Thrombolysis In Stroke Patients Research Articles

MON-P016: Oral Injection is Related to the Risk of Pneumonia After Mechanical Thrombolysis in Stroke Patients

MON-P016: Oral Injection is Related to the Risk of Pneumonia After Mechanical Thrombolysis in Stroke Patients

Dynamic change of neutrophil to lymphocyte ratio and hemorrhagic transformation after thrombolysis in stroke.

BackgroundThe neutrophil to lymphocyte ratio (NLR) has been shown to predict short- and long-term outcomes in ischemic stroke patients. We sought to explore the temporal profile of the plasma NLR in stroke patients treated with intravenous thrombolysis (IVT) and its relationship with intracranial bleeding complications after thrombolysis.MethodsA total of 189 ischemic stroke patients were prospectively enrolled. Blood samples for leukocyte, neutrophil, and lymphocyte counts were obtained at admission and at 3–6, 12–18, and 36–48 h after IVT. Head CT was performed on admission and repeated after 36–48 h, and a CT scan was done immediately in case of clinical worsening. Hemorrhagic events were categorized as symptomatic intracranial hemorrhage (sICH) and parenchymal hematomas (PH) according to previously published criteria.ResultsAn increasing trend in the NLR was observed after stroke, and the NLR was higher in patients who developed PH or sICH at 3–6, 12–18, and 36–48 h after IVT (P < 0.01) than in those without PH or sICH. The optimal cutoff value for the serum NLR as an indicator for auxiliary diagnosis of PH and sICH was 10.59 at 12–18 h. Furthermore, the NLR obtained at 12–18-h post-treatment was independently associated with PH (adjusted odds ratio [OR] 1.14) and sICH (adjusted OR 1.14). In addition, patients with a NLR ≥10.59 had an 8.50-fold greater risk for PH (95 % confidence interval [CI] 2.69–26.89) and a 7.93-fold greater risk for sICH (95 % CI 2.25–27.99) than patients with a NLR <10.59.ConclusionsNLR is a dynamic variable, and its variation is associated with HT after thrombolysis in stroke patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12974-016-0680-x) contains supplementary material, which is available to authorized users.

Risks of atrial fibrillation and death at discharge after thrombolysis in stroke patients: Northumbrian Sentinel Stroke Audit, 2013-2015.

The aim of this study was to examine risks of atrial fibrillation and death at discharge in stroke patients treated with thrombolysis in a subregional setting covering full calendar years with a clear study catchment drawn serving as a confirmatory statistical analysis from the northeast of England in the last 2 years. Data between 16 June, 2013 and 15 June, 2015 were extracted from Sentinel Stroke National Audit Programme in Northumbria Healthcare NHS Foundation Trust that has covered health service for Northumberland and North Tyneside. The very old people aged 80 and above were less likely to have thrombolysis treatment, while there was no sex difference observed. Moreover, thrombolysis treatment was more likely to be given in ischemic patients with severe stroke symptoms. There was no difference in comorbidities including atrial fibrillation, congestive heart failure, diabetes, hypertension, and stroke/TIA as well. Those who received thrombolysis treatment were more likely to have atrial fibrillation or die at discharge. The ORs were higher after additionally adjusting for comorbidities. Similarly, these patients also had poorer scoring in modified Rankin scale than those who did not receive thrombolysis treatment. However, there was no difference at 6 months after survival. For future research, clinical outcomes in addition to atrial fibrillation and quality of life both at discharge and 6 months after thrombolysis treatment should be included for examination as well. For clinical practice, giving thrombolysis treatment in hospitals might need to be reconsidered if clinical outcomes were actually worse than not.

