Thrombolytic Treatment Research Articles

Radio frequency identification technology reduce intravenous thrombolysis time in acute ischemic stroke.

To inspect whether time management with radio frequency identification technology (RFID) reduces symptom onset-to-intravenous thrombolysis time (OTT) in acute ischemic stroke (AIS). In the retrospective study, patients with AIS, transferred by Emergency Medical Services (EMS) to Hunan Provincial People's Hospital between September 2019 to June 2022, divided into three groups, as traditional group, in-hospital RFID group and whole process RFID group. Baseline characteristics and time metrics were compared. After the whole emergency process applied with RFID time management, Door to intravenous thrombolysis time (DNT) was reduced from 125.00±43.16 min to 32.59±25.45 min (F = 121.857, p<0.001), and OTT was reduced from 235.53±57.27 min to 144.31±47.96 min (F = 10.377, p<0.001). Time management with RFID is effective in reducing OTT in AIS patients with thrombolysis treatment.

Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020.

We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020. We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively. The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90-4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63-26.43) per 100,000 and 17.14% (95% CI: 12.98-21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96-9.77) per 100,000 and 6.91% (95% CI: 5.15-8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016. Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism.

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14-2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06-1.93), and decreased PaO2/FiO2 ratio (p = 0.001, OR = 0.56 95% CI 0.41-0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO2/FiO2 <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO2/FiO2, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan

Acute stroke treatment rates in the US lag behind those in other high-income nations. To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis. This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023. Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted. The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type. In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30). This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage. ClinicalTrials.gov Identifier: NCT036455900.

Effect of Atherogenic Index of Plasma on Pre-Percutaneous Coronary Intervention Thrombolysis in Myocardial Infarction Flow in Patients With ST Elevation Myocardial Infarction.

Dyslipidemia is an important risk factor for cardiovascular morbidity and mortality. Although low-density lipoprotein (LDL) is primarily responsible, the importance of triglyceride (TG) and high-density lipoprotein (HDL) has also been recognized. The present study investigated the effect of the atherogenic index of plasma (AIP), in which atherogenic and protective lipoproteins were evaluated together, on the initial flow in patients with ST elevation myocardial infarction. AIP was calculated as log(TG/HDL-cholesterol). Patients included in the study (n = 1535) were divided into Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 and >0. AIP was found to be significantly different between 2 groups (.55 ± .23 vs .67 ± .21; P < .001). AIP was an independent predictor for pre-intervention TIMI flow (Odds Ratio: 2.778). A moderate correlation was found between TIMI frame count measurements, calculated in patients with TIMI 2-3, and AIP (Pearson correlation coefficient: .63, P < .001). In the receiver operating characteristic analysis, AIP showed the highest area under curve (AUC) compared with other lipid parameters for predicting vascular patency. The AUC of AIP was .634, the cut-off value was .59, and the sensitivity and specificity were 67.6% and 68.4%, respectively (P < .001). In conclusion, AIP was found to be an important marker affecting pre-percutaneous coronary intervention TIMI flow.

The Effect of High-dose Allopurinol Pretreatment on Inflammatory Biomarkers and Post-revascularization Coronary Blood Flow in Non-STEMI Patients: A Randomized Double Blind Clinical Trial.

The use of allopurinol has shown promising outcomes in reducing oxidative processes responsible for atherogenic-related cardiovascular events. The current study aims to assess the effects of high-dose allopurinol on the post-revascularization coronary blood flow and inflammatory biomarkers in patients with non-ST segment elevated myocardial infarction (NSTEMI). Eighty NSTEMI patients were randomly divided into two groups: the intervention group (n=40), medicated with a high loading dose of 600 mg allopurinol before the coronary angiography, and the control group (n=40), treated with a placebo. The highly sensitive C-reactive protein (hs-CRP) was measured at baseline and within 24 hours after the cardiac interventions and compared between the case and control groups. Post percutaneous coronary intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow grading was also evaluated as a revascularization endpoint. The two groups of the study were similar in terms of demographic, clinical, laboratory, and angiographic characteristics (P-value>0.050). The assessed TIMI flow was similar between the cases and the controls both prior to (P-value=0.141) and after (P-value=0.395) the coronary angioplasty. The hs-CRP (P-value=0.016) was significantly higher in the control group. Post-angiographic assessment of hs-CRP revealed an insignificant difference between the groups (P-value=0.104). In conclusion, premedication with a high dose of allopurinol in NSTEMI patients did not affect the inflammatory biomarker or the revascularization endpoint.

