Received Tissue Plasminogen Activator Research Articles

Novel Algorithm to Help Identify Stroke Mimics

Stroke is a major cause of disability in the United States. A portion of patients presenting with stroke-like symptoms in the emergency room who receive tissue plasminogen activator (tPA) do not end up having a true stroke, leading to unnecessary health-care costs. The aim of our study is to identify those patients who have a high likelihood of experiencing a stroke mimic using a novel stroke mimic score and to identify a cutoff point with a high specificity of ruling in stroke mimics. We reviewed literature on stroke mimics and the various associated risk factors. We devised a 9-point scoring system and applied it retrospectively to patients who received tPA from 2010 to 2014 to calculate a score for each patient. The final sample size was 105 patients, out of which 25% turned out to be patients with stroke mimics. Patients with stroke mimic were significantly younger and more likely to have history of seizure, migraine, or prior psychiatric illness. History of atrial fibrillation had the highest correlation with true stroke. We found approximately 100% specificity in ruling in a stroke mimic if a patient scored more than 5 points. Our stroke mimic scoring system along with a basic neurologic examination could be a useful tool in the identification of stroke mimics with a high specificity in the emergency room setting. These patients may require further studies such as rapid magnetic resonance imaging, which would decrease unnecessary tPA administration and hospital admissions.

TPA-Induced Angioedema in a Patient Taking Angiotensin Converting Enzyme Inhibitors: A Case Report and Review of the Literature

SESSION TITLE: Nervous System Disorders in the ICU 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Asymmetric Orolingual Angioedema (AOA) is a rare, but important and potentially fatal adverse drug reaction that requires prompt recognition. We present a case of AOA in a 96-year-old woman after receiving tissue plasminogen activator (tPA). AOA is characterized by often unilateral swelling of the tongue and lips that in severe cases can result in airway obstruction. In this report, we describe a patient on angiotensin converting enzyme inhibitor (ACEI) who presented with angioedema after tPA administration. CASE PRESENTATION: This is a 96 year old female with a past medical history of two transient ischemic attacks, hypertension on lisinopril, presenting with 2 hours of right sided hemiparesis and slurred speech. In the emergency room, patient’s neurologic status continued to decline to severe aphasia, right upper and lower flaccidity. NIHSS score was 20. Stroke code was activated and computed tomography of the head without contrast revealed no acute hemorrhage. tPA was administered and 11 minutes later the nurse noticed partial swelling of left side of tongue and urticaria of the right cheek. Benadryl, Epinephrine and Solu-medrol were immediately given with no interval decrease in swelling. The decision was made to intubate for airway protection. During the course of her ICU stay, patient’s swelling improved and eventual MRI was found to be negative for acute stroke. DISCUSSION: In a systematic review of manuscripts between 1950-2012, only 41 cases of tPA induced angioedema are described with an incidence ranging from 1.7 to 5.8%. While thought to be very infrequent, a trend in the increase of primary stroke centers and therefore tPA use will likely lead to an increase in adverse event reports. The pathophysiologic mechanism of this disease is poorly understood, but thought to involve plasmin and complement mediated bradykinin release. While the relationship is unclear, reports have discovered an association of AOA with middle cerebral artery infarction and prior use of ACEI. Our patient was on Lisinopril at home, but was found not to have acute infarction on MRI. As the potential of catastrophic airway compromise is high, detailed history on ACEI use, previous tPA administration, and C1-esterase inhibitor deficiency must be taken. CONCLUSIONS: In conclusion, with the development and increasingly strong evidence of benefit of early fibrinolytics in acute ischemic stroke, tPA use has increased. This is the first case of AOA at our institution. In the setting of acute stroke in patients with previous angiotensin converting inhibitor use, close monitoring is necessary post-administration in case emergent intervention is necessary. Reference #1: Hill MD, et al. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. Neurology. 2003;60(9):1525-7. Reference #2: Hill MD, et al. Anaphylactoid reactions and angioedema during alteplase treatment of acute ischemic stroke. CMAJ. 2000;162(9):1281-4. DISCLOSURE: The following authors have nothing to disclose: Christian Castaneda, Samarth Beri, Sheelan Karim No Product/Research Disclosure Information

Efficacy and safety of recombinant tissue plasminogen activator for venous thrombosis after paediatric heart surgery.