Abstract 150: Complications and Outcomes of Thrombolysis in Stroke Patients Aged 90 and Over: UK National Registry Data

Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided without restriction based on age. However, thrombolysis trials have included very few patients aged 90 and over. We therefore analysed data from the national stroke register of England and Wales to describe the safety and outcomes of thrombolysis in patients aged 90 and over. Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke treated in all hospitals in England and Wales from April 2013-March 2015. Results: Of 128826 adults with acute ischemic stroke admitted to 202 hospitals, 14854 (11.5%) were aged 90 or over. Of these, 1262 (8.5%) were treated with intravenous alteplase (iv-tPA). Females comprised 70.0% of treated patients aged 90 or over, 6.3% had stroke onset whilst already an inpatient, 65.0% were independent prior to stroke (mRS of 2 or less), 71.2% were fully conscious upon arrival at hospital and 37.2% had a diagnosis of atrial fibrillation prior to stroke. The median age of the thrombolysed patients was 92 (IQR 91-94), similar to patients aged 90 or over who were not treated. Median NIHSS score was 14 (IQR 9-20). Following tPA, 12.5% of patients had complications; 4.8% had symptomatic intracranial hemorrhage, 0.7% had angioedema, 0.6% had extracranial bleeds and 6.6% had some other type of tPA complication. The median NIHSS 24h after tPA was 10 (IQR 4-18). Of the 871 patients (69.0%) who had a fully completed NIHSS at arrival and at 24h after thrombolysis, the median improvement was 3 points on the scale (IQR 0-7). Inpatient case fatality rate was 32.8%, 20.9% were independent upon discharge from inpatient care (Rankin 2 or below), 14.1% were newly institutionalised into a care home (21.0% of those discharged alive). Conclusions: Patients aged 90 and over treated with iv-tPA have a similar rate of complications as reported for younger patients in national registries and clinical trials. However stroke in this age group carries a high risk of mortality and a high proportion of survivors are discharged to long term care for the first time.

Abstract 152: Complications and Outcomes From Thrombolysis in Stroke Patients With Significant Pre-stroke Disability: Data From the UK National Stroke Registry

Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided regardless of pre-stroke disability, but thrombolysis trials have included very few patients with a modified Rankin scale (mRS) score of more than 2. We therefore analysed data from the national stroke register of England and Wales of over 100,000 records to determine the safety and outcomes of thrombolysis in patients with varying levels of pre-stroke disability. Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke treated in all hospitals in England and Wales from April 2013-March 2015. Results: Of 128826 adults with acute ischemic stroke admitted to 202 hospitals, 23850 (18.5%) were dependent in some activities of daily living before stroke (mRS of more than 2). Of these, 1926 (8.1%) were treated with intravenous alteplase (iv-tPA). Of the patients with an mRS greater than 2 who were treated with iv-tPA, 1239 (64.3%) were female, 120 (6.2%) had an onset whilst already an inpatient, and 1395 (72.4%) were fully conscious upon arrival at hospital. The median age was 84 years (IQR 78-89); the median NIHSS score 15 (IQR 9-21). Of the 1320 patients (68.5%) with a fully completed NIHSS at arrival and at 24h after thrombolysis, the median change in NIHSS was a 3 point improvement (IQR 0-7). A total of 214 patients (11.1%) had complications from thrombolysis; 104 (5.4%) had symptomatic intracranial hemorrhage, 10 (0.5%) had angioedema, 21 (1.1%) had extracranial bleeds and 82 (4.3%) had some other type of thrombolysis complication. Inpatient case fatality rate was 29.2%, and 10.2% were newly institutionalised in a care home (14.4% of those discharged alive). Conclusions: Patients treated with iv-tPA who were not independent before stroke have similar rates of complications as reported for independent patients in national registries and clinical trials. However stroke for patients with pre-stroke disability carries a high risk of mortality and a high proportion of survivors are discharged to long term care for the first time.

