Tissue Plasminogen Activator Treatment Research Articles

Outcomes and safety of mechanical thrombectomy, alteplase, and conventional medical care in the treatment of acute M2 segment middle cerebral artery occlusion: a comparative study

BackgroundData on mechanical thrombectomy (MT) to treat M2 occlusions of the middle cerebral artery (MCA) are sparse. We report the outcome and safety of MT versus intravenous recombinant tissue plasminogen activator (IV rTPA) versus conventional medical treatment (CMT) of acute ischemic stroke (AIS) due to occlusion of the M2 segment of the MCA. This prospective longitudinal intervention study compared the outcomes and safety of MT, rTPA, and CMT in M2 occlusion AIS patients. National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (mRS), and recanalization rate assessed outcomes.Results74 AIS patients were recruited (23 MT, 23 rTPA, 28CMT). MT group had significantly higher admission NIHSS (p = 0.018) and mRS (p = 0.023) than rTPA. At 24 h, NIHSS improved more with MT and rTPA than CMT (p < 0.0001). At 3 months, mRS were better with MT and rTPA versus CMT (p < 0.0001). Successful recanalization occurred in 73.9% of the MT group. 69% of the MT group required stent retrieval plus aspiration thrombectomy, and 60.9% required ≥ 3 trials, but outcomes did not differ by technique or number of trials. A good outcome (mRS 0–2) at 3 months was achieved in 69.6% MT versus 65.2% rTPA versus 7.1% CMT (p < 0.0001). Symptomatic intracranial hemorrhage (sICH) rates were slightly, but insignificantly, higher with CMT. Mortality did not significantly differ between groups.ConclusionsFor M2 occlusions, MT and rTPA achieved better early and 3-month outcomes than CMT; however, MT was not superior to rTPA. MT of M2 is feasible and effective, with a lower hemorrhage rate than rTPA and CMT.Trial registration: This study was prospectively registered in the clinical trial with ClinicalTrials.gov ID (NCT05091320). The link: https://clinicaltrials.gov/study/NCT05091320

Abstract 192: Angioedema Following Lifesaving Thrombolysis In Acute Ischemic Stroke

Introduction Orolingual angioedema is a recognized adverse effect of tissue plasminogen activator (tPA) treatment in the setting of acute ischemic stroke (AIS). Although its incidence is relatively low (0.1‐0.7%), the reaction is generally mild but may trigger life‐threatening airway occlusion and necessitate rapid intubation. This is the first study to examine the differences in complications, management, and outcomes of AIS patients with and without tPA‐induced angioedema. Methods The National Inpatient Sample (NIS) was queried by ICD‐9‐CM/ICD‐10‐CM codes to identify AIS patients treated with tPA who experienced subsequent angioedema. Baseline characteristics, treatment, complications, and functional outcomes were analyzed through multivariate regression and compared through a propensity score matching (PSM) analysis. Results This study examined 99,935 patients diagnosed with AIS and administered tPA between 2010 and 2019. AIS patients with tPA‐induced angioedema were younger (67.44 years vs 69.32 years, p &lt; 0.01), less likely to be white (53.83% vs 66.48%, p &lt; 0.01), and presented with higher acute stroke severity scores (0.69 vs 0.63, p &lt; 0.01) than non‐angioedema AIS patients. Following PSM analysis, patients with angioedema had higher rates of tracheostomy (5.7% vs 0.49%, p &lt; 0.01) and lower rates of endovascular mechanical thrombectomy (4.72% vs 9.63%, p &lt; 0.01). Angioedema patients were observed to have similar rates of decompressive hemicraniectomy (p = 0.16), pneumonia (p = 0.06), sepsis (p = 0.82), acute kidney injury (p = 0.05), acute myocardial infarction (p = 0.43), cardiac arrest (p = 0.56), poor functional outcome (p = 0.25), and in‐hospital mortality (p = 0.32). Patients who developed angioedema were also observed to have longer LOS (7.34 days vs 5.41 days, p &lt; 0.01). Conclusion There appears to be no difference in complication risk, functional outcome, and in‐hospital mortality between AIS patients with and without tPA‐induced angioedema. The observed increase in LOS may be attributed to the increased rates of tracheostomy following oropharyngeal swelling. Airway instability may also preclude AIS patients with angioedema from mechanical thrombectomy, offering one explanation for the observed difference in intervention rates. Further research is needed to better understand the impact of tPA‐induced angioedema on interventions and outcomes of patients with acute ischemic stroke. Abbreviations Nationwide Inpatient Sample (NIS), acute ischemic stroke (AIS), tissue plasminogen activator (tPA), mechanical thrombectomy (MT), propensity score matching (PSM), deep vein thrombosis (DVT), pulmonary embolism (PE), urinary tract infection (UTI), length of stay (LOS)

