Thrombolysis For Ischemic Stroke Research Articles

Outcome after Intravenous Thhrombolysis in patients with Acute Ischemic Stroke

Introduction: Vascular disorders represent a major cause of mortality worldwide, with ischemic stroke to be the second cause of mortality, after coronary artery disease. Aim: The aim of the present review was to investigate the contribution of thrombolysis in the outcome of patients with ischemic stroke. Material and Method: This is a systemic review of the literature. The sources of the literature were the databases EBSCO HOST, Elsevier Science Direct, PubMed, Medline, CINAHL, and Google Scholar.No time limit was set. The following keywords were used: ischemic stroke, thrombolysis, infarction, outcome, time window, side effects, benefits, alteplase, etiology, diagnosis, treatment. Results: Three multicenter studies were found to meet the inclusion criteria, the NINDS trial, the ECASS II and the STARS. Thrombolysis in ischemic stroke has been associated with a significantly lower mortality, fewer intracranial hemorrhages and improved neurological outcome when administered in less than 3 hours. Conclusions: The therapeutic benefits of alteplase reduced with time, while it has been determined that after 4.5 hours from the onset of symptoms of ischemic stroke has a significant benefit.

Abstract TP360: Does Weekend Admission for Intravascular Thrombolysis Post-Acute Ischemic Stroke Associated With Worse Short-Term Outcomes? A 5-Years Us Experience

Background: No large-scale study available to establish ‘weekend effect’ of higher in-hospital mortality and 30-day readmissions after admission for post-Acute ischemic stroke (AIS) thrombolysis. Our objective was to determine short term outcomes and its trends associated with weekend vs weekday index hospitalization. Methods: Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify AIS using appropriate ICD-9CM codes in primary diagnosis fields. IVT was identified by ICD9 procedure code 99.10 in any procedural field. HCUP variable “aweekend” was used to identify weekend vs weekday admission and Cochrane-Armitage test was used to generate p value. Results: We identified 164,007 AIS patients undergoing IVT (Mean age=69.5 years,49.6% Female). Weekend admission (6,229 in 2010 to 11,156 in 2014) were associated with increasing trends of hospitalization for thrombolysis with a relative change of 78%. Weekend admissions were associated with overall higher 30-day readmissions (11.03% vs 10.8%), with decreasing trend from 11.5% (vs 12% weekdays) in 2010 to 10.5% (vs 10.3% weekdays) in 2014 with a relative decrease of 8.1% (vs 16.5%- weekdays) (p<0.001). Weekend admissions were associated with overall higher in hospital mortality 9.2% vs 9.03% as compared to weekdays, though exhibiting a decline from 10.9% to 7.5% (relative change -32.5%, p<0.001). Weekend admissions were associated with overall lower cost of hospitalization 25,929$ vs 26,523$ as compared to weekdays, though exhibiting a decline from 27,215$ to 24,613$ (relative change -10.5%, p<0.001). There is no significant difference in length of stay between weekend vs weekday admission (9days vs 9 days). Conclusion: Our study showed that weekend admissions for AIS patients undergoing IVT are associated with higher in-hospital mortality, 30-day readmission and lower cost of hospitalization. We speculate that better access of care on weekends will improve then outcome for patients getting IVT and reduce the healthcare burden associated with readmissions.

The Risk of Symptomatic Intracranial Hemorrhage after Thrombolysis for Acute Stroke: Current Concepts and Perspectives.

Background:Thrombolysis is the standard of treatment for acute ischemic stroke, with a time window of up to 4½ h from stroke onset. Despite the long experience with the use of recombinant tissue plasminogen activator and the adherence to protocols symptomatic intracranial hemorrhage (SICH) may occur in around 6% of cases, with high-mortality rate and poor-functional outcomes. Many patients are excluded from thrombolysis on the basis of an evaluation of known risk factors, but there are other less known factors involved.Objective:The purpose of this work is to analyze the less known risk factors for SICH after thrombolysis. A search of articles related with this field has been undertaken in PubMed with the keywords (brain hemorrhage, thrombolysis, and acute ischemic stroke). Some risk factors for SICH have emerged such as previous microbleeds on brain magnetic resonance imaging, leukoaraiosis, and previous antiplatelet drug use or statin use. Serum matrix metalloproteinases have emerged as a promising biomarker for better selection of patients, but further research is needed.Conclusions:In addition to the already known risk factors considered in the standard protocols, an individualized evaluation of risks is needed to minimize the risk of brain hemorrhage after thrombolysis for ischemic stroke.

