Early Antiplatelet for Minor Stroke following Thrombolysis (EAST): Rationale and Design

BACKGROUND

Early neurological deterioration (END) occurs in about 10% of patients after intravenous thrombolysis (IVT), and is related to poor outcome. In theory, early antiplatelet following IVT could reduce END by preventing re-occlusion and stroke progression, but current guidelines recommend starting antiplatelet treatment at 24 hours after IVT due to concerns about hemorrhagic transformation. Given higher risk of hemorrhagic transformation in severe stroke, we hypothesized that minor stroke patients following IVT can safely benefit from early antiplatelet treatment.

AIMS

To explore the efficacy and safety of early antiplatelet in minor stroke patients after IVT.Sample size estimates: A maximum of 1022 patients are required to test the superiority hypothesis with 80% power according to a two-side 0.05 level of significance, stratified by age, gender, history of stroke or transient ischemic attack, history of hypertension, history of diabetes mellitus, systolic blood pressure at admission, time from IVT to treatment, thrombolysis drug, stroke territory, and stroke etiology.

DESIGN

Early antiplatelet for minor stroke following thrombolysis is a prospective, double blinded, multicenter, randomized and placebo-controlled trial. Minor stroke patients within 6h following IVT are randomly assigned into experimental group and control group with the ratio of 1:1. The experimental group is orally administered with 300 mg clopidogrel and 100 mg aspirin, and control group with placebo. Subsequently, both groups received guideline-based antithrombotic treatment from 24 hours after IVT to 90 days.

OUTCOME

The primary efficacy endpoint is excellent functional outcome, defined as the modified Rankin Scale 0-1 at 90 days after randomization, while primary safety endpoint is symptomatic intracerebral hemorrhage, defined as National Institutes of Health Stroke Scale score increase ≥4 caused by intracranial hemorrhage within 36 hours after randomization.

CONCLUSIONS

The results of EAST will provide us powerful early antiplatelet evidence for minor stroke population following intravenous thrombolysis in clinical practice.

Low-dose alteplase for the management of acute ischemic stroke in South Asians: A systematic review on cost, efficacy and safety

INTRODUCTION

South Asia is responsible for more than 40% of the stroke burden and stroke mortality in the developing world. South Asia, which is home to one-fourth of the world's population, is the most densely populated and one of the poorest regions. The majority of patients in this region are unable to afford intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). If low-dose alteplase proves effective and safe in South Asians, it may be a more cost-effective treatment option.

METHODS

The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Researchers searched PubMed, EMBASE, and Google Scholar for English literature from 2005 to 2021. END, ENI, good functional outcome, SICH, and all-cause mortality were used to assess efficacy and safety.

RESULTS

In the low-dose alteplase treated patients, different studies reported 32 to 57% ENI 24 h after IVT, and 7% to 9.7% END. At 3 months follow-up, good functional outcome was achieved by 48%-76.92% of low-dose alteplase treated patients. SICH rates ranged from 0% to 16.6% across studies. Asymptomatic ICH occurred in 5-14% of patients. The mortality rate in all included studies varied from none to 25%.

CONCLUSION

Our systematic review demonstrates that the use of low-dose alteplase for AIS in the South Asians offer comparable efficacy and reduced risk of SICH at a significantly lower cost than standard alteplase dose. Future well-randomized clinical trials are necessary to validate the findings of our study.

Impact of COVID-19 pandemic on STEMI thrombolysis and Emergency Department's performance in a non-PCI capable tertiary hospital

Introduction

Some guidelines had recommended “thrombolysis first” in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre.

Methods

This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays.

Results and discussion

We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02–4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic.

Conclusion

STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.