Prognostic Value of Fibrosis-4 in Acute Ischemic Stroke Patients Undergoing Intravenous Thrombolysis.

Although recombinant tissue plasminogen activator (rt-PA) treatment is efficient in patients with acute ischemic stroke (AIS), a significant percentage of patients who received rt-PA intravenous thrombolysis (IVT) do not achieve a good prognosis. Therefore, the factors that affect the poor prognosis of patients with IVT are needed. The Fibrosis-4 (FIB-4) index has been used as a liver fibrosis biomarker. We aimed to investigate the relationship between the FIB-4 index and functional outcomes in patients with AIS receiving IVT. This study prospectively included consecutive patients with AIS receiving IVT between April 2015 and May 2022. We collected clinical and laboratory data and calculated the FIB-4 index. Clinical outcome was poor functional outcome (mRS ≥3) at 3 months after IVT. Multivariate logistic regression analysis was used to analyze the association between FIB-4 and outcome. We explored the interactive effect of FIB-4 and dyslipidemia on poor outcomes, and subgroup analysis was performed. Furthermore, an individualized prediction model based on the FIB-4 for functional outcome was established in the dyslipidemia group. A total of 1135 patients were included, and 41.50% had poor 3-month outcomes. After adjusted by other variants that P value <0.05 in univariable analysis, FIB-4 was independently associated with poor outcomes (OR=1.420; 95% CI: 1.113-1.812; P=0.004). There was a significant interaction between FIB-4 and dyslipidemia on poor outcome (P=0.036), and the independent association between FIB-4 and poor outcome was maintained in the dyslipidemia subgroup (OR=1.646; 95% CI: 1.228-2.206; P=0.001). Furthermore, in the dyslipidemia group, the FIB-4-based prediction model had good predictive value (the AUC of the training and validation sets were 0.767 and 0.708, respectively), good calibration (P-values for the Hosmer-Lemeshow test >0.05), and clinical usefulness. FIB-4 is an independent risk factor for poor outcomes in IVT patients with dyslipidemia, which can be used as a simple predictor of their prognosis.

Differences in Acute Expression of Matrix Metalloproteinases-9, 3, and 2 Related to the Duration of Brain Ischemia and Tissue Plasminogen Activator Treatment in Experimental Stroke.

Matrix metalloproteinases (MMPs) such as MMP-9, 3, and 2 degrade the cellular matrix and are believed to play a crucial role in ischemic stroke. We examined how the duration of ischemia (up to 4 h) and treatment with recombinant tissue plasminogen activator altered the comparative expression of these MMPs in experimental ischemic stroke with reperfusion. Both prolonged ischemia and r-tPA treatment markedly increased MMP-9 expression in the ischemic hemisphere (all p < 0.0001). The duration of ischemia and r-tPA treatment also significantly increased MMP-2 expression (p < 0.01-0.001) in the ischemic hemisphere (p < 0.01) but to a lesser degree than MMP-9. In contrast, MMP-3 expression significantly decreased in the ischemic hemisphere (p < 0.001) with increasing duration of ischemia and r-tPA treatment (p < 0.05-0001). MMP-9 expression was prominent in the vascular compartment and leukocytes. MMP-2 expression was evident in the vascular compartment and MMP-3 in NeuN+ neurons. Prolonging the duration of ischemia (up to 4 h) before reperfusion increased brain hemorrhage, infarction, swelling, and neurologic disability in both saline-treated (control) and r-tPA-treated mice. MMP-9 and MMP-2 expression were significantly positively correlated with, and MMP-3 was significantly negatively correlated with, infarct volume, swelling, and brain hemorrhage. We conclude that in experimental ischemic stroke with reperfusion, the duration of ischemia and r-tPA treatment significantly altered MMP-9, 3, and 2 expression, ischemic brain injury, and neurological disability. Each MMP showed unique patterns of expression that are strongly correlated with the severity of brain infarction, swelling, and hemorrhage. In summary, in experimental ischemic stroke in male mice with reperfusion, the duration of ischemia, and r-tPA treatment significantly altered the immunofluorescent expression of MMP-9, 3, and 2, ischemic brain injury, and neurological disability. In this model, each MMP showed unique patterns of expression that were strongly correlated with the severity of brain infarction, swelling, and hemorrhage.