A New Paradigm Shift in Acute Ischemic Stroke, Large Vessel Occlusions, and Endovascular Therapy.

In the past threeyears, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy. This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management. Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24h after symptom onset stresses the need for advanced imaging to recognize the target group. EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24h after symptoms onset can significantly improve patient outcomes.

Lipoproteinuria as an independent predictor of unfavorable outcome after intravenous thrombolysis in ischaemic stroke

Patients with proteinuria and declined glomerular filtration rate (GFR) are at high risk of developing stroke. Purpose of this study was to review and analyze available literature to identify role of proteinuria along with decreased GFR as one the of predictors of unfavorable outcome of ischaemic stroke in patients receiving intravenous thrombolysis therapy in routine clinical practice. Proteinuria is an independent predictor of negative outcome after intravenous thrombolysis treatment in ischaemic stroke, which demonstrates significant impact of chronic kidney disorders in effectiveness of thrombolytic therapy.

缺血性卒中静脉溶栓后症状性颅内出血研究进展 Progress of Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Ischemic Stroke

缺血性卒中静脉溶栓后症状性颅内出血研究进展 Progress of Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Ischemic Stroke

Intravenous thrombolysis for ischemic stroke in the Veneto region: the gap between eligibility and reality.

Intravenous thrombolysis (IVT) is the treatment of choice for most patients with acute ischemic stroke. According to the recently updated guidelines, IVT should be administered in absence of absolute exclusion criteria. We aimed to assess the proportion of ischemic strokes potentially eligible and actually treated with IVT, and to explore the reasons for not administering IVT. We prospectively collected and analyzed data from 1184 consecutive ischemic stroke patients admitted to the 22 Stroke Units (SUs) of the Veneto region from September 18th to December 10th 2017. Patients were treated with IVT according to the current Italian guidelines. For untreated patients, the reasons for not administering IVT were reported by each center in a predefined model including absolute and/or relative exclusion criteria and other possible reasons. Out of 841 (71%) patients who presented within 4.5h of stroke onset, 704 (59%) had no other absolute exclusion criteria and were therefore potentially eligible for IVT according to the current guidelines. However, only 323 (27%) patients were eventually treated with IVT. Among 861 (73%) untreated patients, 480 had at least one absolute exclusion criterion, 283 only relative exclusion criteria, 56 only other reasons, and 42 a combination of relative exclusion criteria and other reasons. Our study showed that only 46% (323/704) of the potentially eligible patients were actually treated with IVT in the SUs of the Veneto region. All healthcare professionals involved in the acute stroke pathway should make an effort to bridge this gap between eligibility and reality.

Predictors of severity and outcome and roles of intravenous thrombolysis and biomarkers in first ischemic stroke

Predictors of severity and outcome and roles of intravenous thrombolysis and biomarkers in first ischemic stroke

Impact of Bradykinin Generation During Thrombolysis in Ischemic Stroke.

Ischemic stroke is one of the leading causes of death and disability worldwide. Current medical management in the acute phase is based on the activation of the fibrinolytic cascade by intravenous injection of a plasminogen activator (such as tissue-type plasminogen activator, tPA) that promotes restauration of the cerebral blood flow and improves stroke outcome. Unfortunately, the use of tPA is associated with deleterious effects such as hemorrhagic transformation, symptomatic brain edema, and angioedema, which limit the efficacy of this therapeutic strategy. Preclinical and clinical evidence suggests that intravenous thrombolysis generates large amounts of bradykinin, a peptide with potent pro-inflammatory, and pro-edematous effects. This tPA-triggered generation of bradykinin could participate in the deleterious effects of thrombolysis and is a potential target to improve neurological outcome in tPA-treated patients. The present review aims at summarizing current evidence linking thrombolysis, bradykinin generation, and neurovascular damage.

Intravenous Thrombolysis and Endovascular Therapy for Childhood Stroke Appear Feasible

The evidence for intravenous thrombolysis and endovascular therapy for acute ischemic stroke is largely based on studies in adults. Applying these data

Stroke networks and telemedicine: An Italian national survey.