Reports in the literature of treatment with recombinant tissue plasminogen activator following cardiac surgery are limited. We reviewed our experience to provide a case series of the therapeutic use of tissue plasminogen activator for the treatment of venous thrombosis in children after cardiac surgery. The data describe the morbidity, mortality, and clinical outcomes of tissue plasminogen activator administration for treatment of venous thrombosis in children following cardiac surgery. The study was designed as a retrospective case series. The study was carried out in a 25-bed cardiac intensive care unit in an academic, free-standing paediatric hospital. Patients All children who received tissue plasminogen activator for venous thrombosis within 60 days of cardiac surgery, a total of 13 patients, were included. Interventions Data was collected, collated, and analysed as a part of the interventions of this study. Measurements and main results Patients treated with tissue plasminogen activator were principally young infants (median 0.2, IQR 0.07-0.58 years) who had recently (22, IQR 12.5-27.3 days) undergone cardiac surgery. Hospital mortality was high in this patient group (38%), but there was no mortality attributable to tissue plasminogen activator administration, occurring within <72 hours. There was one major haemorrhagic complication that may be attributable to tissue plasminogen activator. Complete or partial resolution of venous thrombosis was confirmed using imaging in 10 of 13 patients (77%), and tissue plasminogen activator administration was associated with resolution of chylous drainage, with no drainage through chest tubes, at 10 days after tissue plasminogen activator treatment in seven of nine patients who had upper-compartment venous thrombosis-associated chylothorax. On the basis of our experience with administration of tissue plasminogen activator in children after cardiac surgery, tissue plasminogen activator is both safe and effective for resolution of venous thrombosis in this high-risk population.

Intra-arterial Thrombolysis for Extremity Frostbite Decreases Digital Amputation Rates and Hospital Length of Stay.

To report outcomes of intra-arterial thrombolysis versus non-thrombolytic management of severe frostbite with respect to digital amputation rates and hospital length of stay (LOS). Seventeen patients with severe frostbite were identified from 2000 to 2017. Eight (47%) patients with mean age of 40years underwent intra-arterial thrombolysis and served as the treatment group. Nine (53%) patients with mean age of 53years received non-thrombolytic management and served as the control group. 2/8 (25%) treatment and 3/9 (33%) control patients had underlying vascular comorbidities (p=0.25). Number of digits at risk, duration of thrombolysis, thrombolytic agents used, digits amputated, hospital LOS, and complications were recorded. Seven upper and nine lower extremities for a total of 80 digits were at risk in the treatment cohort. Eight upper and 12 lower extremities for a total of 100 digits were at risk in the control group. Mean duration of thrombolysis was 26h. All treatment patients received tissue plasminogen activator in addition to systemic heparin. 4/16 (25%) limbs received intra-arterial alprostadil, 2/16 (13%) received nitroglycerin, and 2/16 (13%) received nicardipine. 12/80 (15%) treatment digits and 77/100 (77%) control digits required amputation (p=0.003). Average hospital LOS was 14days in the treatment group and 38days in the control group (p=0.011). No major complications occurred in the treatment group; however, 2/9 (22%) patients in the control group required extended hospitalizations secondary to amputation complications. Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.

A System-Based Intervention to Improve Access to Hyperacute Stroke Care.

Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move "walk-in" patients from non-hyperacute hospitals to regional stroke centres (RSCs). Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes, p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%. A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.