Association between Admission Serum 25-Hydroxyvitamin D Levels and Functional Outcome of Thrombolyzed Stroke Patients

25-Hydroxyvitamin D (25(OH)D) deficiency is a frequent condition in patients who suffer a stroke, and several studies suggested that it may be associated with a poorer prognosis. The aim of this study was to investigate specifically the association between 25(OH)D levels and functional outcome at 3 months in ischemic stroke patients treated with intravenous thrombolysis. Consecutive ischemic stroke patients who received intravenous thrombolysis were enrolled between 2010 and 2013. Baseline characteristics were collected, and serum concentrations of 25(OH)D were measured within the first 24 hours after admission and were analyzed according to the quartiles of their distribution (<25 nmol/L versus ≥ 25 nmol/L). Multivariable ordinal logistic regression was used to evaluate the association between 25(OH)D and 3-month functional outcome assessed by the modified Rankin score. Three hundred fifty-two patients were included (mean age 68.6 ± 15.8, 50.7% women, mean 25(OH)D level 45 ± 25 nmol/L). The characteristics of the patients only differed with regard to higher premorbid functional impairment in patients with low 25(OH)D. In univariate analysis, the risk of functional impairment in patients with low 25(OH)D levels was greater than that in patients with higher 25(OH)D levels (odds ratio [OR] 2.10, 95% confidence interval [CI]: 1.35-3.27, P = .001). This association was still observed after adjustment for confounding variables (OR 1.70, 95% CI: 1.06-2.71, P = .027). A low serum 25(OH)D level is associated with worse functional outcome in patients with acute ischemic stroke treated with intravenous thrombolysis. Further investigations are required to understand the underlying mechanisms of this association.

Thrombolysis in Stroke Patients with Isolated Aphasia

Background: Data about evolution of aphasia following stroke are rare and controversial especially following fibrinolysis. The aim of this study was to describe the early clinical patterns of isolated aphasia in consecutive stroke patients with or without thrombolysis. Methods: Clinical and radiological data of consecutive stroke patients were routinely entered in prospective registry. Patients were considered aphasic when NIHSS (National Institutes of Health Stroke Scale) item 9 >0. ‘Isolated aphasia' was defined by aphasic patients without motor limb deficit. We created a ‘composite language score' obtained by summing the NIHSS items 1b, 1c and 9, which reflects language-processing ability. Recovery of functions was evaluated as measured by global NIHSS, composite language score and language screening test (LAST) at baseline, H24 and day 7 (D7). ‘Mild deficit' was defined as global NIHSS <5. Results: A total of 100 consecutive patients met study criteria for isolated aphasia. Twenty-five underwent thrombolysis and 75 did not. There was no difference between the 2 groups concerning demographic characteristics, involved territories and presence of arterial occlusion, initial median NIHSS, composite language and LAST scores at entrance. Evolution was significantly better in thrombolysed patient for the 3 testings: NIHSS, composite language score and LAST at D7 (respective p = 0.0002; p = 0.01 and p = 0.004). Similar results were found when we focused on the subgroups of patients with initial ‘mild' deficits (p = 0.01; p = 0.0003 and p = 0.007). No symptomatic hemorrhagic transformation occurred following thrombolysis. Conclusion: These data strongly suggest that thrombolysis is safe and effective in patients with ‘isolated aphasia,' even if the global NIHSS score is <5.

ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients.

BackgroundPatients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions.MethodsWe retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association.ResultsSeventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity.ConclusionThe ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.

Follow-up C-reactive protein level is more strongly associated with outcome in stroke patients than admission levels.

The value of C-reactive protein (CRP) as a prognostic tool in stroke patients is unclear. The aim of this study is to explore the prognostic impact of CRP levels assessed at different time points on functional outcome in a large cohort of thrombolysed acute stroke patients. All thrombolysed stroke patients admitted to our department were entered in an open, prospective database. Clinical and demographic data were recorded. CRP was measured upon admission, within 24 h, and in the following days. Functional outcome was assessed using the modified Rankin Scale (mRS) at 3 months. Among 1242 thrombolysed patients, we found a statistically significant difference in median CRP values upon admission, within 24 h, and follow-up with respect to outcome parameters (p < 0.001) including symptomatic intracerebral hemorrhage (sICH; p < 0.001). In regression models, follow-up CRP showed better predictive properties for outcome parameters compared to CRP assessed upon admission or within 24 h. The ROC analysis showed a good predictive value of follow-up CRP concerning dependent outcome [c-statistic 0.71 (95 % CI 0.67-0.75) p < 0.001] and mortality [c-statistic 0.70 (95 % CI 0.66-0.75) p < 0.001]. After adjustment for risk factors, follow-up CRP, but not admission CRP, was independently associated with dependent outcome (OR 2.67, 95 % CI 1.76-4.06; p < 0.001), mortality (OR 2.53, 95 % CI 1.50-4.25; p < 0.001), and sICH (OR 3.03, 95 % CI 1.51-6.06; p = 0.002). Follow-up CRP is strongly associated with functional outcome, sICH, and mortality after 90 days in thrombolysed stroke patients.

