Recombinant Tissue Plasminogen Activator Therapy Research Articles

Cardioembolic stroke related to limb-girdle muscular dystrophy 1B

BackgroundCardioembolic stroke is an under-recognized complication in patients with limb-girdle muscular dystrophy 1B. Here we present a young stroke patient who had a novel lamin A/C gene (LMNA) mutation.Case presentationThis is a 39-year-old man who had slowly progressive proximal muscle weakness and cardiac arrhythmia since adolescent and a family history of similar manifestation. He sustained acute ischemic stroke in the left middle cerebral artery territory. Intravenous recombinant tissue plasminogen activator therapy was given with significant neurological improvement. Additionally, genetic sequencing of the LMNA gene of the patient identified a mutation in c.513+1 G>A that resulted in a splicing aberration.ConclusionWe suggested that LMNA gene related myopathies should be considered in young stroke patients with long-standing myopathic features.

Stroke Scale Items Associated with Neurologic Deterioration within 24 Hours after Recombinant Tissue Plasminogen Activator Therapy

It is unclear when and which neurologic deficits should be examined within 24 hours after intravenous recombinant tissue plasminogen activator (rt-PA) therapy for acute ischemic stroke. Relationships between serial changes in National Institutes of Health Stroke Scale (NIHSS) subscores and neurologic deterioration (ND) within the first 24 hours after therapy were investigated in 43 consecutive patients. The NIHSS score was measured by neurologists 28 times within 24 hours after therapy. Assessments of subscores associated with ND, defined as the first change 4 or more points from baseline, were performed at 15 minutes (most frequent time of the first ND), 120 minutes (median time of the first ND), and 24 hours after therapy. Seventeen of 43 patients (age range, 55-94 years) showed ND. Of the NIHSS subscores, increases in scores for loss of consciousness (15 minutes, P = .001; 120 minutes, P = .026; 24 hours, P = .018) and motor limbs total (15 minutes, P = .014; 120 minutes, P = .031) were related to deterioration. Items such as questions, gaze, visual fields, ataxia, language, dysarthria, and extinction/inattention were not related to deterioration at any time. In conclusion, ND of ischemic stroke patients treated with intravenous rt-PA therapy was frequently seen within 120 minutes after therapy. Items such as loss of consciousness and motor limbs total may be considered indices for monitoring neurologic deficits after therapy.

Successful Treatment of Arterial Thrombus in an Extremely Low-Birth-Weight Preterm Neonate

Arterial thromboembolism in the pediatric population frequently occurs secondary to arterial catheterization. Catheterization-related complications are more common in smaller and sicker infants, due to high prothrombotic activity, low levels of natural anticoagulants, and various fibrinolytic imbalances. Arterial thrombus management in neonates remains controversial. Recombinant tissue plasminogen activator is the most commonly used thrombolytic agent in children, however there is very little experience with recombinant tissue plasminogen activator therapy in small prematures, especially in the first week of life. This case study reports catheter-related femoral artery occlusion in an extremely low-birth-weight preterm infant. Despite continuous heparin infusion for 6 hours, no resolution of the thrombus was seen by clinicians. Heparin was stopped, and recombinant tissue plasminogen activator therapy enabled complete recovery from the thrombus. The risk of bleeding (including intracranial hemorrhage) with recombinant tissue plasminogen activator treatment, especially in small preterm neonates is unknown. However, in this extremely low-birth-weight preterm infant, recombinant tissue plasminogen activator therapy was effective, and limiting the infusion rate to ≤0.4 mg/kg/hour was safe.