Stroke is the leading cause of disability and death. Nowadays, clinical benefits of stroke units and thrombolysis in ischemic stroke are evidence-based. Also the benefit of endovascular treatment for acute ischemic stroke has been established. Telemedicine has been used to improve access to care by allowing a neurologist at a remote location to interact with the patient and their family members. Prior studies have shown that the use of telemedicine for acute ischemic stroke is not only safe and effective, but it also increases the utilization of tPA, improving patient outcomes. This study aimed to investigate the diffusion of telemedicine in Italian stroke networks with an online questionnaire to assess: type of stroke care setting, Volume of thrombolysis- thrombectomy/year, access to stroke care between different hospitals, the presence of imaging sharing protocols within the network or patients dispatchment screening; type of network solutions. We have interviewed 24 Italian neurologists, working in large urban areas, from north southward, including Italian islands. In particular, these neurologists represented 14 different regions and 20 countries. A majority of neurologists replying to the survey (47.83%) worked in large general hospitals or smaller general hospitals (26%) and a smaller number of physicians (17.3%) were committed in University Hospital or (8.7%) independent foundation hospitals. The 60.87% of stroke networks involved in the survey had a low thrombolysis/year volume while the 30.43% had a thrombolysis/year volume above 100. According to the survey a local stroke network was established in 87.50% of cases. In the 45.83% of cases, the hospitals care is not homogeneous within the network. A network for the consultation of neuroimaging between hospitals is available in 33.33% of cases. Whitin those describing an active network for Teleconsult the 57.14% used personal devices, while only the 25 % use professional teleconference system, and in 25% of cases used medical devices. Our findings demonstrated a relevant diffusion of Teleconsult in Italian stroke networks. The systems adopted are mostly individual solutions not integrated in protocolled pathways. These findings may encourage a systematization of Telemedicine medical curricula to increase larger access to neurological consults.

Administrative data underestimate acute ischemic stroke events and thrombolysis treatments: Data from a multicenter validation survey in Italy.

BackgroundInforming health systems and monitoring hospital performances using administrative data sets, mainly hospital discharge data coded according to International-Classification-Diseases-9edition-Clinical-Modifiers (ICD9-CM), is now commonplace in several countries, but the reliability of diagnostic coding of acute ischemic stroke in the routine practice is uncertain. This study aimed at estimating accuracy of ICD9-CM codes for the identification of acute ischemic stroke and the use of thrombolysis treatment comparing hospital discharge data with medical record review in all the six hospitals of the Florence Area, Italy, through 2015.MethodsWe reviewed the medical records of all the 3915 potential acute stroke events during 2015 across the six hospitals of the Florence Area, Italy. We then estimated sensitivity and Positive Predictive Value of ICD9-CM code-groups 433*1, 434*1 and thrombolysis code 99.10 against medical record review with clinical adjudication. For each false-positive case we obtained the actual diagnosis. For each false-negative case we obtained the primary and secondary ICD9-CM diagnoses.ResultsThe medical record review identified 1273 acute ischemic stroke events. The hospital discharge records identified 898 among those (true-positive cases),but missed 375 events (false-negative cases), and identified 104 events that were not eventually confirmed as acute ischemic events (false-positive cases). Code-group specific Positive Predictive Value was 85.7% (95%CI,74.6–93.3) for 433*1 and 89.9% (95%CI, 87.8–91.7) for 434*1 codes. Thrombolysis treatment, as identified by ICD9-CM code 99.10, was only documented in 6.0% of acute ischemic stroke events, but was 13.6% in medical record review.ConclusionsHospital discharge data were found to be fairly specific but insensitive in the reporting of acute ischemic stroke and thrombolysis, providing misleading indications about both quantity and quality of acute ischemic stroke hospital care. Efforts to improve coding accuracy should precede the use of hospital discharge data to measure hospital performances in acute ischemic stroke care.

Comorbid Psychiatric Disease Is Associated With Lower Rates of Thrombolysis in Ischemic Stroke.