Factors related to therapeutic outcomes of intravenous thrombolysis in stroke patients with different severity

To investigate the factors related to therapeutic outcomes of intravenous thrombolysis in patients with acute ischemic stroke (AIS) of different severity. Clinical data of patients with AIS treated with intravenous thrombolysis in the Second Affiliated Hospital, Zhejiang University School of Medicine between June 2009 and December 2013 were retrospectively reviewed. According to National Institutes of Health Stroke Scale (NIHSS), patients were categorized as mild stroke (≤8, n=134), moderate stroke (9-15, n=121) and severe stroke(≥16, n=110). The good outcome was defined as modified Rankin Scale ≤ 2. The factors related to functional outcomes and hemorrhagic transformation (HT) were analyzed and compared among 3 groups. Among 365 enrolled patients, good outcomes in 3 groups were 78.4% (105/134), 47.9% (58/121) and 24.5%(27/110), respectively. In patients with mild stroke, age (OR=0.937, 95%CI: 0.898-0.978; P=0.003), baseline NIHSS (OR=0.732, 95%CI:0.564-0.950; P=0.019), onset to needle time (ONT) within 270 min (OR=4.109, 95%CI:1.441-11.719; P=0.008) independently predicted good outcome, while baseline glucose (OR=1.326, 95%CI:1.009-1.743; P=0.043) was independently associated with parenchymal hematoma (PH). In patients with moderate stroke, age (OR=0.954, 95%CI: 0.924-0.984; P=0.003) and baseline NIHSS (OR=0.760, 95%CI: 0.619-0.933; P=0.009) independently predicted good outcome, while atrial fibrillation (OR=3.307, 95%CI: 1.140~9.596; P=0.028) and systolic pressure (OR=0.967, 95%CI: 0.943~0.991; P=0.008) was independently associated with hemorrhagic infaction. Atrial fibrillation (OR=36.972, 95%CI: 1.770-772.462; P=0.02) was independently associated with PH. In patients with severe stroke, baseline NIHSS (OR=0.808, 95%CI:0.677-0.963; P=0.018) independently predicted good outcome, while no independent risk factors of HT was found. For different severity of AIS patients, the related factors of functional outcome and HT after thrombolysis were different.

Floating Arterial Thrombus Related Stroke Treated by Intravenous Thrombolysis

Background: The effects of intravenous thrombolysis on floating thrombi in cervical and intracranial arteries of acute ischemic stroke patients are unknown. Similarly, the best prevention methods of early recurrences remain controversial. This study aimed to describe the clinical and radiological outcome of thrombolyzed strokes with floating thrombi. Methods: We retrospectively analyzed all thrombolyzed stroke patients in our institution between 2003 and 2010 with floating thrombi on acute CT-angiography before the intravenous thrombolysis. The floating thrombus was diagnosed if an elongated thrombus of at least 5 mm length, completely surrounded by contrast on supra-aortic neck or intracerebral arteries, was present on CT-angiography. Demographics, vascular risk factors, and comorbidities were recorded and stroke etiology was determined after a standardized workup. Repeat arterial imaging was performed by CTA at 24 h or before if clinical worsening was noted and then by Doppler and MRA during the first week and at four months. Results: Of 409 thrombolyzed stroke patients undergoing acute CT Angiography, seven (1.7%) had a floating thrombus; of these seven, six had it in the anterior circulation. Demographics, risk factors and stroke severity of these patients were comparable to the other thrombolyzed patients. After intravenous thrombolysis, the floating thrombi resolved completely at 24 h in four of the patients, whereas one had an early recurrent stroke and one developed progressive worsening. One patient developed early occlusion of the carotid artery with floating thrombus and subsequently a TIA. The two patients with a stable floating thrombus had no clinical recurrences. In the literature, only one of four reported cases were found to have a thrombolysis-related early recurrence. Conclusions: Long-term outcome seemed similar in thrombolyzed patients with floating thrombus, despite a possible increase of very early recurrence. It remains to be established whether acute mechanical thrombectomy could be a safer and more effective treatment to prevent early recurrence. However, intravenous thrombolysis should not be withheld in eligible stroke patients.