Early Neurologic Improvement Based on the National Institutes of Health Stroke Scale Score Predicts Favorable Outcome within 30 Minutes after Undergoing Intravenous Recombinant Tissue Plasminogen Activator Therapy

The aim of the present study was to evaluate whether early neurologic improvement (within 30 minutes), as measured using the National Institutes of Health Stroke Scale (NIHSS) score, predicts favorable outcome at 90 days. Consecutive acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator (i.v. rt-PA) within 3 hours poststroke between March 2006 and September 2011 were analyzed retrospectively. The association between early neurologic improvement based on the NIHSS score (an improvement of ≥3 points at 15 minutes and ≥5 points at 30 minutes) and favorable outcome at 90 days was examined. A favorable outcome was defined as a modified Rankin scale (mRS) score of 0 or 1 at 90 days after treatment. On examination of the time course of the NIHSS score in patients with an improvement of ≥8 points or a score of 0 on the NIHSS after 24 hours, the NIHSS score improved significantly from 15 minutes after i.v. rt-PA treatment (P = .042) and at 30 minutes (P = .014). On logistic regression analysis, an improvement of ≥3 NIHSS points at 15 minutes (odds ratio [OR] 6.78; 95% confidence interval [CI] 1.72-26.70; P = .006) and an improvement of ≥5 NIHSS points at 30 minutes (OR 4.83; 95% CI 1.05-22.28; P = .043) were associated with a favorable outcome. An improvement of at least 3 points in the NIHSS score at 15 minutes or of at least 5 points at 30 minutes appears to be a predictor of favorable outcome and helps to identify patients who will not respond to rt-PA therapy.

PCV25 A Pharmacoeconomic Assessment of Recombinant Tissue Plasminogen Activator Therapy for Acute Ischemic Stroke in a Tertiary Hospital in China

PCV25 A Pharmacoeconomic Assessment of Recombinant Tissue Plasminogen Activator Therapy for Acute Ischemic Stroke in a Tertiary Hospital in China

Combined Full-Dose IV and Endovascular Thrombolysis in Acute Ischaemic Stroke

There is an increasing trend to treating proximal vessel occlusions with intravenous-inter-arterial (IV-IA) thrombolysis. The best dose of IV tissue plasminogen activator (tPA) remains undetermined. We compared the combination of full-dose IV recombinant tissue plasminogen activator (rtPA) and IA thrombolytic therapy to IA therapy. Between 2002 and 2009, we reviewed our computed tomographic angiography database for patients who received full-dose intravenous rtPA and endovascular therapy or endovascular therapy alone for acute ischaemic stroke treatment. Details of demographics, risk factors, endovascular procedure, and symptomatic intracranial haemorrhage were noted. Modified Rankin Scale ≤2 at three-months was used as good outcome. Recanalization was defined as Thrombolysis in Myocardial Ischaemia 2-3 flow on angiography. Among 157 patients, 104 patients received IV-IA treatment and 53 patients underwent direct IA therapy. There was a higher recanalization rate with IV-IA therapy compared with IA alone (71% vs. 60%, P < 0·21) which was driven by early recanalization after IV rtPA. Mortality and independent outcome were comparable between the two groups. Symptomatic intracranial haemorrhage occurred in 8% of patients (12% in the IA group, 7% in the IV-IA group) but was more frequent as the intensity of intervention increased from device alone to thrombolytic drug alone to device plus thrombolytic drug(s). Recanalization was a strong predictor of reduced mortality risk ratio (RR) 0·48 confidence interval95 0·27-0·84) and favourable outcome (RR 2·14 confidence interval95 1·3-3·5). Combined IV-IA therapy with full-dose intravenous rtPA was safe and results in good recanalization rates without excess symptomatic intracranial haemorrhage. Testing of full-dose IV tPA followed by endovascular treatment in the IMS3 trial is justified.

Early Neurological Deterioration within 24 Hours after Intravenous rt-PA Therapy for Stroke Patients: The Stroke Acute Management with Urgent Risk Factor Assessment and Improvement rt-PA Registry