The effect of the mean platelet volume on short-term prognosis in acute ischemic stroke patients who underwent intravenous thrombolytic therapy

Objective: To evaluate the effect of the mean platelet volume (MPV), on the short-term prognosis and bleeding complications of acute ischemic stroke patients who underwent intravenous tissue plasminogen activator (IV-tPA) treatment. Patients and Methods: Between 01.01.2018 and 01.06.2021, 314 ischemic stroke patients who applied to our clinic with acute neurological deficit were included in the study retrospectively. Alteplase was administered as IV-tPA treatment for 1 hour. MPV value was measured before the treatment and was evaluated as the main parameter. The patients were examined under 4 groups (≤8.8fL, &amp;gt;8.8 – ≤9.9, &amp;gt;9.9-≤10.8, &amp;gt;10.8fL) according to their MPV values, and age, gender, comorbidities, and treatment initiation parameters were standardized by statistical methods. It was compared whether there was a significant difference between the MPV groups in terms of short-term prognosis according to the admission National Institutes of Health Stroke Scale (NIHSS) scores and discharge NIHSS scores and also bleeding complications. Results: A total of 314 patients, 145 women with a mean age of 76.7±13.0, and 169 men with a mean age of 66.3±13.1, were included in the study. 31 patients (9.9%) died before discharge. The mean MPV value was 9.64±1.15fL and the mean NIHSS score was 9.1±4.9 at admission, and the mean NIHSS score was 4.3±4.7 at discharge. When the NIHSS difference between admission and discharge was compared in the 4 groups, it was found that the prognosis was better in Group 3 with MPV &amp;gt;9.9-≤10.8 compared to Groups 1 and 4. (p=0.002; p&amp;lt;0.01). Despite this, it was seen that low or high MPV values could not be considered as a prognostic factor alone in patients who received IV-tPA treatment, since, there was no significant difference between the 3rd group and the 2nd group in terms of NIHSS decrease and the 4th group had a worse prognosis than the 3rd group. There was no statistical significance between MPV groups in terms of hemorrhage complications (p value for intracerebral, gastrointestinal, urogenital hemorrhage complications were 0.540, 0.980, 0.783, respectively). Conclusion: In our study, it was revealed that MPV value, is not an independent risk factor in patients with acute ischemic stroke receiving IV-tPA treatment and cannot be used as a prognostic marker.

Therapeutic Effect of Thrombolytic Therapy on Motor Function Loss After Ischaemic Stroke: A Case Study

Stroke is a serious cerebrovascular disease that can cause disability and death if not treated with appropriate treatment methods at the right time. In ischaemic stroke, recombinant tissue plasminogen activator (rt-PA) treatment is effective in motor deficit recovery, especially in the first 4.5 hours. In this case study, rt-PA thrombolytic treatment of patients with motor deficit after acute ischaemic stroke aged 58 and 79 years was found to improve the loss of motor function.

Predictive value of neutrophil to apolipoprotein A1 ratio in patients with acute ischaemic stroke.