Endovascular Procedures versus Intravenous Thrombolysis in Stroke Patients with Tandem Occlusion of the Anterior Circulation

Stroke is a devastating disease that affects more than 795,000 Americans each year and costs the health care system an estimated $36.5 billion annually ( 1 Go A.S. Mozaffarian D. Roger V.L. et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014; 129: e28-e292 Crossref PubMed Scopus (4415) Google Scholar ). In the past, treatment of acute ischemic stroke was essentially based on damage control and consisted of physical and occupational therapy to maximize function in the setting of permanent neurologic deficits. The management of acute ischemic stroke has advanced greatly during the past two decades with the introduction of novel pharmacologic and endovascular therapies aimed at reperfusion of ischemic brain. Endovascular Procedures versus Intravenous Thrombolysis in Stroke with Tandem Occlusion of the Anterior CirculationJournal of Vascular and Interventional RadiologyVol. 25Issue 8PreviewStroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome. Full-Text PDF

Advance preferences regarding thrombolysis in patients at risk for stroke: a cross-sectional study: Table 1

It is difficult to obtain informed consent for thrombolysis in stroke patients given the emergency setting, the need for a speedy decision and the effects of neurological deficits. To determine the advance preferences for thrombolysis of patients at risk for stroke following discussion of the potential risks and benefits. Cross-sectional survey. Data on benefits and risks of thrombolysis within 3 h and between 3 and 4.5 h after stroke were presented orally, in writing and pictorially to patients attending geriatric and stroke services in a teaching hospital with specified stroke risk factors and preferences for thrombolysis were recorded. Of the 121 participants, 108 (89.3%; 95% confidence interval [CI] 82.4-93.7) would opt for thrombolysis within the 3-h period and 100 (82.6%; 95% CI 74.9-88.4) within the 3- to 4.5-h period after acute stroke (P = 0.04, McNemar's test for correlated proportions). Previous stroke or transient ischaemic attack was more common among those who agreed to thrombolysis (54.1% vs. 30.4%, P = 0.04) and those who opted for thrombolysis were significantly more likely to agree to have their preferences recorded and used in the event of a stroke than those who refused thrombolysis (88.8% vs. 30.4%, P = 0.002). Advance discussion of the potential risks and benefits of thrombolysis in at-risk patients may improve decision making if thrombolysis is being considered and the patient can no longer make a decision.

Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time

Background: In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator ‘door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. Methods: We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. Results: Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. Conclusion and Implications: The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.

Safe intravenous thrombolysis in acute stroke despite treatment with rivaroxaban

Data regarding intravenous thrombolysis in stroke patients receiving new oral anticoagulant drugs (nOAC) is sparse. In the near future, however, an increasing number of patients with atrial fibrillation will suffer recurrent stroke despite treatment with nOAC. This will cause a significant therapeutic dilemma as thrombolysis is contraindicated under such circumstances. We describe an 81-year-old patient presenting with acute ischemic stroke who was successfully treated with intravenous thrombolysis despite ongoing treatment with rivaroxaban. Our case report indicates that thrombolysis under nOAC may be safe under certain conditions and emphasizes the importance of establishing and performing specific anticoagulation tests for nOAC.