Background: The initial 24 h after thrombolysis are critical for patients’ conditions, and continuous neurological assessment and blood pressure measurement are required during this time. The goal of this study was to identify the clinical factors associated with early neurological deterioration (END) within 24 h of stroke patients receiving intravenous recombinant tissue plasminogen activator (rt-PA) therapy and to clarify the effect of END on 3-month outcomes. Methods: A retrospective, multicenter, observational study was conducted in 10 stroke centers in Japan. A total of 566 consecutive stroke patients [211 women, 72 ± 12 years old, the median initial NIH Stroke Scale (NIHSS) score of 13] treated with intravenous rt-PA (0.6 mg/kg alteplase) was studied. END was defined as a 4-point or greater increase in the NIHSS score at 24 h from the NIHSS score just before thrombolysis. Results: END was present in 56 patients (9.9%, 18 women, 72 ± 10 years old) and was independently associated with higher blood glucose [odds ratio (OR) 1.17, 95% confidence intervals (CI) 1.07–1.28 per 1 mmol/l increase, p < 0.001], lower initial NIHSS score (OR 0.92, 95% CI 0.87–0.97 per 1-point increase, p = 0.002), and internal carotid artery (ICA) occlusion (OR 5.36, 95% CI 2.60–11.09, p < 0.001) on multivariate analysis. Symptomatic intracranial hemorrhage within the initial 36 h from thrombolysis was more common in patients with END than in the other patients (per NINDS/Cochrane protocol, OR 10.75, 95% CI 4.33–26.85, p < 0.001, and per SITS-MOST protocol, OR 12.90, 95% CI 2.76–67.41, p = 0.002). At 3 months, no patients with END had a modified Rankin Scale (mRS) score of 0–1. END was independently associated with death and dependency (mRS 3–6, OR 20.44, 95% CI 6.96–76.93, p < 0.001), as well as death (OR 19.43, 95% CI 7.75–51.44, p < 0.001), at 3 months. Conclusions: Hyperglycemia, lower baseline NIHSS score, and ICA occlusion were independently associated with END after rt-PA therapy. END was independently associated with poor 3-month stroke outcome after rt-PA therapy.

Abstract 3204: Acute Mechanical Embolectomy Use in the US Doubled from 2008 to 2010

BACKGROUND: Intravenous recombinant tissue plasminogen activator (rtPA) therapy has been established by randomized clinical trials for administration within 4.5 hours. Both the MERCI Retrieval Device and the Penumbra Aspiration System are options for endovascular mechanical embolectomy based on single-arm studies of treatment initiated within 8 hours. Both devices receive Centers for Medicare and Medicaid Services (CMS) reimbursement at a higher rate than IV rtPA. In this context, we sought to determine if embolectomy use is increasing over time, and further characterize this group. METHODS: We reviewed the Premier Perspective Database for ischemic stroke-related hospitalizations (ICD-9 codes 433.x1, 434.x1 and 436) of patients of 18+ years during 2008, 2009 and 2010 fiscal years. This database includes all payor sources, and additional demographic and drug utilization data, from a sampling of 15% of US hospitals. We identified 187,764 (92%) from such hospitalizations representing first admissions. Use of reperfusion therapies was determined through the thrombolysis procedure code (99.10), pharmacy records (use of 50 or 100 mg Alteplase vials), hospital billing information (notation of the Penumbra or MERCI device), and/or the mechanical thrombectomy procedure code (39.74). We also compared characteristics of those treated with mechanical embolectomy versus thrombolysis alone. RESULTS: An increasing proportion of ischemic strokes were treated with reperfusion therapies each year: 4.1%( 2482/61096) in 2008, 4.7% (2983/63093) in 2009, and 5.4% (3451/63575) in 2010 (p&lt;0.001). Embolectomy use almost doubled (191%), and also increased as a proportion of reperfusion treatments by 37%, over the last three years: 11.1% (275/2482) in 2008, 11.9% (354/2983) in 2009, and 15.2% (524/3451) in 2010 (p&lt;0.001). Overall, those who received embolectomy, as compared to rtPA alone, were younger (66.7 vs 69.5 mean years; p&lt;0.001), with higher mortality rates (28% vs 11%; p&lt;0.001), at larger hospitals (43% vs 37% &gt;500 beds; p&lt;0.001), at teaching hospitals (68% vs 49%; p&lt;0.001), at urban hospitals, (95.5% vs 93.2%;p=0.003), on Medicare (63% vs 57%; p&lt;0.001), and of Caucasian race (72.45 vs 67.4%;p&lt;0.001). Multimodal imaging use, based on CT-perfusion on patient bills, was more common among those treated with embolectomy than rtPA alone (4.0 vs 1.8% in 2008, p=0.021; 17.8 vs 5.6% in 2009, p&lt;0.001; 24.2 vs 6.7% in 2010, p&lt;0.001). CONCLUSIONS: Mechanical embolectomy use has almost doubled in the US over the last three years, and is associated with a substantially higher rate of CT-based multimodal imaging use. As healthcare resources are increasingly being used to treat patients with mechanical embolectomy, it becomes imperative that the effectiveness of mechanical embolectomy and associated CT-based multimodal imaging selection be determined in definitive clinical trials.