The neutrophil to apolipoprotein A1 ratio has emerged as a possible prognostic biomarker in different medical conditions. Nonetheless, the predictive potential of neutrophil to apolipoprotein A1 ratio in determining the 3-month prognosis of acute ischaemic stroke patients who undergo intravenous thrombolysis has yet to be fully acknowledged. In this study, 196 acute ischaemic stroke patients with recombinant tissue plasminogen activator and 133 healthy controls were included. Meanwhile, we incorporated a total of 386 non-thrombolytic acute ischaemic stroke patients. The acute ischaemic stroke patients with recombinant tissue plasminogen activator were divided into four groups based on quartiles of neutrophil to apolipoprotein A1 ratio. The association between neutrophil to apolipoprotein A1 ratio and the 3-month prognosis was evaluated through univariate and multivariate regression analyses. Additionally, subgroup analyses were conducted to investigate the predictive value of neutrophil to apolipoprotein A1 ratio in different patient populations. Adverse outcomes were defined as a modified Rankin Scale score of 3-6. The study findings revealed a significant association between elevated neutrophil to apolipoprotein A1 ratio levels and poor prognosis in acute ischaemic stroke patients. In the highest quartile of neutrophil to apolipoprotein A1 ratio levels (Q4), after controlling for age, gender, admission National Institutes of Health Stroke Scale score, blood urea nitrogen and stroke subtypes, the odds ratio for adverse outcomes at 3 months was 13.314 (95% confidence interval: 2.878-61.596, P = 0.001). An elevated neutrophil to apolipoprotein A1 ratio value was found to be associated with a poor prognosis in acute ischaemic stroke patients, regardless of whether they received recombinant tissue plasminogen activator treatment or not. The new model, which incorporating neutrophil to apolipoprotein A1 ratio into the conventional model, demonstrated a statistically significant improvement in discriminatory power and risk reclassification for 3-month poor outcomes in acute ischaemic stroke patients treated with recombinant tissue plasminogen activator. The new model exhibited a categorical net reclassification index (P = 0.035) of 12.9% and an integrated discrimination improvement (P = 0.013) of 5.2%. Subgroup analyses indicated that the predictive value of neutrophil to apolipoprotein A1 ratio differed across stroke subtypes. Neutrophil to apolipoprotein A1 ratio is a potential biomarker for predicting the prognosis of acute ischaemic stroke patients. The clinical implications of our findings are significant, as early identification and intervention in high-risk patients can improve their outcomes. However, further studies are required to validate our results and elucidate the underlying mechanisms of the association between neutrophil to apolipoprotein A1 ratio and poor prognosis in acute ischaemic stroke patients.

Factors predicting functional outcome after rtPA for patients with acute ischemic stroke

BackgroundAccurate outcome prediction for patients with acute ischemic stroke after intravenous recombinant tissue plasminogen activator (rtPA) treatment is essential for optimizing patients’ management. We aimed to identify factors associated with unfavorable outcomes following intravenous rtPA treatment. This study was carried out on 162 patients who presented with acute ischemic stroke within 4.5 h from onset of neurological symptoms and were eligible for intravenous rtPA. After exclusion of 48 patients, 114 patients were finally eligible for follow-up. After complete medical and neurological history, complete medical and neurological examination and brain image (CT and or MRI brain) were collected from the patients. patients eligible were included in the study. NIHS scale was assessed for all patients at time of admission, after 24 h, and follow-up for 3 months.ResultsAfter a 90-day follow-up period for 114 patients with acute ischemic stroke after rtPA, 35.8% had good outcome (MRS; 0–2), 18.5% had partial outcome (MRS; 3–4) and 12.5% had poor outcome (MRS; 5–6). Atrial fibrillation (AF), PH of stroke, stroke severity, and severity of symptom (NIHSS) score were significantly (P: 0.004, 0.001, 0.007 and 0.001) correlated with poor outcome after rtPA. Similarly, old age, high blood pressure at time of presentation, hypertension, and dyslipidemia were showed to carry poor outcome.ConclusionsAF, high NIHSS score, PH of stroke, previous stroke, hypertension, dyslipidemia, and high blood pressure on presentation were significantly correlated with poor functional outcome.

Performance comparison of stress hyperglycemia ratio for predicting fatal outcomes in patients with thrombolyzed acute ischemic stroke.