Efficacy and Safety of Butylphthalide in Patients With Acute Ischemic Stroke

DL-3-n-butylphthalide (NBP) is a drug for treating acute ischemic stroke and may play a neuroprotective role by acting on multiple active targets. The efficacy of NBP in patients with acute ischemic stroke receiving reperfusion therapy remains unknown. To assess the efficacy and safety of NBP in patients with acute ischemic stroke receiving reperfusion therapy of intravenous thrombolysis and/or endovascular treatment. This multicenter, double-blind, placebo-controlled, parallel randomized clinical trial was conducted in 59 centers in China with 90-day follow-up. Of 1236 patients with acute ischemic stroke, 1216 patients 18 years and older diagnosed with acute ischemic stroke with a National Institutes of Health Stroke Scale score ranging from 4 to 25 who could start the trial drug within 6 hours from symptom onset and received either intravenous recombinant tissue plasminogen activator (rt-PA) or endovascular treatment or intravenous rt-PA bridging to endovascular treatment were enrolled, after excluding 20 patients who declined to participate or did not meet eligibility criteria. Data were collected from July 1, 2018, to May 22, 2022. Within 6 hours after symptom onset, patients were randomized to receive NBP or placebo in a 1:1 ratio. The primary efficacy outcome was the proportion of patients with a favorable outcome based on 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) thresholds of 0 to 2 points, depending on baseline stroke severity. Of 1216 enrolled patients, 827 (68.0%) were men, and the median (IQR) age was 66 (56-72) years. A total of 607 were randomly assigned to the butylphthalide group and 609 to the placebo group. A favorable functional outcome at 90 days occurred in 344 patients (56.7%) in the butylphthalide group and 268 patients (44.0%) in the placebo group (odds ratio, 1.70; 95% CI, 1.35-2.14; P < .001). Serious adverse events within 90 days occurred in 61 patients (10.1%) in the butylphthalide group and 73 patients (12.0%) in the placebo group. Among patients with acute ischemic stroke receiving intravenous thrombolysis and/or endovascular treatment, NBP was associated with a higher proportion of patients achieving a favorable functional outcome at 90 days compared with placebo. ClinicalTrials.gov Identifier: NCT03539445.

Sex differences in acute telestroke care: more to the story.

Previous studies have shown sex differences in stroke care. Female patients have both lower thrombolytic treatment rates with OR reported as low as 0.57 and worse outcomes. With updated standards of care and improved access to care through telestroke, there is potential to reduce or alleviate these disparities. Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 203 facilities (23 states) from January 1, 2021 to April 30, 2021 were extracted from the Telecare by TeleSpecialists™ database. The encounters were reviewed for demographics, stroke time metrics, thrombolytics candidate, premorbid modified Rankin Score, NIHSS score, stroke risk factors, antithrombotic use, admitting diagnosis of suspected stroke, and reason not treated with thrombolytic. The treatment rates, door to needle (DTN) times, stroke metric times, and variables of treatment were compared for females and males. There were 18,783 (10,073 female and 8,710 male) total patients included. Of the total, 6.9% of females received thrombolytics compared to 7.9% of males (OR 0.86, 95% CI 0.75-0.97, p = 0.006). Median DTN times were shorter for males than females (38 vs. 41 min, p < 0.001). Male patients were more likely to have an admitting diagnosis of suspected stroke, p < 0.001. Analysis by age showed the only decade with significant difference in thrombolytics treatment rate was 50-59 with increased treatment of males, p = 0.047. When multivariant logistic regression analysis was performed with stroke risk factors, NIHSS score, age, and admitting diagnosis of suspected stroke, the adjusted odds ratio for females was 0.9 (95% CI 0.8, 1.01), p = 0.064. While treatment differences between sexes existed in the data and were apparent in univariate analysis, no significant difference was seen in multivariate analysis once stroke risk factors, age, NIHSS score and admitting diagnosis were taken into consideration in the telestroke setting. Differences in rates of thrombolysis between sexes may therefore be reflective of differences in risk factors and symptomatology rather than a healthcare disparity.