Effect of Serum Lipid Levels on Stroke Outcome after rt-PA Therapy: SAMURAI rt-PA Registry

Background: The effects of lipid levels on clinical outcomes after ischemic stroke are controversial. Whether admission lipid levels and prior statin use are associated with early intracerebral hemorrhage (ICH) and long-term functional outcome after recombinant tissue plasminogen activator (rt-PA) therapy for stroke patients was investigated. Methods: Ischemic stroke patients who received intravenous rt-PA from a multicenter registry were studied. Lipid levels on admission, including total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, and triglyceride levels, as well as prior statin use, were assessed. The primary outcome was favorable outcome at 3 months corresponding to a modified Rankin Scale score ≤1. The secondary outcome was any or symptomatic ICH within the initial 36 h. Results: Of 489 enrolled patients (171 women, 70.8 ± 11.6 years old), 60 used statins prior to stroke, 93 developed ICH (19.0%), and 188 (38.4%) had a favorable 3-month outcome. Of the lipid levels, only the HDL-C level was an independent predictor of favorable outcome after multivariate adjustment for baseline characteristics (OR 1.95, 95% CI 1.10–3.47 per 1 mmol/l; p = 0.023) and after further adjustment for pretreatment radiological findings (OR 2.03, 95% CI 1.07–3.84; p = 0.029). For the 187 stroke patients without cardioembolism, the HDL-C level was more strongly associated with favorable outcome (OR 4.94, 95% CI 1.91–12.76 per 1 mmol/l; p = 0.001). There were no significant associations between ICH and any lipid levels. Prior statin use was not associated with outcomes. Conclusions: The admission HDL-C level was associated with favorable outcome 3 months after intravenous rt-PA therapy in stroke patients without cardioembolism.

当院におけるrt-PA静注療法 : 平日日中と夜間休日の比較検討

当院におけるrt-PA静注療法 : 平日日中と夜間休日の比較検討

Hemorrhagic complications of thrombolytic therapy

Stroke is the most frequent neurological disorder, and the most common cause of severe disability compared to other diseases. Recombinant tissue plasminogen activator (rt-PA) is the only approved specific therapy for acute ischemic stroke. Hemorrhage is a significant complication of thrombolytic treatment. This study, which included a hundred patients (52 male and 48 female), was aimed at assessing the safety according to our experience with 100 thrombolytic treatments for stroke. The death rate related to hemorrhage after thrombolysis was 3%. The frequency of hemorrhagic events (hemorrhagic infarctions type 1 and 2, parenchymal hematomas type 1 and 2) was 16%. The study results have shown that the intravenous recombinant tissue plasminogen activator (rt-PA) therapy is safe.

Racial and Ethnic Disparities in the Use of Intravenous Recombinant Tissue Plasminogen Activator and Outcomes for Acute Ischemic Stroke