The stress hyperglycemia ratio (SHR), a newly developed metric, is used to assess adverse outcomes in patients with acute ischemic stroke (AIS). However, the relationship between SHR and fatal outcomes (in-hospital mortality [IHM], malignant cerebral edema [MCE], symptomatic intracerebral hemorrhage [sICH], 3-month mortality, and poor functional outcome) in AIS patients receiving recombinant tissue plasminogen activator (rt-PA) treatment is unclear, and determining the optimal threshold remains incomplete. We retrospectively enrolled a total of 345 AIS patients treated with rt-PA during 2015-2022 and collected data on various glucose metrics, including different types of SHR, glycemic gap (GG), random plasma glucose (RPG), fasting plasma glucose (FPG), and hemoglobin A1c (HbA1c). SHR and GG were calculated using these equations: SHR1, [FPG]/[HbA1c]; SHR2, [admission RPG]/[HbA1c]; SHR3, FPG/[(1.59 × HbA1c)-2.59]; SHR4, [admission RPG]/[(1.59 × HbA1c)-2.59]; GG, admission RPG - [(1.59 × HbA1c)-2.59]. We used multivariable logistic regression analysis (MVLR) to identify the association between different glucose metrics and outcomes while comparing their predictive values. SHR1 had the greatest predictive power and a more significant correlation with fatal outcomes than other continuous glucose metrics. The area under the curve of the SHR1 for IHM, MCE, and sICH, 3-month mortality, and poor functional outcome were 0.75, 0.77, 0.77, 0.76, and 0.73, respectively. SHR1 (per 1-point increases) was independently associated with IHM (Odds ratios [ORs] = 5.80; 95% CI [1.96, 17.17]; p = 0.001), MCE (ORs = 4.73; 95% CI [1.71, 13.04]; p = 0.003), sICH (ORs = 4.68, 95% CI [1.48-14.82]; p = 0.009), 3-month mortality (ORs = 10.87; 95% CI [3.56, 33.21]; p<0.001), and 3-month poor functional outcome (ORs = 8.05; 95% CI [2.77, 23.39]; p<0.001) after adjustment in MVLR. In subgroup analysis, elevated SHR1 was associated with fatal outcomes in patients with non-diabetes, SBP≥ 180 mmHg, and NIHSS <16. SHR1 demonstrates an independent association with fatal outcomes in AIS patients treated with rt-PA, exhibiting superior predictive ability over other glucose metrics.

Effect of rt-PA on Shear Wave Mechanical Assessment and Quantitative Ultrasound Properties of Blood Clot Kinetics In Vitro.

The consequences associated with blood clots are numerous and are responsible for many deaths worldwide. The assessment of treatment efficacy is necessary for patient follow-up and to detect treatment-resistant patients. The aim of this study was to characterize the effect of treatment on blood clots in vitro using quantitative ultrasound parameters. Blood from 10 pigs was collected to form three clots per pig in gelatin phantoms. Clots were subjected to 1) no treatment, 2) rt-PA (recombinant tissue plasminogen activator) treatment after 20 minutes of clotting, and 3) rt-PA treatment after 60 minutes of clotting. Clots were weighted before and after the experiment to assess the treatment effect by the mass loss. The clot kinetics was studied over 100 minutes using elastography (Young's modulus, shear wave dispersion, and shear wave attenuation). Homodyne K-distribution (HKD) parameters derived from speckle statistics were also studied during clot formation and dissolving (diffuse-to-total signal power ratio and intensity parameters). Treated clots loosed significantly more mass than non-treated ones (P < .005). A significant increase in Young's modulus was observed over time (P < .001), and significant reductions were seen for treated clots at 20 or 60 minutes compared with untreated ones (P < .001). The shear wave dispersion differed for treated clots at 60 minutes versus no treatments (P < .001). The shear wave attenuation decreased over time (P < .001), and was different for clots treated at 20 minutes versus no treatments (P < .031). The HKD intensity parameter varied over time (P < .032), and was lower for clots treated at 20 and 60 minutes than those untreated (P < .001 and P < .02). The effect of rt-PA treatment could be confirmed by a decrease in Young's modulus and HKD intensity parameter. The shear wave dispersion and shear wave attenuation were sensitive to late and early treatments, respectively. The Young's modulus, shear wave attenuation, and HKD intensity parameter varied over time despite treatment.