Editors' Note

Editors' Note: In China, the most common reason for eligible patients with acute strokes to not receive tissue plasminogen activator is patient or family refusal, while in the United States, it is mild or resolving symptoms. Hu et al. and article authors Messé and Schwamm discuss possible reasons for this difference. In reference to “Therapeutic coma for status epilepticus: Differing practices in a prospective multicenter study,” Dr. Sethi states that since the study showed that therapeutic coma in status epilepticus resulted in an increased length of stay and associated costs with no change in mortality, the recommendation to follow published evidence-based guidelines in the treatment of status epilepticus should remain in place, with the use of therapeutic coma considered on a case-by-case basis. Authors Alvarez et al. agree. —Megan Alcauskas, MD, and Robert C. Griggs, MD Editors' Note: In China, the most common reason for eligible patients with acute strokes to not receive tissue plasminogen activator is patient or family refusal, while in the United States, it is mild or resolving symptoms. Hu et al. and article authors Messé and Schwamm discuss possible reasons for this difference.

Vascular closure devices in stroke patients receiving tissue plasminogen activator: A retrospective analysis from an academic tertiary medical center and a teaching community hospital stroke database

ObjectivesTo determine the safety and effectiveness of vascular closure devices in prevention of access site complications in acute stroke patient receiving intravenous (IV) and/or intra-arterial (IA) IV tissue plasminogen activator (tPA). Patients and methodsAll patients with acute stroke onset treated with IV and/or IA tPA closed with vascular closure device and adult age (>18 years) were identified from an academic tertiary medical center and a teaching community hospital stroke database for 9 years (from March 2005 to June 2014). ResultsA total of 69 patients were included in the study. The mean age was 68.86±16.70 years and 49.2% female. All accesses were under fluoroscopic guidance into the right common femoral artery. We observed a 5.8% complication rate in patients receiving IV and/or IA tPA closed with vascular closure device. Access site complications included 3 cases of hematoma and 1 case of residual oozing. One patient required transfusion due to access site hematoma. Three patients were on aspirin and heparin and 1 was on no prior anticoagulation. ConclusionsVascular closure device access site hemorrhagic complication rate in those receiving IV and/or IA tPA is low and similar to reported rates in those not receiving thrombolytic therapy. Vascular closure device use in patients receiving thrombolytic therapy is safe and effectively achieves hemostasis.

Abstract 226: Strokes Worse in Women at 24 hours but Severity Reduced in Younger Women With Hormone Therapy

Background: Gender related differences in stroke incidence hallmark the increased observation of women experiencing strokes later in life. Complications of women longevity has accounted for their increased risk of cardiovascular and cerebrovascular diseases. However, the severity of acute ischemic stroke (AIS) outcomes in women remains problematic. Previous studies have reported that women experience more disabilities and have poorer outcomes at three month follow-ups and may be related back to age at the time of stroke. We retrospectively examined 12 months of neurology consults in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telemedicine program. Objective: To investigate whether gender influenced recovery at 24 hours following therapy for AIS. Methods: During 12 consecutive months 809 patients received neurology acute stroke consults and 238 (29%) received tissue plasminogen activator (tPA). Outcome data at 24 hours was available on 216 tPA-consults. Patient demographics, age, and gender, were analyzed along with baseline and 24 hour outcome National Institutes of Health Stroke Scale (NIHSS), onset to tPA, smoking, alcoholism, and hormone replacement therapy (HRT). Co-morbidity information collected included previous transient ischemic attacks (TIA), atrial fib (AF), diabetes, chronic obstructive pulmonary disease (COPD), hypertension (HT), hyperglycemia and coronary artery disease (CAD). Results: A total of 108 men and 108 women tPA treated patients showed no significant differences in age for male vs. female (mean±se 67.5±1.3 vs. 70±1.5, p=0.79). However, the men had twice the number of women in the 70-79 age range and women had twice the number of men at &gt;80 years of age ( χ 2 p=0.0096 for all age ranges for both sexes). While baseline NIHSS was not significant in men vs. women (10.8±0.6 and 11.8±0.7, p=0.32, respectively), the women’s 24 hour NIHSS was significantly greater (5.9±0.7 vs. 9.1±0.9, p=0.0047, respectively). The incidence of HRT use in n=11 women &lt; 80 years of age was associated with lower NIHSS’s at 24 hours vs. women without HRT (2.3±0.8 vs. 8.7±1.4, p=0.03, respectively). Males had a higher incidence of smoking ( χ 2 p=0.007). All other co-morbidities occurred equally between sexes. Conclusion: Women in this study had more severe 24 hour AIS outcomes than men but this improved with HRT use in women younger than 80 years. This cannot be fully explained by age differences as there could be other underlying factors. Improving 24 hour NIHSS may correctly predict later outcomes following AIS. Further study of HRT use in AIS outcomes is justified.