Racial and ethnic disparities in acute stroke care in the United States have been previously reported. This study investigated possible racial and ethnic disparities in the administration and outcome of recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke in whites, blacks, Hispanics, and Asian/Pacific Islanders. Using the National Inpatient Sample for 2001-2008, we selected patients with a primary diagnosis of acute ischemic stroke who received treatment with rtPA. Patient data were stratified by race (white, black, Hispanic, and Asian/Pacific Islander). We analyzed the association of patient race on rtPA utilization rate, in-hospital morbidity (ie, discharge to long-term facility), intracranial hemorrhage (ICH) rate, and in-hospital mortality. We performed a multivariate logistic regression analysis to determine independent predictors of poor outcomes. White patients had a higher rate of tPA utilization than black and Hispanic patients (2.3% vs 1.8% and 2.0%, respectively; P < .0001 for both groups). There was no difference in the rate of tPA utilization between whites and Asian/Pacific Islanders (2.3% vs 2.2% P = .07). Multivariate analysis of morbidity, mortality, and ICH rates found that Asian/Pacific Islanders had significantly higher rates of mortality (odds ratio, 1.22, 95% confidence interval, 1.03-1.44; P = .02) and ICH (odds ratio, 2.01; 95% confidence interval, 1.91-2.11; P < .0001) compared with whites. rtPA utilization was greater in white and Asian/Pacific Islander patients than in black and Hispanic patients. Asian/Pacific Islander race was associated with increased risk of ICH and mortality after rtPA administration.

Are Quality Improvements in the Get With The Guidelines-Stroke Program Related to Better Care or Better Data Documentation?

BACKGROUND- Increased compliance with performance measures could reflect better care or better data documentation. We examined trends in the documentation of eligibility criteria, treatment contraindications, and missing data in the Get With The Guidelines-Stroke program to quantify their contribution to increased performance measure compliance. METHODS AND RESULTS- Data on 569 883 ischemic stroke admissions to 1028 GWTG-Stroke hospitals between April 2003 and September 2009 were obtained. Seven measures were examined: intravenous recombinant tissue plasminogen activator therapy, early antithrombotics, deep vein thrombosis prophylaxis, anticoagulants for atrial fibrillation/flutter, discharge antithrombotics, lipid therapy, and smoking cessation. Within each target population, the proportion of subjects treated, not treated, not treated because of contraindications, or with missing data were generated by calendar year. There were minimal changes in the size of the target populations for 6 of the measures; however, the size of the deep vein thrombosis prophylaxis population was reduced ≈5% in 2008 because of a format change to the data collection form. All measures showed significant increases in the proportion of eligible subjects treated across the study period. These increases occurred without major shifts in contraindications or missing data, with the exception of anticoagulation for atrial fibrillation/flutter where the increase occurred in conjunction with a decline in contraindications. Similar findings were seen when the data were examined by the duration of hospital participation in the program. CONCLUSIONS- These findings suggest that the majority of performance improvement in the Get With The Guidelines-Stroke program represent an increase in the number of patients with stroke treated and not changes to the underlying target populations or documentation of contraindications or missing data.

ACR Appropriateness Criteria® on Cerebrovascular Disease

Stroke is the sudden onset of focal neurologic symptoms due to ischemia or hemorrhage in the brain. Current FDA-approved clinical treatment of acute ischemic stroke involves the use of the intravenous thrombolytic agent recombinant tissue plasminogen activator given <3 hours after symptom onset, following the exclusion of intracerebral hemorrhage by a noncontrast CT scan. Advanced MRI, CT, and other techniques may confirm the stroke diagnosis and subtype, demonstrate lesion location, identify vascular occlusion, and guide other management decisions but, within the first 3 hours after ictus, should not delay or be used to withhold recombinant tissue plasminogen activator therapy after the exclusion of acute hemorrhage on noncontrast CT scans. MR diffusion-weighted imaging is highly sensitive and specific for acute cerebral ischemia and, when combined with perfusion-weighted imaging, may be used to identify potentially salvageable ischemic tissue, especially in the period >3 hours after symptom onset. Advanced CT perfusion methods improve sensitivity to acute ischemia and are increasingly used with CT angiography to evaluate acute stroke as a supplement to noncontrast CT. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Intravenous Recombinant Tissue Plasminogen Activator Therapy for Stroke Patients Receiving Maintenance Hemodialysis: The Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement (SAMURAI) rt-PA Registry