Multi-enzyme mimetic iridium nanozymes-based thrombus microenvironment-modulated nanoplatform for enhanced thrombolytic therapy

Intravenous injection of thrombolytic drugs is the most feasible strategy for the clinical treatment of thrombotic diseases, however, its applications are yet limited by narrow therapeutic index, short half-life, and hemorrhagic risk. Inspired by the excessive ROS and inflammatory factors at the thrombus site, we manufactured a thrombus microenvironment-modulated nanosystem, which achieved the targeted delivery of thrombolytic drugs and ROS scavenging agents. Ir monomers (Ir-PVP) with enzyme-mimetic activity were prepared and then wrapped with lumbrokinase (LK) by HA materials of thrombo-inflammatory affinity, forming multifunctional thrombolytic agents Ir-LK@HA. Ir-LK@HA could prolong the biological half-life of LK and target the thrombus site to release LK with reduced bleeding risk. Moreover, Ir-NPs, as both CT imaging contrast agent and ROS scavenger, not only allowed us to observe the progression of thrombolytic treatment through CT imaging in real time, but also played an important role in elimination of excessive ROS at thrombus site. Taken together, the in vitro and in vivo experiments illustrated that Ir-LK@HA with CT function displayed an excellent efficiency in thrombolysis, anti-inflammation and ROS scavenging. Our work may encourage further exploration of thrombus microenvironment-modulated theranostic platforms.

Acute stroke CDS: automatic retrieval of thrombolysis contraindications from unstructured clinical letters.

Thrombolysis treatment for acute ischaemic stroke can lead to better outcomes if administered early enough. However, contraindications exist which put the patient at greater risk of a bleed (e.g. recent major surgery, anticoagulant medication). Therefore, clinicians must check a patient's past medical history before proceeding with treatment. In this work we present a machine learning approach for accurate automatic detection of this information in unstructured text documents such as discharge letters or referral letters, to support the clinician in making a decision about whether to administer thrombolysis. We consulted local and national guidelines for thrombolysis eligibility, identifying 86 entities which are relevant to the thrombolysis decision. A total of 8,067 documents from 2,912 patients were manually annotated with these entities by medical students and clinicians. Using this data, we trained and validated several transformer-based named entity recognition (NER) models, focusing on transformer models which have been pre-trained on a biomedical corpus as these have shown most promise in the biomedical NER literature. Our best model was a PubMedBERT-based approach, which obtained a lenient micro/macro F1 score of 0.829/0.723. Ensembling 5 variants of this model gave a significant boost to precision, obtaining micro/macro F1 of 0.846/0.734 which approaches the human annotator performance of 0.847/0.839. We further propose numeric definitions for the concepts of name regularity (similarity of all spans which refer to an entity) and context regularity (similarity of all context surrounding mentions of an entity), using these to analyse the types of errors made by the system and finding that the name regularity of an entity is a stronger predictor of model performance than raw training set frequency. Overall, this work shows the potential of machine learning to provide clinical decision support (CDS) for the time-critical decision of thrombolysis administration in ischaemic stroke by quickly surfacing relevant information, leading to prompt treatment and hence to better patient outcomes.

Thrombolysis in Patients With Large‐Vessel Occlusion Directly Admitted or Transferred to a Thrombectomy Center: A Population‐Based Study

Background Our goal is to evaluate whether the administration of thrombolytic treatment has varying effects on clinical and radiological outcomes in patients with large‐vessel occlusion stroke, based on the type of stroke center where the treatment was given (thrombectomy‐capable center versus local stroke center). Methods We included patients with an acute ischemic large‐vessel occlusion stroke who were directly admitted to thrombectomy‐capable centers and treated with endovascular thrombectomy, or were transferred from local stroke centers as thrombectomy candidates, in Catalonia, Spain, between 2017 and 2021. The primary outcome was the shift analysis on the modified Rankin scale score at 90 days. Secondary outcomes included death at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse‐probability weighting clustered at the type of stroke center was used to estimate the effects. Results The analysis included 2268 patients directly admitted to thrombectomy‐capable centers, of whom 975 (49%) were treated with thrombolysis, and 938 patients transferred from local stroke centers, of whom 580 (66%) were treated with thrombolysis and 616 (67%) were treated with thrombectomy. Mean age was 72 (SD ±13) years, median National Institute of Health Stroke Scale score was 17 (interquartile range, 12–21), and 1363 patients were women (48%). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image, higher Alberta Stroke Program Early Computed Tomography Score, and lower rates of wake‐up stroke, atrial fibrillation, and anticoagulation intake. Patients treated with thrombolysis had better functional outcome at 90 days, with no difference between patients directly admitted to thrombectomy‐capable centers (adjusted common odds ratio [acOR], 1.50 [95% CI, 1.24–1.81]) and patients transferred from local stroke centers (acOR, 1.44 [95% CI, 1.04–2.01]). Patients treated with intravenous thrombolysis had lower death rate, higher rate of parenchymal hematoma, and similar rate of successful reperfusion, with no difference according to type of center ( P interaction &gt;0.1). Conclusion Administration of intravenous thrombolysis in patients with a large‐vessel stroke with intention of thrombectomy was associated with lower degrees of disability, lower death rate, and higher rates of parenchymal hematoma both in thrombectomy‐capable centers and in local stroke centers.