Intravenous thrombolysis (IVT) improves outcomes after acute ischemic stroke but is underused in certain patient populations. Mental illness is pervasive in the United States, and patients with comorbid psychiatric disease experience inequities in treatment for a range of conditions. We aimed to determine whether comorbid psychiatric disease is associated with differences in IVT use in acute ischemic stroke. Acute ischemic stroke admissions between 2007 and 2011 were identified in the Nationwide Inpatient Sample. Psychiatric disease was defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes for secondary diagnoses of schizophrenia or other psychoses, bipolar disorder, depression, or anxiety. Using logistic regression, we tested the association between IVT and psychiatric disease, controlling for demographic, clinical, and hospital factors. Of the 325 009 ischemic stroke cases meeting inclusion criteria, 12.8% had any of the specified psychiatric comorbidities. IVT was used in 3.6% of those with, and 4.4% of those without, psychiatric disease (P<0.001). Presence of any psychiatric disease was associated with lower odds of receiving IVT (adjusted odds ratio, 0.80; 95% confidence interval, 0.76-0.85). When psychiatric diagnoses were analyzed separately individuals with schizophrenia or other psychoses, anxiety, or depression each had significantly lower odds of IVT compared to individuals without psychiatric disease. Acute ischemic stroke patients with comorbid psychiatric disease have significantly lower odds of IVT. Understanding barriers to IVT use in such patients may help in developing interventions to increase access to evidence-based stroke care.

Development and validation of the Dutch Stroke Score for predicting disability and functional outcome after ischemic stroke: A tool to support efficient discharge planning.

IntroductionWe aimed to develop and validate a prognostic score for disability at discharge and functional outcome at three months in patients with acute ischemic stroke based on clinical information available on admission.Patients and methodsThe Dutch Stroke Score (DSS) was developed in 1227 patients with ischemic stroke included in the Paracetamol (Acetaminophen) In Stroke study. Predictors for Barthel Index (BI) at discharge (‘DSS-discharge’) and modified Rankin Scale (mRS) at three months (‘DSS-3 months’) were identified in multivariable ordinal regression. The models were internally validated with bootstrapping techniques. The DSS-3 months was externally validated in the PRomoting ACute Thrombolysis in Ischemic StrokE study (1589 patients) and the Preventive Antibiotics in Stroke Study (2107 patients). Model performance was assessed in terms of discrimination, expressed by the area under the receiver operating characteristic curve (AUC), and calibration.ResultsAt model development, the strongest predictors of Barthel Index at discharge were age per decade over 60 (odds ratio = 1.55, 95% confidence interval (CI) 1.41–1.68), National Institutes of Health Stroke Scale (odds ratio = 1.24 per point, 95% CI 1.22–1.26) and diabetes (odds ratio = 1.62, 95% CI 1.32–1.91). The internally validated AUC was 0.76 (95% CI 0.75–0.79). The DSS-3 months, additionally consisting of previous stroke and atrial fibrillation, performed similarly at internal (AUC 0.75, 95% CI 0.74–0.77) and external validation (AUC 0.74 in PRomoting ACute Thrombolysis in Ischemic StrokE (95% CI 0.72–0.76) and 0.69 in Preventive Antibiotics in Stroke Study (95% CI 0.69–0.72)). Observed outcome was slightly better than predicted.Discussion: The DSS had satisfactory performance in predicting BI at discharge and mRS at three months in ischemic stroke patients.ConclusionIf further validated, the DSS may contribute to efficient stroke unit discharge planning alongside patients' contextual factors and therapeutic needs.

Abstract 196: Comorbid Psychiatric Disease is Associated With Lower Rates of Thrombolysis in Ischemic Stroke

Introduction: Intravenous thrombolysis (IVT) improves outcomes after acute ischemic strokes (AIS) but is underutilized in vulnerable patients such as racial minorities, women, and those with low income. At the same time, mental illness affects 20% of U.S. adults, and these individuals are more likely than those without mental illness to experience inequities in treatment for a range of medical conditions, and are more likely to die within a year if they have a stroke. We aimed to determine if comorbid psychiatric disease is associated with differences in IVT use in AIS. Methods: We studied AIS admissions, identified by ICD9-CM codes, from 2007-2011 in the Nationwide Inpatient Sample. Psychiatric disease was defined by ICD9-CM codes for secondary diagnoses of schizophrenia or other psychoses, anxiety, depression, or bipolar disorder. We used logistic regression to test the association between IVT and psychiatric disease, controlling for demographic, clinical, and hospital factors. Results: In total, 335,923 AIS cases met inclusion criteria, of which 12.8% had any of the specified psychiatric comorbidities. IVT was used in 3.6% of those with, and 4.5% of those without, comorbid psychiatric disease ( p &lt; 0.001). In multivariable logistic regression, having any psychiatric disease was associated with 20% decreased odds of receiving IVT (OR 0.80, 95% CI 0.76-0.85, Table 1). When each psychiatric diagnosis was analyzed separately, schizophrenia and other psychoses, anxiety, and depression were associated with significantly lower odds of receiving IVT (Table 1). Conclusions: AIS patients with comorbid psychiatric disease have significantly lower odds of receiving IVT. Understanding barriers to IVT use in such patients may help in developing interventions aimed at improving outcomes and increasing access to evidence-based stroke care.