Background: To examine the therapeutic effect of intravenous recombinant tissue plasminogen activator (rt-PA) therapy for stroke patients receiving maintenance hemodialysis (HD). Methods: Of 600 stroke patients receiving intravenous rt-PA using 0.6 mg/kg alteplase who were enrolled in a multicenter observational study in Japan, 4 patients (3 men, 64–77 years old) on maintenance HD were studied. Results: The primary kidney disease requiring HD was glomerulonephritis in 2 patients, diabetic nephropathy in 1, and undetermined in 1. The duration of HD ranged between 1.2 and 28 years. Three patients developed stroke on the day of HD, including 1 during HD and another just after HD. All patients had stroke in the carotid arterial territory. Pretreatment NIH Stroke Scale scores ranged between 4 and 20, and decreased by 2–5 points at 7 days. One patient needed intravenous antihypertensive therapy before rt-PA; he developed an ectopic cortical hematoma and intraventricular hemorrhage after rt-PA. The other 3 did not develop hemorrhagic complications. The modified Rankin Scale score at 3 months was 0 in 1 patient, 2 in 2 patients, and 4 in 1 patient. Conclusions: rt-PA therapy for stroke patients receiving maintenance HD might improve the stroke outcome. Ectopic hematoma was a unique complication in our case series.

Potential Eligibility for Recombinant Tissue Plasminogen Activator Therapy in Children: A Population-Based Study

Intravenous recombinant tissue plasminogen activator is an established therapy for adults with ischemic stroke. In this Greater Cincinnati/Northern Kentucky population-based study, 8% were eligible. However, no established therapy exists for children with acute ischemic stroke. Accordingly, investigators assessed rates of eligibility for recombinant tissue plasminogen activator therapy among children (<18 years of age) in the same population to aid planning of future clinical trials. The investigators identified 29 pediatric ischemic strokes during 3 separate study periods (1993-1994, 1999, and 2005) and determined potential eligibility for recombinant tissue plasminogen activator therapy based on 2007 American Heart Association guidelines for adults. Depending on how relative contraindications were considered, 1 to 3 cases (3%-10%) met eligibility criteria. On the basis of national pediatric stroke incidence rates extrapolated from our population, it is estimated that up to 178 children might be eligible for intravenous recombinant tissue plasminogen activator therapy annually in the United States. Thus, recruitment for clinical studies is likely to be challenging and requires a concerted multicenter effort.

Simultaneous Combined Intravenous Recombinant Tissue Plasminogen Activator and Endovascular Therapy for Hyperacute Middle Cerebral Artery M1 Occlusion

We investigated the efficacy and safety of combined intravenous (IV) recombinant tissue plasminogen activator (rtPA) and simultaneous endovascular therapy (ET) for hyperacute middle cerebral artery (MCA) M1 occlusion. Between October 2005 and April 2007, in the combined group, 22 patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, were treated with IV rtPA and simultaneous ET was initiated as soon as possible. The other patients were treated with IV rtPA alone (IV group A: n = 11). Between May 2007 and November 2008, all patients eligible for IV rtPA, who were diagnosed as having MCA M1 occlusion, underwent thrombolysis by IV rtPA alone (IV group B: n = 24). The improvement of the National Institutes of Health Stroke Scale score at 24 hours was highest in the combined group (10 ± 4.1). In contrast, it was 5.1 ± 4.7 in the IV group A (P = 0.017) and 5.6 ± 5.6 in IV group B (P = 0.006). In the combined group, successful recanalization was observed in 18 of 22 patients with one symptomatic intracranial hemorrhage. The rate of mRS0-2 at three months was highest in the combined group, 36% in the IV group A and 33% in the IV group B (P = 0.008).Simultaneous treatment with IV rtPA and ET improved the clinical outcome of MCA M1 occlusion without a significant increase of adverse effects in our study.