GOx-Powered Janus Platelet Nanomotors for Targeted Delivery of Thrombolytic Drugs in Treating Thrombotic Diseases.

Low efficiency of targeting and delivery toward the thrombus site poses challenges to using thrombolytic drugs. Inspired by the biomimetic system of platelet membranes (PMs) and glucose oxidase (GOx) modification technologies, we develop a novel GOx-powered Janus nanomotor by asymmetrically attaching the GOx to polymeric nanomotors coated with the PMs. Then the PM-coated nanomotors were conjugated with urokinase plasminogen activators (uPAs) on their surfaces. The PM-camouflaged design conferred excellent biocompatibility to the nanomotors and improved their targeting ability to thrombus. The Janus distribution of GOx also allows the uneven decomposition of glucose in biofluids to produce a chemophoretic motion, increasing the drug delivery efficiency of nanomotors. In addition, these nanomotors are located at the lesion site due to the mutual adhesion and aggregation of platelet membranes. Furthermore, thrombolysis effects of nanomotors are enhanced in static and dynamic thrombus as well as in mouse models. It is believed that the novel PM-coated enzyme-powered nanomotors represent a great value for thrombolysis treatment.

Using a Transradial Method, The Results of Primary Percutaneous Coronary Intervention at a Tertiary Care Cardiac Centre

Objective: The purpose of this study is to investigate the in-hospital outcomes of primary percutaneous coronary intervention (PCI) performed using a transradial technique in a cardiac centre that provides tertiary care. Study Design: Descriptive/ observational study Place and Duration: Department of cardiology, Peshawar Institute of Cardiology, Hayatabad phase 5 Peshawar, KPK in the duration from April, 2022 to September, 2022. Methods: 104 patients were included in the trial; all had ST-segment elevation myocardial infarction and had presented within 12 hours of symptom onset without a history of thrombolytic treatment, coronary angioplasty, or cardiac surgery. Patients were monitored for forearm hematoma and mortality during their hospital stays after diagnostic angiography and primary percutaneous coronary intervention (PCI) of the artery supplying the infarct.SPSS 24.0 was used to analyze all data. Results: There were majority 75 (72.1%) males and 29 (27.9%) females among all cases. Included patients had mean age 48.44±13.67 years and had mean BMI 27.6±3.48 kg/m2. 48 (46.2%) patients were smokers and most common comorbidity was diabetes found in 63 (60.6%) cases followed by HTN, CAD, hyperlipidemia and obesity. Success rate of PCI by using transradial method was found in 101 (97.1%) cases. Mortality was only found in 2 cases and post-procedure forearm hematoma was found in 1 patients. Mortality and forearm hematoma was found because of old age among patients. Conclusion: In this study, we came to the conclusion that primary percutaneous coronary intervention (PCI) performed using a transradial technique is a viable alternative that has great success rates in terms of both mortality rates and morbidity, such as hematoma of the forearm. Keywords: Primary percutaneous coronary intervention, transradial approach, Forearm hematoma, mortality

Clinical Observation of Uninterrupted Thrombolytic Therapy via Indwelling Catheter for Lower Limb Deep Vein Thrombosis.