Stop Stroke: A Brief Report on Door-to-Needle Times and Performance After Implementing an Acute Care Coordination Medical Application and Implications to Emergency Medical Services.

The objective of this study was to evaluate the effect of the Stop Stroke (Pulsara; Bozeman, Montana USA) medical application on door-to-needle (DTN) time in patients presenting to the emergency department (ED) with an acute ischemic stroke (AIS). This was a retrospective cohort study of the Good Shepherd Health System (Longview, Texas USA) stroke quality improvement dashboard for a 25-month period from February 2012 through February 2014. Data analysis includes all data from Center for Medicare and Medicaid Services (CMS; Baltimore, Maryland USA) reportable cases receiving Tissue Plasminogen Activator (TPA) for AIS during the study period. The primary outcome was mean DTN times before and after initiating Stop Stroke. Secondary outcome was the effect on the DTN≤60-minute benchmark. During the study period, there were 533 stroke activations (200 before Stop Stroke implementation and 333 after). A total of 68 patients meeting inclusion criteria were analyzed (34 pre-app and 34 post- app). The observed mean DTN times post-app decreased 21 minutes (77 to 56 minutes), a 28% improvement (P=.001). Further, the patients meeting DTN≤60 minutes improved from 32% (11 of 34) to 82% (28 of 34) after the app's implementation. In this cohort of patients with AIS, Stop Stroke improved mean DTN times and number of patients treated within 60 minutes of arrival. These results demonstrate the app's effect of increasing awareness of suspected AIS and improving coordination of care, evidenced by the magnitude of its effect on treatment times. Dickson R , Nedelcut A , McPeek Nedelcut M . Stop Stroke: a brief report on door-to-needle times and performance after implementing an acute care coordination medical application and implications to Emergency Medical Services. Prehosp Disaster Med. 2017;32(3):343-347.

Abstract WP336: Impact of Anti-Hypertensive Interventions for Treatment of Acute Ischemic Stroke in Patients Receiving Tissue Plasminogen Activator

Introduction: Early treatment of acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset is associated with neurologic improvement. A risk of rtPA is hemorrhagic conversion, which has a higher incidence in patients with elevated blood pressure at presentation. Current literature supports the use of blood pressure goals (&lt;185/110 mm Hg) in patients qualifying for rtPA, but the effects of anti-hypertensive (anti-HTN) medications within the first 24 hours of AIS on outcomes has not been evaluated. Hypothesis: AIS patients requiring anti-HTN medications (anti-HTN group) before rtPA have a poorer outcome at 90 days compared to those that do not need anti-HTN medications (control group). Methods: This was a retrospective cohort study of patients &gt;18 years diagnosed with AIS from January 2011 through December 2015 who received one or multiple anti-HTN medication(s) prior to rtPA administration, compared to control patients who did not. Primary endpoint was poor outcome at 90 days, defined as a modified Rankin Scale (mRS) of ≥3. Univariate analysis with Chi-square, Fisher’s exact test or t-test was performed. Multivariate analysis was conducted. Results: Of 235 patients evaluated for AIS, 145 (61.7%) were included. Baseline demographics were well matched, though more patients in the anti-HTN group had a history of HTN (86.7% vs. 62.5%, p&lt;0.01), diabetes (33.3% vs. 17.5%, p=0.04) and chronic kidney disease (20% vs. 7.5%, p=0.04). There was no difference in the primary endpoint of poor outcome (mRS ≥3) between groups who received blood pressure medication versus those who did not (37% anti-HTN group vs. 30% control, p=.374). There was no difference in hemorrhagic conversion (13.3% anti-HTN group vs. 6.3% control, p=.187). Mortality at 90 days did not differ between groups (11% who received anti-HTN vs. 7.5%, p=.508). Conclusion: No difference was observed in poor outcomes, hemorrhagic conversion, or 90-day mortality in patients receiving anti-HTN medications prior to rtPA compared to those that did not. These results suggest that aggressive blood pressure management should be used to control hypertension in AIS who may qualify for rtPA, though larger, randomized trials are needed to confirm this finding.