Outcomes of Intravenous Thrombolytic Therapy for Acute Ischemic Stroke With an Integrated Acute Stroke Referral Network: Initial Experience of a Community-Based Hospital in a Developing Country

Some of the literature encourages the use of intravenous (IV) thrombolytic therapy for acute ischemic stroke (AIS) in centers with no previous experience with this therapy. The benefits of an acute stroke referral network for IV thrombolytic therapy remain controversial, however. We present outcomes of IV thrombolytic therapy for AIS with an integrated acute stroke referral network at an institution with no previous experience in stroke thrombolysis and compare the results with previously published data. A total of 458 patients with AIS or transient ischemic attack (TIA), referred from a hospital in the acute stroke referral network or walk-ins, admitted to the stroke unit of Thammasat Hospital between October 2007 and January 2009 (16 months) were prospectively assessed. The main outcome measures were IV thrombolytic treatment rate, initial National Institutes of Health Stroke Scale (NIHSS) score, door-to-needle time, onset-to-treatment time (OTT), intracerebral hemorrhage, and morbidity and mortality at 3 months after onset. A total of 100 patients (59 from hospitals in the stroke referral network) received IV recombinant tissue plasminogen activator (rt-PA) therapy (21% of the admissions with AIS and TIA); 41% of the patients referred from a hospital in the network received IV rt-PA. The median NIHSS score before thrombolysis was 15 (range, 3-34). Mean door-to-needle time was 54 minutes (range, 15-125 minutes), and mean OTT was 160 minutes (range, 60-270 minutes). There were 13 asymptomatic intracerebral hemorrhages and 2 symptomatic intracerebral hemorrhages (1 fatal). By 3 months, 42 patients had achieved excellent recovery (modified Rankin Scale score of 0-1), and 14 had died. These outcomes are comparable to data from the National Institute of Neurological Disorders and Stroke and previous studies of IV rt-PA therapy in Thailand. Our findings indicate that integrating an acute stroke referral network into IV thrombolytic therapy for AIS in a community-based setting is safe and feasible and should help increase the rate of thrombolytic therapy. Previously inexperienced community-based centers can reproduce the experience and outcome measures reported by clinical trials and in the landmark literature of IV thrombolytic therapy in patients with stroke.

超急性期虚血性脳血管障害に対するrt-PA静注療法と脳血管内治療：combined therapyの有用性

●Abstract● Objective: To assess the efficacy and safety of intravenous recombinant tissue plasminogen activator (IV-tPA) therapy and combining IV-tPA with neuroendovascular therapy (combined therapy [ComT]) in acute ischemic stroke. Methods: Among 481 consecutive patients with acute ischemic stroke, we investigated the recanalization rate, clinical outcomes three months after stroke onset, and the incidence of symptomatic intracranial hemorrhage (sICH) in 33 patients who received IV-tPA therapy (0.6 mg/kg for 60 minutes). We performed ComT in 9 of these 33 patients who satisfied the treatment indications. Results: The recanalization rate immediately after IV-tPA therapy was 39.3% in 28 of the 33 patients, i.e., excluding the five with small-artery occlusions. In the ComT group, the rate of recanalization was 44.4% (4 of the 9 patients). Good and intermediate clinical outcomes (0-3 points on the modified Rankin Scale at three months) were seen in 17 patients (51.5%), and sICH occurred in only one (3.0%). Rates of recanalization (immediately after IV-tPA therapy/ComT) in the internal carotid artery (ICA), the proximal middle cerebral artery (MCA), the distal MCA, and the basilar artery were 0%/ 50%, 42.9%/ 50%, 77.8%/ - and 50%/ 0%, respectively. Among those with ICA and proximal MCA occlusions, a large number of patients had poor outcomes. In fact, the only patients with good outcomes were in the recanalized group. Conclusion: IV-tPA therapy was not particularly useful in patients with ICA occlusion. However, if used according to strict indications, ComT can be performed safely and might improve the recanalization rate and clinical outcomes of patients with ICA occlusion.

FP18-TU-04 The clinical profile and treatment outcome of acute ischemic stroke patients who underwent thrombolysis with recombinant tissue plasminogen activator therapy, Philippine experience: a retrospective study

FP18-TU-04 The clinical profile and treatment outcome of acute ischemic stroke patients who underwent thrombolysis with recombinant tissue plasminogen activator therapy, Philippine experience: a retrospective study