Conservative treatment vs thrombus removal for Iliofemoral vein thrombosis in patients with congenital abnormalities of the inferior vena cava: a case report and systematic review of the literature

Congenital abnormalities of the Inferior Vena Cava (IVC) should be suspected in cases of Deep Venous Thrombosis (DVT), especially in young patients, with no other risk factors and apparent causes. Currently, there is no guidance regarding the management of such patients. We report a case of Iliofemoral vein thrombosis in a young patient with congenital absence of the IVC that was successfully treated with catheter-directed thrombolysis (CDT) and perform a systematic review of the literature to identify evidence about the epidemiology, clinical presentation, management, and prognosis of this rare cause of DVT. A total of 42 studies reporting on 56 cases were included in the review. The mean age of the patients at the presentation of their first DVT episode is 23.6 years, 83.9% of patients were males, conservative management with anticoagulation was used in 68% of the reported cases, and thrombolysis was used in 32% of the cases. Only 10.7% of patients presented with PE potentially justified by the abnormal anatomy of the deep veins which makes the propagation of thrombi into the pulmonary arteries less possible. Comparing the long-term outcomes of the two treatment groups; 42.3% of the patients treated conservatively vs 15.4% of the patients treated with thrombolysis developed chronic symptoms (residual heaviness, pain, swelling, and cramping). 11.5% of patients who received conservative treatment developed post-thrombotic syndrome. None of the patients treated with thrombolysis developed post-thrombotic syndrome. There were no procedure-related complications and thrombolysis was well tolerated by the entirety of the thrombolysis treatment group. Recurrence of DVT occurred in 13% of the patients treated conservatively and in 7.7% of patients treated with thrombolysis. Thrombus removal by means of thrombolysis is the recommended treatment and can offer excellent short and long-term results. Anticoagulation with NOACs may be prescribed for life to prevent recurrence or for at least 6 months and then reconsidered following further evaluation of patients' bleeding risk. It may be of value to organise an international registry for such patients. Guidelines issued by the relevant scientific societies will then be able to make a clear recommendation about the management of such patients.

Assessment of myocardial salvage in patients with STEMI undergoing thrombolysis: ticagrelor versus clopidogrel

Background

In the setting of ST-segment elevation myocardial infarction (STEMI), the faster and stronger antiplatelet action of ticagrelor compared to clopidogrel, as well as its pleiotropic effects, could result in a greater degree of cardioprotection and final infarct size (FIS) limitation. The aim of our study was to comparatively evaluate the effect of ticagrelor and clopidogrel on myocardial salvage index (MSI) in STEMI patients undergoing thrombolysis.

Methods

Forty-two STEMI patients treated with thrombolysis were randomized to receive clopidogrel (n = 21) or ticagrelor (n = 21), along with aspirin. Myocardial area at risk (AAR) was calculated according to the BARI and the APPROACH jeopardy scores. FIS was quantified by cardiac magnetic resonance imaging (CMR) performed 5–6 months post-randomization. MSI was calculated as (AAR-FIS)/AAR × 100%. Primary endpoint of our study was MSI. Secondary endpoints were FIS and CMR-derived left ventricular ejection fraction (LVEF) at 5 –6 months post-randomization.

Results

By using the BARI score for AAR calculation, mean MSI was 52.25 ± 30.5 for the clopidogrel group and 54.29 ± 31.08 for the ticagrelor group (p = 0.83), while mean MSI using the APPROACH score was calculated at 51.94 ± 30 and 53.09 ± 32.39 (p = 0.9), respectively. Median CMR-derived FIS—as a percentage of LV—was 10.7% ± 8.25 in the clopidogrel group and 12.09% ± 8.72 in the ticagrelor group (p = 0.6). Mean LVEF at 5–6 months post-randomization did not differ significantly between randomization groups.

Conclusions

Our results suggest that the administration of ticagrelor in STEMI patients undergoing thrombolysis offer a similar degree of myocardial salvage, compared to clopidogrel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02735-1.