Abstract WP41: Endovascular Therapy versus Intravenous Thrombolysis in Cervical Artery Dissection Ischemic Stroke - A Systematic Review and Meta-analysis and Results From the Swiss Registry

Background: Data on endovascular therapy (EVT) in patients with stroke attributable to CeAD is scarce. We performed a systematic review and meta-analysis of all studies comparing EVT to intravenous thrombolysis (IVT) in CeAD-patients and compared EVT to IVT with regard to 3-month outcome and complications. Additionally, we included data of IVT-/EVT-treated CeAD-patients from a Swiss multicenter IVT-/EVT registry based cohort study. Methods: We systematically searched the pubmed® database to identify all existing studies comparing IVT to EVT in CeAD-patients. Studies were eligible if IVT-treated CeAD- patients were compared to EVT-treated patients, and 3-month outcomes were reported as modified Rankin Scale (mRS) score. Outcome measures in this study were favorable 3-month outcome (i.e. mRS 0-2), excellent 3-month outcome (i.e. mRS 0-1), symptomatic intracranial hemorrhage (sICH) and death. Additionally, in a Swiss multicenter IVT-/EVT registry based cohort-study (SWISS) we identified all consecutive patients with ischemic stroke attributable to CeAD and included outcome data of these patients in our analyses. In a meta-analysis across all studies, we compared EVT to IVT with regard to primary and secondary outcome measures using a fixed-effect Mantel-Haenszel model. Results: The literature search yielded 388 results. We identified 7 eligible studies for a systematic comparison of EVT versus IVT. Data on 62 patients from the SWISS cohort were included as an additional study. In total, we compared EVT (n=102) versus IVT (n=110) in 212 CeAD-patients. With regard to the occurrence of mRS 0-2, there was no significant difference between both treatment groups (OR 1.04 (95% CI 0.57-1.88)). Separate Data on mRS 0-1 was available in 5 studies (OR 0.88 (95% CI 0.39-2.00)). There was no difference between groups with regard to death at 3 months (OR 0.66 (0.22-1.94)) which was separately reported in 6 studies. For sICH there were too few data (n=5 patients) available for meta-analysis. Conclusion: In this systematic review and meta-analysis of all existing studies comparing EVT to IVT in CeAD patients there was no clear signal of superiority of EVT. Further investigation of EVT with up-to-date devices is warranted.

Abstract WP185: The Influence of Diabetes on Subtype, Treatment and Outcome in Stroke Patients in Scotland