Observe uninterrupted thrombolytic therapy via indwelling catheter for lower limb deep vein thrombosis. We retrospectively studied data from 32 patients with lower extremity deep vein thrombosis who received comprehensive treatment, consisting of general treatment, inferior vena cava filter implantation, interventional thrombolysis, angioplasty, stenting, and post-operative monitoring. The efficacy and safety of the comprehensive treatment were observed for a follow-up period of 6-12 months. The treatment was 100% effective; patient results indicated no serious bleeding, acute pulmonary embolism, or death after surgery. The combination of intravenous and healthy side femoral vein puncture and directed thrombolysis to treat acute lower limb deep vein thrombosis is safe, effective, and minimally invasive while still achieving a good therapeutic effect.

Ultrasound-Accelerated Catheter-Directed Thrombolysis.

Venous thromboembolism is a very common presentation in the hospital setting. In patients with high-risk pulmonary embolism (PE) or PE and hemodynamic instability, systemic thrombolytic treatment is generally indicated. In those with contraindications to systemic thrombolysis, catheter-directed local thrombolytic therapy and surgical embolectomy are currently considered. In particular, catheter-directed thrombolysis (CDT) is a drug delivery system coupling the endovascular drug administration nearby in the thrombus and the local facilitating effect of ultrasounds. The applications of CDT are currently debated. Here we provide a systematic review of the clinical utilization of CDT.

Feasibility of switching from alteplase to tenecteplase for stroke thrombolysis - A retrospective cohort analysis.

Tenecteplase (TNK-tPA) has several benefits over alteplase (tPA) in treatment of acute ischaemic stroke. Randomised controlled trials have shown promising results. In June 2017, the Stroke Unit at Sundsvall County Hospital switched from tPA to TNK-tPA in standard clinical practice. This study examines the effects of that shift. All thrombolysis treatments performed during the first twenty-four months with TNK-tPA (168) were compared to the last twenty-four months with tPA (191). Data were collected from patient records. Follow-up time was 30 days. Co-primary outcomes were death and symptomatic intracranial haemorrhage (SICH). Secondary outcomes were types of intracerebral bleeding and cause of death. Tertiary outcome was door-to-needle time (DNT). Treatment groups were of comparable age (75.7±0.2 years). tPA-treated patients had an NIHSS (National Institutes of Health Stroke Scale) score of 9.2 versus 7.5 for TNK-tPA. Patients older than 80 had more severe strokes (median NIHSS 9 versus 5). SICH occurred in 6 (3.6%) patients in the TNK-tPA group and in 2 (1.0%) treated with tPA, odds ratio (OR) 3.41 (0.70-16.7). Numbers for death were 21 (12.5%) and 31 (15.2%), OR 0.77 (0.46-1.29), meaning no statistically significant differences in primary outcomes. There were no significant differences in secondary outcomes. Predominant cause of death was cerebral infarction. DNT with tenecteplase was shorter: mean 44 versus 26, and median 35 versus 19min. Switching from alteplase to tenecteplase was associated with shorter time to treatment. To draw certain conclusions regarding safety or efficacy would require a larger material.

Intravenous thrombolysis of ischemic stroke-Current status

Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5‑h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.

Energy spectrum CT index-based machine learning model predicts the effect of intravenous thrombolysis in lower limbs.

To develop a noninvasive machine learning (ML) model based on energy spectrum computed tomography venography (CTV) indices for preoperatively predicting the effect of intravenous thrombolytic treatment in lower limbs. A total of 3492 slices containing thrombus regions from 58 veins in lower limbs in a cohort of 18 patients, divided in good and poor thrombolysis prognosis groups, were analyzed. Key indices were selected by univariate analysis and Pearson correlation coefficient test. A support vector machine classifier-based model was developed through ten-fold cross validation. Model performance was assessed in terms of discrimination, calibration, and clinical usefulness at both per-slice and per-vessel levels. Continuous variables and categorical variables were compared between good and poor thrombolysis prognosis group by Mann-Whitney U-test and chi-square test, respectively. A nomogram was built by integrating clinical factors and the energy spectrum CTV index-based score calculated by the model. Six indices selected from 192 indices were used to build the predictive model. The ML model achieved area under the curves (AUCs) of 0.838 and 0.767 [95% CI (confidence interval), 0.825-0.850, 0.752-0.781] in the training and validation datasets at the per-slice level, and the per-vessel level AUCs were 0.945 and 0.876 (95% CI, 0.852-0.988, 0.763-0.948) in the training and validation datasets, respectively. The nomogram showed better performance with the per-vessel level AUC, accuracy, sensitivity and specificity, yielding 0.901(95% CI, 0.793-0.964), 86.2%, 87.9% and 84.0% in the validation dataset, respectively. There was no significant difference in the vessel distribution between good and poor thrombolysis prognosis groups (chi-square test, p=0.671). The energy spectrum CTV index-based ML model achieved favorable effectiveness in predicting the outcome of vessel-level intravenous thrombolysis. A nomogram integrating clinical factors, and risk score calculated by the developed model showed improved performance and had potential to be used as a noninvasive preoperative tool for clinicians.

