Wallis for multiple comparisons between groups and Chi-square analysis for comparison of proportions. Results: Among the 1,117 patients included within the study period, 189 received IVT. In this cohort, 759 patients spoke English, 194 spoke Spanish, and 164 spoke Other languages including Vietnamese, Arabic, and Mandarin. The severity of stroke per mean NIHSS on arrival was highest at 12 (95% CI, 10-13) in Other-language group, 9.1 (95% CI, 8.5-9.7, P &lt;0.001) in English group and 8.6 (95% CI, 7.5-9.7, P =0.002) in Spanish group. There was no significant difference in the rate of receiving IVT among the 3 groups, with 16% in English and Spanish groups and 19.5% in Other-language group ( P =0.62). The Other language group has significantly longer LOS (6.7, 95% CI 5.6-7.8) than the Spanish (6.0, 95% CI 5.0-6.9) and English (5.2, 95% CI, 4.8-5.6, P &lt;0.001) groups and worse outcomes with mean mRS 3.5 (95% CI, 3.2-3.7) at hospital discharge compared to English (2.9, 95% CI, 2.8-3.1, P =0.008) and Spanish (2.9, 95% CI, 2.7-3.2, P =0.02) groups, and lower rate of favorable outcome with mRS 0-2 (26.8%) compared to English (41.5%) and Spanish groups (38.7%) ( P =0.0022). Mortality was not significantly different between English (7.9%), Spanish (3.2%), and Other groups (7.9%, P =0.06). Conclusions: At our multiethnic cohort, primary language has no effect on acute stroke therapy with IVT. However, the non-English and non-Spanish speaking patients tended to have longer LOS and worse functional outcome.

Abstract WP301: Clinical characteristics and Outcomes of Acute Ischemic Stroke by Hospital Arrival Time : CRCS-K (Clinical Research Collaboration for Stroke in Korea) registry

Background and Objectives: The aim of this study was to evaluate the clinical characteristics and outcomes of acute ischemic stroke according to the patients’ arrival time at hospital. Methods: In this prospective stroke registry, all consecutive patients, who admitted via emergency room of 12 participating centers nationwide from 2009/12 to 2017/11, were identified. All patients were presented with first-ever stroke within 7 days from symptom onset, and had relevant ischemic lesions on brain imaging. We categorized hospital arrival time into 4 groups, such as early morning (EM, 0 to 6), late morning (LM, 6 to 12), afternoon (AF, 12 to 18), and evening (EV, 18 to 24 o’clock). Results: Total of 31992 patients were included. In patients arriving in EM, the number was 2034 (6.4%) [vs. 9400 (29.4%), 13277 (41.5%), 7281 (22.8%)], age (mean) was 64.9 years (vs. 68.2, 67.4, and 67.0, p&lt;0.001), subtype of cardioembolism was 26.7% (vs. 21.6%, 20.3%, and 24.4%, p&lt;0.001), initial NIHSS (median) was 4 (vs. 4, 3 and 4, p&lt;0.001), the rates of total thrombolysis (IV+IA) was 24.8% (vs. 17.9%, 14.8%, and 21.4%, p&lt;0.001), and mRS (0-2) at 3 months was 53.6% (vs. 58.4%, 62.7%, 58.9%, p&lt;0.001) compared to LM, AF, and EV, respectively. Conclusion: Though the number of patients arriving at hospital in EM was lowest, that group required highest rate of thrombolysis, showed younger age, higher cardioembolism, higher stroke severity, and poor functional outcome at 3 months. Adequate management needs to be considered for the patients arriving in EM.

Abstract WP427: Thrombolysis in With Patients With Down Syndrome and Ischemic Stroke

Background: Down Syndrome (DS) is a genetic disorder cause by trisomy 21. With improvements in medical care, the life expectancy of individuals with DS has increased. As this population ages, they are at risk of strokes. They may have a higher predisposition for cardio embolic strokes given that DS is associated with congenital heart disease. There is scarce data regarding strokes in the DS population. Methods: Nationwide Inpatient Sample (NIS) from 2005 to 2014 was utilized to identify down syndrome patients using ICD CM code 758.0 in secondary diagnostic field and acute ischemic stroke (AIS) with appropriate diagnostic codes in primary field. Intravascular thrombolysis utilization was identified by ICD9 procedure code 99.10 in any procedural field. Differences between categorical variables were tested using the chi-square test and continuous variables using the Student t-test. Results: We identified 4332783 patients with acute ischemic stroke (AIS), 1333 (0.03%) also had a diagnosis of DS. Average age was 71.2years; 47.2% were male and 52.8% female. Patients with DS and AIS were younger (45.6yo vs 71.2years; p&lt;0.0001). They were also more likely to be female (60.7 % vs. 52.8%; p&lt;0.0001). Despite being younger and having less comorbid conditions, patients with ischemic stroke who have DS are less likely to receive thrombolysis than those with ischemic stroke without DS (3.67% vs 5.77%; p =0.001). Although, there was no statistically significant difference in the use of mechanical thrombectomy. DS patients that received thrombolysis were more likely to be male (61.8% vs 38.2%; p=0.0011), and at a teaching hospital (p=0.0016). However, there was increased in-hospital mortality among those DS patients who received thrombolysis compared to the group without thrombolysis (20.5% vs. 5.7%; p=0.004). Conclusion: Patients with DS and AIS have a decreased rate of thrombolysis, yet similar rates of mechanical thrombectomy. However, those DS patients that received thrombolysis had increased in-hospital mortality. We postulate that this may be secondary to increased beta-amyloid peptide accumulation and risk of cerebral amyloid angiopathy in DS. Thrombolysis in this population needs to be further studied.