Background: Diabetic patients are at a higher risk of stroke than non-diabetic patients. However, the consensus of the effect of diabetes on stroke prognosis is still ongoing. Aims: This study aims to investigate whether diabetes influences the type, treatment and mortality outcomes in stroke patients in Scotland using the Scottish Stroke Care Audit. Methods: The Scottish Stroke Care Audit was used to identify 58,099 stroke cases in Scotland from January 2005 to December 2013. Baseline characteristics, stroke subtypes, six simple variable (SSV) assessment scores, acute treatment and mortality outcomes were examined in persons with and without a corresponding diabetes diagnosis in hospital coding. Statistical tests were used to compare these characteristics in the two groups, with logistic regression and cox-proportional hazards to evaluate the odds ratios and hazard ratios for mortality outcomes up to one year after first time stroke event. Results: The Scottish Stroke Care Audit stroke population included 6119 (10.5%) with a hospital based code of diabetes. These patients had significantly more ischaemic strokes and less haemorrhagic strokes than non-diabetic patients (P &lt; 0.0001), they also had better SSV scores indicating less severe strokes. Diabetic patients were less likely to receive thrombolysis for ischaemic stroke (P = 0.001), but were more likely to be given aspirin (P &lt; 0.0001), with both groups treated similarly with antiplatelet therapy in-hospital (P = 0.566), and anticoagulant therapy upon discharge (P = 0.247). Less diabetic patients died up to 9 months after stroke, but at one year the mortality cases were similar in both groups (P = 0.061). Diabetes was not an independent risk factor for mortality, but when the cox proportional hazard model was adjusted for age, gender, stroke subtype and SSVs, the mortality risk increased in diabetics with HR 1.06 (95% CI: 1.01 - 1.12, p = 0.018) Conclusions: Diabetes impacts on the type, treatment and mortality outcomes in stroke patients in Scotland, with a predisposition for milder ischaemic strokes in this group. As diabetes increases the risk of recurrent strokes, improving treatment of even mild events may reduce disease burden longer term.

Improving Access to Thrombolysis and Inhospital Management Times in Ischemic Stroke: A Stepped-Wedge Randomized Trial.

A suboptimal number of ischemic stroke patients eligible for thrombolysis actually receive it, partly because of extended inhospital delays. We developed a comprehensive program designed for emergency unit staff and evaluated its effectiveness for reducing intrahospital times and improving access to thrombolysis. We conducted a randomized stepped-wedge controlled trial in 18 emergency unit. The sequentially implemented training intervention, targeting emergency physicians and nurses, was based on specifically designed videos and interactive simulation workshops on intrahospital management optimization. The effectiveness was assessed on intrahospital times and thrombolysis proportion. During the study period, all consecutive patients with confirmed ischemic stroke and no contraindications to thrombolysis were included. A total of 328 patients were enrolled in the control group and 363 in the intervention group. Mean age was 73.6 years. Overall thrombolysis proportion was 34.2% in the intervention group versus 25.6% in the control group (adjusted odds ratio, 1.42; 95% confidence interval, 1.01-2.01), thrombolysis proportion within 4 hours 30 minutes almost doubled (adjusted odds ratio, 1.9; 95% confidence interval, 1.32-2.73). Although imaging-to-stroke unit time was significantly decreased in the intervention group (39 versus 53 minutes; P=0.03), median door-to-imaging and door-to-needle times were not different between groups (P=0.70 and P=0.40, respectively). An interactive and multifaceted training program targeting emergency professionals was significantly associated with an increased access to thrombolysis, especially within 4 hours and 30 minutes. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02814760.

STARTING-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis for Stroke.

Symptomatic intracerebral hemorrhage (sICH) is a rare but the most feared complication of intravenous thrombolysis for ischemic stroke. We aimed to develop and validate a nomogram for individualized prediction of sICH in intravenous thrombolysis-treated stroke patients included in the multicenter SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register). All patients registered in the SITS-ISTR by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was sICH per the European Cooperative Acute Stroke Study II definition (any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline or death <7 days). On the basis of multivariate logistic model, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver-operating characteristic curve and calibration of risk prediction model by using the Hosmer-Lemeshow test. A total of 15 949 patients with complete data for generating the nomogram was randomly dichotomized into training (3/4; n=12 030) and test (1/4; n=3919) sets. After multivariate logistic regression, 10 variables remained independent predictors of sICH to compose the STARTING-SICH (systolic blood pressure, age, onset-to-treatment time for thrombolysis, National Institutes of Health Stroke Scale score, glucose, aspirin alone, aspirin plus clopidogrel, anticoagulant with INR ≤1.7, current infarction sign, hyperdense artery sign) nomogram. The area under the receiver-operating characteristic curve of STARTING-SICH was 0.739. Calibration was good (P=0.327 for the Hosmer-Lemeshow test). The STARTING-SICH is the first nomogram developed and validated in a large SITS-ISTR cohort for individualized prediction of sICH in intravenous thrombolysis-treated stroke patients.

Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke - Results from the SWISS registry.

In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications. In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0-1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel-Haenszel model. Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9-11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00-14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38-2.44]) among endovascular therapy patients and intravenous thrombolysis patients. In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which - given the limitation of our sample size - does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.