Intravenous thrombolysis for acute ischemic stroke during two COVID-19 outbreaks in China: Wuhan pandemic and Beijing pandemic

IntroductionThe COVID-19 pandemic has had an impact on the emergency department (ED). Door-to-needle time (DNT) could be prolonged for intravenous thrombolysis (IVT) treatment. We aimed to investigate the impact of two COVID-19 pandemics on the workflow of IVT in our neurovascular ED.MethodWe performed a retrospective analysis of patients who received IVT treatment in the neurovascular ED of Beijing Tiantan Hospital, Beijing, from January 20, 2020, to October 30, 2020, covering two COVID-19 pandemics in China. The time-based performances of IVT treatment including onset-to-arrival time, arrival-to-CT time, CT-to-needle time, door-to-needle time, and onset-to-needle time were recorded. Data on clinical characteristics and imaging information were also collected.ResultsFour hundred forty patients that received IVT were enrolled in this study. The number of patients admitted to our neurovascular ED began to decrease in December 2019 and was the lowest in April 2020 (n = 95). Longer DNT (Wuhan pandemic: 49.00 [35.00, 64.00] min; Beijing pandemic: 55.00 [45.50, 77.00] min) interval delays were observed during the two pandemics (p = .016). More patients admitted during the two pandemics had an ‘unknown’ subtype (Wuhan pandemic: 21.8%; Beijing pandemic: 31.4%. p = .008). The percentage of the cardiac embolism subtype was higher during the Wuhan pandemic (20.0%) than during other periods. The median admission NIHSS score increased during the Wuhan pandemic and the Beijing pandemic (8.00 [4.00, 12.00], 7.00 [4.50, 14.00], respectively, p < .001).ConclusionThe number of patients who received IVT decreased during the Wuhan pandemic. Higher admission NIHSS scores and prolonged DNT intervals were also observed during the Wuhan pandemic and the Beijing pandemic.

Three-Year Clinical Outcomes Based on Pre-Percutaneous Coronary Intervention Coronary Blood Flow Grade and Symptom-to-Balloon Time in Patients with Non-ST-Segment Elevation Myocardial Infarction.

We compared the 3-year clinical outcomes according to the degree of pre-percutaneous coronary intervention thrombolysis in myocardial infarction flow grade (pre-PCI TIMI) and symptom-to-balloon time (SBT) individuals who underwent successful stent implantation with a diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI). A total of 4910 patients with NSTEMI were divided into two groups: pre-PCI TIMI 0/1 (SBT < 48 h: n = 1328, SBT ≥ 48 h: n = 558) and pre-PCI TIMI 2/3 (SBT < 48 h: n = 1965, SBT ≥ 48 h: n = 1059). The primary outcome was a 3-year all-cause death rate, and the secondary outcome was the composite endpoint of 3-year all-cause death, recurrent MI, or any repeat revascularization rate. After adjustment, in the pre-PCI TIMI 0/1 group, the 3-year all-cause death (p = 0.003), cardiac death (CD, p < 0.001), and secondary outcome (p = 0.030) values were significantly higher in the SBT ≥ 48 h group than in the SBT < 48 h group. However, patients with pre-PCI TIMI 2/3 had similar primary and secondary outcomes, regardless of the SBT group. Within the SBT < 48 h group, the pre-PCI TIMI 2/3 group exhibited significantly higher rates of 3-year all-cause death, CD, recurrent MI, and secondary outcome values than the pre-PCI TIMI 0/1 group. Patients in the SBT ≥ 48 h group with either pre-PCI TIMI 0/1 or TIMI 2/3 had similar primary and secondary outcomes. Our results suggest that shortening the SBT may confer a survival benefit in patients with NSTEMI and those in the pre-PCI TIMI 0/1 group compared to those in the pre-PCI TIMI 2/3 group.