Elevated Homocysteine Level Related to Poor Outcome After Thrombolysis in Acute Ischemic Stroke.

BackgroundHyperhomocysteinemia (HHcy) is a well-known risk factor for ischemic stroke. However, whether HHcy can influence the treatment outcome of acute ischemic stroke (AIS) patients has yet to be fully determined. In this study, we investigated the relationship between serum homocysteine (Hcy) level and prognosis in AIS patients who received tissue plasminogen activator (tPA) treatment.Material/MethodsPatients were recruited according to the research criteria and grouped by their serum Hcy levels. Neurological outcome was evaluated by National Institute of Health Stroke Scale (NIHSS) score system before and 1 week after treatment, and functional outcome was evaluated by modified Rankin Scale (MRS) score system after 3 months. All patients took CT/MRI examination to detect cerebral hemorrhage in 24 hours after tPA treatment. Receiver operating characteristic curve (ROC) was employed to assess if serum homocysteine level can be used as an index to predict the outcome after tPA treatment.ResultsThe mean (±SD) serum Hcy level of 194 patients was 22.62±21.23 μmol/L. After 1-week tPA treatment, the NIHSS scores of high Hcy level group were significantly higher than those of low level group (p<0.05), meantime the high Hcy group showed obvious symptomatic intracerebral hemorrhage risk after 24 hours (p<0.05). Poor outcome was presented in mRS score results after 3 months in high Hcy level group, which compared with low Hcy level group (p<0.01). The ROC showed that Hcy level was a moderately sensitive and specific index to predict the prognosis with an optimal cut-off value at 19.95 μmol/L (sensitivity [58.2%], specificity [80.3%]).ConclusionsHigh serum homocysteine level could potentially predict poor prognosis in acute ischemic stroke patients after tPA treatment.

Acute Antithrombotics and Hemorrhage After Ischemic Stroke

For patients with acute ischemic stroke who receive tissue plasminogen activator (TPA), antithrombotic agents such as aspirin customarily are withheld

The Influence of Language Discordance Between Patient and Physician on Time-to-Thrombolysis in Acute Ischemic Stroke.

Reducing door-to-imaging (DIT) time is a major focus of acute stroke quality improvement initiatives to promote rapid thrombolysis. However, recent data suggest that the imaging-to-needle (ITN) time is a greater source of treatment delay. We hypothesized that language discordance between physician and patient would contribute to prolonged ITN time, as rapidly taking a history and confirming last known well require facile communication between physician and patient. This is a retrospective analysis of all patients who received tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2014. Baseline characteristics and relevant time intervals were compared between encounters where the treating neurologist and patient spoke the same language (concordant cases) and where they did not (discordant cases). A total of 279 patients received tPA during the study period. English was the primary language for 51%, Spanish for 46%, and other languages for 3%; 59% of cases were classified as language concordant and 41% as discordant. We found no differences in median DIT (24 vs 25, P = .5), ITN time (33 vs 30, P = .3), or door-to-needle time (DTN; 58 vs 55, P = .1) between concordant and discordant groups. Similarly, among patients with the fastest and slowest ITN times, there were no differences. In a high-volume stroke center with a large proportion of Spanish speakers, language discordance was not associated with changes in DIT, ITN time, or DTN time.