Thrombolysis in acute ischaemic stroke

Sir, We read with interest the recent paper by Balami et al. (2013) concerning thrombolysis in stroke patients. In medicine, every procedure requires a careful evaluation of benefit-to-risk ratio, and thrombolysis is no exception. As reported by the authors, the selection of patients is crucial to obtain the best benefit with the lowest risk. Time to treatment is critical in this selection and the reduction of the avoidable delay represents the key factor in improving the number of potentially treatable patients. Optimal management of the acute phase could contribute to obtaining this result, with a pre-notification of …

The Effect of Time to Treatment on Outcome in Very Elderly Thrombolysed Stroke Patients

Intravenous thrombolysis is beneficial in, even very elderly, acute ischemic stroke patients. However, while the relation between treatment benefit and treatment delay (onset time to treatment) in patients younger than 80 years is well known, it is uncertain in the very elderly. This analysis aims at examining this relationship in the elderly, and to provide a comparison with the derived relationship in younger patients as a check of validity. We assessed the interaction between age, onset time to treatment, and thrombolysis exposure by analyzing the modified Rankin scale score distribution or mortality rate at 90 days, among patients registered in a trials archive. We established whether the effect of alteplase changes with onset time to treatment, by treating onset time to treatment as a continuum in a multivariate logistic regression model. Data were available for 3063 patients, of whom 2341 were thrombolysed. Five hundred ninety-seven patients were aged >80, of whom 352 were thrombolysed. Among patients aged >80, no significant interaction of outcome with onset time to treatment was observed (P = 0·4650), but the estimated slope of the decay in benefit with onset time to treatment was comparable with that established for younger patients. Analyzing the entire dataset, there was an interaction between onset time to treatment and alteplase treatment (P = 0·0159), but neither between age and onset time to treatment (P = 0·7098) nor between age and alteplase treatment (P = 0·0755). In this nonrandomized comparison, the relationship of benefit and safety with thrombolysis across onset time to treatment in very elderly stroke patients was comparable with that in their younger counterparts. Across the investigated time span of 3·5 h, we can safely treat with the same time window as we use for younger patients.

Mild Stroke and Advanced Age Are the Major Reasons for Exclusion from Thrombolysis in Stroke Patients Admitted within 4.5 Hours

Only 2%-3% of patients with acute ischemic stroke receive thrombolysis. The aim of this study was to identify the reasons for exclusion from thrombolysis in patients admitted within the therapeutic time window. Patient data in the hospital stroke registry between January 2012 and September 2013 were retrospectively examined. All cases with a diagnosis of ischemic stroke were screened, and those admitted to the neurology wards within 4.5 hours of symptom onset were analyzed. The reasons for exclusion from thrombolysis were examined. Logistic regression analysis was used to find independent predictors of thrombolysis treatment. Of the 1579 cases of ischemic stroke, 234 patients were admitted to the neurology ward within 4.5 hours of symptom onset. A total of 57 patients received thrombolysis. The thrombolysis rate was 3.6% of all ischemic stroke patients. Of the 177 patients who were excluded from thrombolysis, 36.2% (n=64) had stroke of insufficient severity to warrant thrombolysis, and 24.9% (n=44) were older than 80 years. Logistic regression analysis showed that the interval between symptom onset and admission (odds ratio 20.24, 95% confidence interval 3.75-109.24) and history of ischemic stroke (odds ratio .11, 95% confidence interval .04-.34) affected the likelihood of thrombolysis. Mild stroke and advanced age were the major reasons for exclusion from thrombolysis in patients admitted within 4.5 hours of symptom onset. Patients who were admitted early and those without a history of ischemic stroke were more likely to receive thrombolysis.