A weakly supervised deep learning model integrating noncontrasted computed tomography images and clinical factors facilitates haemorrhagic transformation prediction after intravenous thrombolysis in acute ischaemic stroke patients

BackgroundHaemorrhage transformation (HT) is a serious complication of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS). Accurate and timely prediction of the risk of HT before IVT may change the treatment decision and improve clinical prognosis. We aimed to develop a deep learning method for predicting HT after IVT for AIS using noncontrast computed tomography (NCCT) images.MethodsWe retrospectively collected data from 828 AIS patients undergoing recombinant tissue plasminogen activator (rt-PA) treatment within a 4.5-h time window (n = 665) or of undergoing urokinase treatment within a 6-h time window (n = 163) and divided them into the HT group (n = 69) and non-HT group (n = 759). HT was defined based on the criteria of the European Cooperative Acute Stroke Study-II trial. To address the problems of indiscernible features and imbalanced data, a weakly supervised deep learning (WSDL) model for HT prediction was constructed based on multiple instance learning and active learning using admission NCCT images and clinical information in addition to conventional deep learning models. Threefold cross-validation and transfer learning were performed to confirm the robustness of the network. Of note, the predictive value of the commonly used scales in clinics associated with NCCT images (i.e., the HAT and SEDAN score) was also analysed and compared to measure the feasibility of our proposed DL algorithms.ResultsCompared to the conventional DL and ML models, the WSDL model had the highest AUC of 0.799 (95% CI 0.712–0.883). Significant differences were observed between the WSDL model and five ML models (P < 0.05). The prediction performance of the WSDL model outperforms the HAT and SEDAN scores at the optimal operating point (threshold = 1.5). Further subgroup analysis showed that the WSDL model performed better for symptomatic intracranial haemorrhage (AUC = 0.833, F1 score = 0.909).ConclusionsOur WSDL model based on NCCT images had relatively good performance for predicting HT in AIS and may be suitable for assisting in clinical treatment decision-making.

A multitrait genetic study of hemostatic factors and hemorrhagic transformation after stroke treatment

BackgroundThrombolytic recombinant tissue plasminogen activator (r-tPA) treatment is the only pharmacologic intervention available in the ischemic stroke acute phase. This treatment is associated with an increased risk of intracerebral hemorrhages, known as hemorrhagic transformations (HTs), which worsen the patient’s prognosis. ObjectivesTo investigate the association between genetically determined natural hemostatic factors’ levels and increased risk of HT after r-tPA treatment. MethodsUsing data from genome-wide association studies on the risk of HT after r-tPA treatment and data on 7 hemostatic factors (factor [F]VII, FVIII, von Willebrand factor [VWF], FXI, fibrinogen, plasminogen activator inhibitor-1, and tissue plasminogen activator), we performed local and global genetic correlation estimation multitrait analyses and colocalization and 2-sample Mendelian randomization analyses between hemostatic factors and HT. ResultsLocal correlations identified a genomic region on chromosome 16 with shared covariance: fibrinogen-HT, P = 2.45 × 10−11. Multitrait analysis between fibrinogen-HT revealed 3 loci that simultaneously regulate circulating levels of fibrinogen and risk of HT: rs56026866 (PLXND1), P = 8.80 × 10−10; rs1421067 (CHD9), P = 1.81 × 10−14; and rs34780449, near ROBO1 gene, P = 1.64 × 10−8. Multitrait analysis between VWF-HT showed a novel common association regulating VWF and risk of HT after r-tPA at rs10942300 (ZNF366), P = 1.81 × 10−14. Mendelian randomization analysis did not find significant causal associations, although a nominal association was observed for FXI-HT (inverse-variance weighted estimate [SE], 0.07 [−0.29 to 0.00]; odds ratio, 0.87; 95% CI, 0.75-1.00; raw P = .05). ConclusionWe identified 4 shared loci between hemostatic factors and HT after r-tPA treatment, suggesting common regulatory mechanisms between fibrinogen and VWF levels and HT. Further research to determine a possible mediating effect of fibrinogen on HT risk is needed.

Abstract 276: CT versus MR based imaging for ischemic stroke triage: effect on workflow during contrast shortage