The lack of documentation of preferences in a cohort of adults who died after ischemic stroke

To measure the extent and timing of physicians' documentation of communication with patients and families regarding limitations on life-sustaining interventions, in a population cohort of adults who died within 30 days after hospitalization for ischemic stroke. We used the California Office of Statewide Health Planning and Development Patient Discharge Database to identify a retrospective cohort of adults with ischemic strokes at all California acute care hospitals from December 2006 to November 2007. Of 326 eligible hospitals, a representative sample of 39 was selected, stratified by stroke volume and mortality. Medical records of 981 admissions were abstracted, oversampled on mortality and tissue plasminogen activator receipt. Among 198 patients who died by 30 days postadmission, overall proportions and timing of documented preferences were calculated; factors associated with documentation were explored. Of the 198 decedents, mean age was 80 years, 78% were admitted from home, 19% had mild strokes, 11% received tissue plasminogen activator, and 42% died during the index hospitalization. Preferences about at least one life-sustaining intervention were recorded on 39% of patients: cardiopulmonary resuscitation 34%, mechanical ventilation 23%, nasogastric tube feeding 10%, and percutaneous enteral feeding 6%. Most discussions occurred within 5 days of death. Greater stroke severity was associated with increased in-hospital documentation of preferences (p < 0.05). Documented discussions about limitations on life-sustaining interventions during hospitalization were low, even though this cohort died within 30 days poststroke. Improving the documentation of preferences may be difficult given the 2015 Centers for Medicare and Medicaid 30-day stroke mortality hospital performance measure that is unadjusted for patient preferences regarding life-sustaining interventions.

Very Early versus Delayed Rehabilitation for Acute Ischemic Stroke Patients with Intravenous Recombinant Tissue Plasminogen Activator: A Nationwide Retrospective Cohort Study

Background: Although the safety and feasibility of very early rehabilitation for stroke are well recognized, the initiation of rehabilitation is sometimes delayed after thrombolysis. The purpose of this study was to clarify the association between very early rehabilitation and outcomes in acute ischemic stroke patients who received tissue plasminogen activator, using a national inpatient database in Japan. Methods: We identified patients who were admitted to acute-care hospitals with ischemic stroke and were treated with intravenous recombinant tissue plasminogen activator on the same day of stroke onset and received rehabilitation within 3 days from admission. The primary outcome was functional independence on discharge. We compared the outcomes of a very early rehabilitation group with a comparison group. Results: We identified 6,153 eligible patients, of whom 4,266 received very early rehabilitation. The proportion of functional independence on discharge was 41.2 and 36.6% in the very early rehabilitation group and the comparison group, respectively. Multivariable logistic regression analysis showed that the very early rehabilitation was significantly associated with a higher proportion of functional independence after adjustment for confounding factors. There was no significant difference in 7-, 30-, 90-day mortality or incidence of intracerebral hemorrhage between the groups after adjusting for baseline characteristics. Instrumental variable analysis confirmed a higher proportion of functionally independent patients in the very early rehabilitation group. Conclusion: Patients with acute ischemic stroke undergoing very early rehabilitation after thrombolysis were more likely to achieve functional independence without an increase in adverse outcomes.