Role of beta‐defensin 2 and interleukin‐4 receptor as stroke outcome biomarkers

Acute ischemic stroke is a complex disease with huge interindividual evolution variability that makes challenging the prediction of an adverse outcome. Our aim was to study the association of bloodstream signatures to early neurological outcome after stroke, by combining a subpooling of samples strategy with protein array discovery approach. Plasma samples from 36 acute stroke patients (< 4.5 h from onset) were equally pooled within outcome groups: worsening, stability, and improvement (n = 3 pools of four patients each, for each outcome group). These nine pools were screened using a 177 antibodies library, and 35 proteins were found altered regarding outcome classification (p < 0.1). Processes of inflammation, immune response, coagulation, and apoptosis were regulated by these proteins. Ten representative candidates, mainly cytokines and chemokines, were assayed for replication in individual baseline plasma samples from 80 new stroke patients: β-defensin2, MIP-3b, plasminogen activator inhibitor 1 active, β-cell-attracting chemokine 1, Exodus-2, interleukin-4 receptor (IL-4R), IL-12p40, leukemia inhibitor factor, MIP-1b, and tumor necrosis factor-related weak inducer of apoptosis. Multivariate logistic regression analysis showed β-defensin 2 (ORadj 4.87 [1.13-20.91] p = 0.033) and IL-4R (ORadj 3.52 [1.03-12.08] p = 0.045) as independent predictors of worsening at 24 h after adjustment by clinical variables. Both biomarkers improve the prediction by 19% as compared to clinical information, suggesting a potential role for risk stratification in acute thrombolyzed stroke patients. Early neurological deterioration after stroke is not easily predictable. The use of blood biomarkers might help in decision-making processes regarding this complication. By combining a sub-pooling of samples strategy with protein array discovery approach, we have found two new biomarkers: beta-defensin-2 and interleukin-4 receptor. Both biomarkers improve the prediction of poor-outcome over clinical variables in the acute phase of stroke.

Abstract W P51: Clinical Outcomes following Thrombolysis for Acute Ischemic Stroke in Patients with Systemic Malignancy: A Nationwide Case-Control Study

Background: The safety of thrombolysis for acute stroke in patients with cancer is not well established. Our aim is to study the outcomes following thrombolysis in stroke patients with cancer. Methods: Acute ischemic stroke (AIS) patients who received thrombolysis were identified from the 2009 and 2010 Nationwide Inpatient Sample using ICD-9 codes. Patients with cancer associated strokes (CS) and non-cancer strokes (NCS) were compared based on demographics, comorbidities, and outcomes. Results: There were 1,135,574 AIS in 2009-2010. Thrombolysis was administered to 807 patients out of 50,437 CS (1.6%), and 31,769 patients out of 1,085,137 non-cancer strokes (2.9%). The prevalence of stroke risk factors such as hypertension (p&lt;0.001) and hyperlipidemia (&lt;0.001) were significantly higher in non-cancer strokes (NCS). CS had a significantly higher percentage of patients in the third and fourth Elixhauser quartiles (p&lt;0.001). Hospitals with &gt; 450 beds were more likely to treat cancer patients with thrombolysis for acute stroke (p=0.011), while the hospital teaching status did not play a significant role. In the univariate analysis, CS was associated with a lower proportion of home discharge in the overall thrombolytic treatment group (OR: 0.57, CI: 0.48-0.68, p&lt;0.001) but mortality was not significant. ICH rates were also comparable in the two groups (6.3% vs 6.4%, p= 0.927). In the regression model, there was no difference in mortality or ICH rates between CS and NCS following thrombolysis. Subgroup analysis of IV thrombolysis only and endovascular treatment also showed no difference in outcomes. Another subgroup analysis showed that compared to liquid cancers, patients with solid had worse home discharge (OR: 0.178, CI: 0.109-0.290, p&lt;0.001), and higher in-hospital mortality (OR: 3.018, CI: 1.37-6.646, p=0.006) following thrombolysis. Metastatic cancers had poorest outcomes. Conclusions: Thrombolytic therapy for acute stroke in patients with cancer is not associated with increased risk of ICH or in-hospital mortality. However, careful consideration of the cancer subtype may help delineate the subset of patients with poor response to thrombolytic therapy. Prospective confirmation and attention to long-term outcomes is warranted.