Introduction We assessed the feasibility and effectiveness of using magnetic resonance (MR) imaging as a substitute for computed tomography (CT) angiography and perfusion for triaging ischemic stroke patients during the national shortage of iodinated contrast medium between May 4th to July 17th 2022. Methods We compared the rates of intravenous tissue plasminogen activator treatment (IVT) and endovascular thrombectomy (EVT), changes in treatment times, and patient outcomes (defined by modified Rankin Scores (mRS) at discharge) before (4 months period) and after (3 months period) transitioning from CT angiography (CTA) and perfusion (CTP) to Fast MRI imaging. Results We analyzed 241 patients in the CT‐based group and 166 patients in the MR‐based group. EVT was performed on almost twice as many patients in the CTA/CTP group (12%) compared to the Fast MRI group (6.6%), but this difference was not statistically significant (p=0.07). Workflow processing time showed no significant difference, with similar time intervals for door‐to‐needle, door‐to‐interventioanal radiology suite, door‐to‐puncture, and door‐to‐first pass. However, the CTA/CTP group exhibited a trend towards faster overall times. Both groups had similar rates of mRS 0‐2 at discharge (41.9% vs 43%, p=0.82). Conclusion We observed a non‐significant reduction in the rate of EVT during the period of MRI substitution secondary to the iodinated contrast medium shortage, although treatment times and patient outcomes were similar.

Examination of Treatment Options According to Clinical Features and Radiological Findings in Wake-up Stroke

Aim: Wake-up stroke patients account for one-fifth of all ischemic stroke patients and they have been deprived of recanalization treatment as the onset of the stroke is not known. It has come into the focus of recent research that this treatment could be applied to particularly patients who are selected on a radiological basis. We aimed to examine clinical and demographic characteristics of wake-up strokes.&#x0D; Material and Methods: All ischemic stroke patients who presented to the emergency service throughout the night were analyzed. Patients with wake up stroke were recorded. The time of finding these patients, clinical features, treatment options and mortality status of these patients were examined. It was examined whether they received intravenous thrombolysis (IVT), endovascular therapy (EVT), or both as acute reperfusion therapy.&#x0D; Results: Age, gender, the last time when they were seen healthy, treatment start time, treatment types, clinical classification, comorbid diseases, and discharge status of 72 wake-up stroke patients were analyzed. It was found that the time of discovery of 51.4% (n=37) of the wake-up stroke patients was 06.00 am and afterwards. Of these patients, 15.3% (n=11) received intravenous tissue plasminogen activator and/or endovascular treatment. These patients’ hospital stay durations, intracerebral hemorrhage status following the procedure, NIHSS scores, angiography findings, and mortality rates were examined. Here, mortality rate was found to be significantly high especially in patients with high NIHSS score.&#x0D; Conclusion: Wake-up stroke is more common in the period close to the time of waking up in the morning. Recanylazation therapy should always be considered as an option in these patients.

Leukoaraiosis and stroke severity scores in post-rtPA intracerebral haemorrhage

IntroductionPost thrombolytic symptomatic intracerebral haemorrhage (sICH) is a major concern in patients who had acute ischaemic stroke. Leukoaraiosis (LA) is reported to be related with sICH after intravenous thrombolytic treatment....

Comparing 5G mobile stroke unit and emergency medical service in patients acute ischemic stroke eligible for t-PA treatment: A prospective, single-center clinical trial in Ya'an, China.

This study aims to assess and compare the functional outcomes of patients with acute ischemic stroke (AIS) eligible for tissue plasminogen activator (t-PA) treatment who received care from either a fifth-generation(5G) mobile stroke unit (MSU) or traditional emergency medical service (EMS). The study recruited patients between February 2020 and January 2022, with the final 90-day follow-up concluded in April 2022. Prior to enrollment, patients were assigned to either EMS or MSU care based on predetermined rules. The primary outcome measure was the Modified Rankin Scale (mRS) score at 90 days, with secondary outcome measures including time metrics, mRS and National Institutes of Health Stroke Scale scores at 7-day follow-up, and hospitalization costs. Of the 2281 enrolled patients, 207 were eligible for t-PA treatment, with 101 allocated to MSU care and 106 to EMS care. The percentage of patients achieving a favorable mRS score (0-2) at 90 days was 82.2% in the MSU group compared to 72.6% in the EMS group (p < .05). Median times from symptom onset to thrombolysis were 146 min in the MSU group and 204 min in the EMS group, while median times from ambulance alert to computed tomography (CT)completion were 53 and 128 min, respectively. Hospitalization charges averaged approximately $3592 in the MSU group and $4800 in the EMS group. Our findings indicate that 5G MSU care significantly reduces the time from symptom onset to stroke diagnosis and intravenous thrombolysis in patients with AIS, resulting in improved functional outcomes compared to EMS care. As China continues its deployment of 5G technology and other digital infrastructures, the adoption of 5G MSU care on a broader scale may eventually supplant traditional stroke treatment approaches.

Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients

IntroductionSeveral reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA. MethodsWe analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis. ResultsFive patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups. ConclusionApproximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.

Low-dose intravenous recombinant tissue plasminogen activator in acute ischemic stroke without large vessel occlusion screened by 3T MRI.

Globally, there are more than six million deaths due to cerebrovascular disease, which is the second leading cause of death. Although the imaging findings of magnetic resonance imaging (MRI) are more accurate than computed tomography for acute ischemic stroke (AIS), it is uncommon in recombinant tissue plasminogen activator (rTPA) treatment. Alteplase is not only strongly recommended treatment for acute ischemic stroke within 4.5 hours, but also decreases the disability and mortality rate. Besides, low-dose rTPA was associated with significant reductions in symptomatic intracerebral hemorrhage (sICH), compared with standard one. However, the benefits of low-dose rTPA for the treatment of AIS without large vessel occlusion (LVO) have not been fully demonstrated. We evaluated whether the low-dose rTPA in AIS without LVO could improve prognosis in patients three months post-treatment. This was a cross-sectional study on patients with AIS treated within 4.5 hours of symptom onset admitted to Can Tho S.I.S General Hospital between February 2019 and July 2021. The eligibility criteria were patients aged > 18 years treated with low-dose rTPA (0.6 mg/kg) and screened by 3T MRI. Patients with a pre-hospital modified Rankin score (mRS) ≥ 2 points, intracranial hemorrhage, LVO, or ≥ 3 microbleeds on brain MRI were excluded. The primary outcomes were the favorable outcome rate at three months and safety, which were evaluated by the rates of intracranial hemorrhage and mortality at three months. This study enrolled 92 eligible patients between February 2019 and July 2021. Their National Institute of Health Stroke Scale (NIHSS) scores were 7.5 ± 3.7 at admission, 3.3 ± 3.5 at discharge or seven days after discharge, and 2.2 ± 2.8 at three months. Their mRS were 2.9 ± 0.8 at admission, 1.4 ± 1.3 at discharge or seven days after discharge, and 1.1 ± 1.1 at three months. Elevated cardiac enzymes, age ≥ 75 years, and body mass index ≥ 25 were associated with increased poor outcomes at three months. While AIS was more common in men than women, a similar number of men (33.3%) and women had poor mRS. Three patients had complications associated with low-dose rTPA treatment: one (1.1%) had intracranial hemorrhage, one (1.1%) had new infarcts, and one (1.1%) had gastrointestinal bleeding. No deaths occurred within three months. Our study indicates the efficacy and safety of low-dose rTPA treatment for AIS without LVO within 4.5 hours. Patient selection for rTPA by 3T MRI decreased complications and mortality.

The Effect of Atrial Fibrillation on Recanalization and Prognosis in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy and/or Intravenous Thrombolysis

ABSTRACT Background: Atrial fibrillation (AF) is the most common cause of cardioembolic ischemic strokes. It causes large-vessel occlusions and a poor prognosis. Regardless of ischemic stroke etiology, hyperacute therapy strategies are effective treatment modalities. Methods: Patients who were diagnosed as having AF were classified as AF (+) and others without AF were classified as AF (-). It is not clear which treatment should be preferred in patients with stroke who are AF (+). We studied demographic characteristics, recanalization rates, and clinical outcomes in acute patients with ischemic stroke with or without nonvalvular AF who underwent hyperacute treatments. Results: We detected that clinical findings were more severe and the NIHSS scores were significantly higher at admission inpatients who were AF (+). In our study, mechanical thrombectomy rates were high in patients who were AF (+), whereas intravenous tissue plasminogen activator treatment rates were higher in patients who were AF (-). Thrombolysis in cerebral infarction scores were similar in our patient groups. We found high rates of both symptomatic (PH 2) and asymptomatic hemorrhagic transformation in patients who were AF (+) in 24th-h cranial computed tomography. A positive correlation was found between symptom-admission, symptom-needle, and symptom-groin times and discharge-modified Rankin Scale scores regardless of the hyperacute treatments in all patient groups. Conclusion: As a result, physicians should focus on the diagnosis of AF, and appropriate anticoagulant treatment is important for primary prevention.

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.