Stop Stroke© Acute Care Coordination Medical Application: A Brief Report on Postimplementation Performance at a Primary Stroke Center

The objective of our study was to evaluate the effect of the Pulsara Stop Stroke© medical application on door-to-needle (DTN) time in patients presenting to our emergency department with acute ischemic stroke (AIS). The secondary objective was to evaluate the DTN performance of dedicated neurohospitalists versus private practice neurologists covering emergency department stroke call. We conducted a retrospective cohort study of the Good Shepherd Health System stroke quality improvement dashboard for an 18-month period. The primary outcome was mean DTN time performance in cases with and without Stop Stroke© usage. Secondary outcome was mean DTN time between neurohospitalist and private neurologists with and without use of Stop Stroke©. During the study period, there were 85 stroke activations receiving tissue plasminogen activator (63 with Stop Stroke©, 22 without Stop Stroke©). In cases where the app was used, we observed a reduction in mean DTN time of 40 minutes (87-47 minutes), a 46% reduction. There was no significant difference in DTN time observed between the neurohospitalist and private neurologist performance independent of app usage. Mean DTN less than 60 minutes improved with app use from 18% to 85% with Stop Stroke©. In patients arriving to our primary stroke center with AIS, use of Pulsara Stop Stroke© acute care coordination app decreased mean DTN time by 40 minutes, a significant 46% improvement in this metric and is consistent with other studies of the app. We further observed a 3.7× improvement in DTN less than 60 minutes with use of the app.

24/7 Neurocritical Care Nurse Practitioner Coverage Reduced Door-to-Needle Time in Stroke Patients Treated with Tissue Plasminogen Activator

Stroke centers with limited on-site neurovascular physician coverage may experience delays in acute stroke treatment. We sought to assess the impact of providing 24/7 neurocritical care acute care nurse practitioner (ACNP) "stroke code" first responder coverage on treatment delays in acute stroke patients who received tissue plasminogen activator (tPA). Consecutive acute ischemic stroke patients treated with intravenous tPA at a primary stroke center on Oahu between 2009 and 2014were retrospectively studied. 24/7 ACNP stroke code coverage (intervention) was introduced on July 1, 2011. The tPA utilization, door-to-needle (DTN) time, imaging-to-needle (ITN) time, and independent ambulation at hospital discharge were compared between the preintervention period (24 months) and the postintervention period (33 months). We studied 166 stroke code patients who were treated with intravenous tPA, 44 of whom were treated during the preintervention period and 122 of whom were treated during the postintervention period. After the intervention, the median DTN time was reduced from 53 minutes (interquartile range [IQR] 45-73) to 45 minutes (IQR 35-58) (P = .001), and the median ITN time was reduced from 36 minutes (IQR 28-64) to 21 minutes (IQR 16-31) (P < .0001). Compliance with the 60-minute target DTN improved from 61.4% (27 of 44 patients) in the preintervention period to 81.2% (99 of 122 patients) in the postintervention period (P = .004). The tPA treatment rates were similar between the preintervention and postintervention periods (P = .60). Addition of 24/7 on-site neurocritical care ACNP first responder coverage for acute stroke code significantly reduced the DTN time among acute stroke patients treated with tPA.

Decrease of Hyperintense Vessels on Fluid-Attenuated Inversion Recovery Predicts Good Outcome in t-PA Patients

Background and Purpose: Hyperintense vessels (HV) detected on fluid-attenuated inversion recovery (FLAIR) in patients with acute ischemic stroke (AIS) indicate cerebral hypoperfusion. However, the clinical meaning of changes in HV is yet to be clarified. Here, we investigated serial changes to HV in patients with AIS who received tissue plasminogen activator (t-PA) therapy. Methods: We studied t-PA patients presenting with HV on FLAIR in the middle cerebral artery territory. Patients underwent brain MRI 1 h before and after t-PA infusion. HV scores (range 1-7) were evaluated according to Alberta Stroke Program Early Computed Tomography Score territories, and then by subtracting HV scores at 1 h after t-PA infusion from those on admission, with a result of >1 defined as decrease in HV score (DHV). Patients were divided into 2 groups based on the presence or absence of DHV. Multivariate logistic regression analysis was conducted to identify variables independently associated with good outcome (modified Rankin Scale score at 90 days after stroke onset of 0-1). Results: A total of 118 consecutive patients were enrolled (73 men; mean age 76 ± 9.7; median initial National Institutes of Health Stroke Scale (NIHSS) 13; median initial HV score 5), of whom 52 (44%) had DHV. Patients with DHV showed a significantly lower NIHSS time course (p < 0.001) and significantly smaller infarct volume time course (p < 0.001) compared to those without DHV. Multivariate analysis showed that DHV was independently associated with good outcome (OR 3.89; 95% CI 1.55-9.77; p < 0.01). The sensitivity and specificity of DHV for good outcome were 70 and 68%, respectively. Conclusion: A DHV on FLAIR predicts good outcome in patients receiving t-PA.

Barriers for acute ischemic stroke treatment using recombinant tissue plasminogen activator in Mansoura Emergency Hospital: prehospital and inhospital delay factors

Introduction Effective treatment must start as early as possible as brain cells die rapidly after stroke. To increase the number of patients who are eligible to receive tissue plasminogen activator, measures are needed to reduce the prehospital and inhospital delay time. The study aimed to evaluate the possibility of thrombolytic therapy in acute ischemic stroke patients in Mansoura Emergency Hospital (MEH) by studying the effect of prehospital and inhospital delay factors. Patients and methods A standardized, structured questionnaire was completed for every stroke suspect; in it we documented the exact time of stroke onset, the way of referral and transport to hospital, and their demographic data. The exact time of patient arrival, time to neurology consultation, and detailed time delay inside MEH was marked on the forms of the hospital as well. Results In total, 435 patients had arrived MEH in less than 24 h, their mean age being 61.7 years. The median prehospital time was 2.7 h. Patients with younger age, locals, those who reached by private vehicle, or reached directly without any medical reference were significantly associated with early hospital admission. Sex, time of arrival, or severity of stroke had no influence on reaching hospital early. The median times to computed tomography request and acquisition were 20 and 35 min versus 25 and 45 min, respectively, National Institute of Neurological Disorders and Stroke recommendations. Conclusion Hyperacute treatment of ischemic stroke is possible in MEH. Methods to improve the emergency medical services and reduction of the patient circulation system in MEH will give more chance for these therapies by reducing prehospital and inhospital delay times.

Abstract T P50: Vanishing of Hyperintense Vessels on FLAIR Predicts Good Outcome in Tissue Plasminogen Activator Patients

Background and Purpose: Hyperintense vessels (HV) on FLAIR detected in patients with acute ischemic stroke indicate cerebral hypoperfusion. Thus, vanishing of HV should indicate reperfusion. We investigated serial changes of HV in patients who received tissue plasminogen activator (t-PA) therapy, comparing changes with clinical outcomes. Methods: We studied t-PA patients presenting with HV on FLAIR in the middle cerebral artery territory. Patients underwent brain MRI before and 1 hour after t-PA infusion. HV scores (range, 1–7) were evaluated according to ASPECTS territories. Patients were divided into two groups based on whether there was a decrease in HV scores (DHV). Multivariate logistic regression analysis was conducted to identify variables independently associated with good outcomes. Results: A total of 118 patients were consecutively enrolled (73 men; mean age, 76±9.7 years; median initial HV score, 5), and 52 (44%) were classified as DHV. Patients in the DHV group had statistically significantly lower NIHSS time course (P&lt;0.001) and smaller infarct volume time course (P&lt;0.001) compared with those not in the DHV group. Multivariate analysis, adjusting for age, sex, glucose, atrial fibrillation, ICA occlusion, baseline NIHSS, time from stroke onset to treatment, and infarct volume on admission, showed that DHV was independently associated with good outcomes (OR 3.59, 95% CI, 1.58–9.97, P&lt;0.01). The sensitivity and specificity of DHV for good outcome were 70% and 68%, respectively. Conclusion: Vanishing of HV on FLAIR predicts good outcome in patients receiving t-PA therapy.