Tenecteplase vs. alteplase for the treatment of patients with acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

At present, studies regarding the efficacy and safety of tenecteplase for the treatment of patients with acute ischemic stroke (AIS) are still limited and inconsistent. The purpose of this systematic review and meta-analysis is to compare the efficacy and safety of tenecteplase with alteplase for the treatment of AIS patients.

METHODS

Literature search was conducted in PubMed, Embase, and Cochrane Library up to May 10, 2022. Primary outcomes of this study included 90-day good outcome (defined as an mRS score of 0-2) and 90-day excellent outcome (defined as an mRS score of 0-1). Risk ratios (RRs) with 95% confidence intervals (95% CIs) were calculated using a random-effect model for each outcome.

RESULTS

Fourteen studies with a total of 3537 patients were finally included in this meta-analysis. There was no statistical difference between patients receiving tenecteplase and those receiving alteplase in the rates of 90-day good outcome (RR 1.01; 95% CI 0.91-1.13; P = 0.79) and 90-day excellent outcome (RR 1.04; 95% CI 0.92-1.19; P = 0.50). Patients receiving tenecteplase might associated with higher incidence of early neurologic improvement compared with those receiving alteplase (RR 1.29; 95% CI 1.04-1.61; P = 0.02). In addition, no statistical difference was observed between the two groups in other outcomes.

CONCLUSION

This meta-analysis indicated that tenecteplase in AIS patients is as safe and effective as alteplase and might provide more benefit than alteplase. However, due to several inherent limitations of this study, more prospective studies should be conducted to confirm the above results.

Assessment of Irreversible Tissue Injury in Extensive Ischemic Stroke-Potential of Quantitative Cerebral Perfusion

Computed tomography perfusion (CTP) is used as a tool to select ischemic stroke patients for endovascular treatment (EVT) and is currently investigated in the setting of extensive stroke with low Alberta Stroke Program Early CT scores (ASPECTS). The purpose of this study was to perform a comprehensive quantitative analysis of cerebral blood flow within the ischemic lesion compared to threshold-derived core lesion volumes. We hypothesized that the degree of cerebral blood volume (CBV) reduction within the ischemic lesion is predictive of irreversible tissue injury and functional outcome in patients with low ASPECTS. Ischemic stroke patients with an ASPECTS ≤ 5 who received multimodal CT on admission and underwent thrombectomy were analyzed. The ischemic lesion on CTP was identified, and CTP-derived parameters were measured as absolute means within the lesion and relative to the physiological perfusion measured in a contralateral region of interest. The degree of irreversible tissue injury was assessed using quantitative net water uptake (NWU). Functional endpoint was good outcome defined as modified Rankin Scale (mRS) scores 0-3 at day 90. One hundred eleven patients were included. The median core lesion volume was 71 ml (IQR: 25-107), and the median quantitative NWU was 9.5% (IQR: 6-13). Relative CBV (rCBV) reduction and ASPECTS at baseline were independently associated with NWU in multivariable linear regression analysis (ß: 12.4, 95%CI: 6.0-18.9, p < 0.0001) and (ß: - 0.78, 95% CI: - 1.53 to - 0.02; p = 0.045), respectively. Furthermore, rCBV was significantly associated with good outcome in patients with core volumes > 50 ml (OR: 0.16, 95% CI: 0.05-0.49, p = 0.001). Our study shows that rCBV reduction serves as an early surrogate for increase of NWU as a marker of irreversible tissue injury and lesion progression. Thus, the analysis of rCBV reduction within ischemic lesions may add another dimension to acute stroke triage in addition to core volumes or ASPECTS as indicators of the infarct extent and viability.

Clinical and therapeutic variables may influence the association between infarct core predicted by CT perfusion and clinical outcome in acute stroke

OBJECTIVES

After an acute ischemic stroke, patients with a large CT perfusion (CTP) predicted infarct core (pIC) have poor clinical outcome. However, previous research suggests that this relationship may be relevant for subgroups of patients determined by pretreatment and treatment-related variables while negligible for others. We aimed to identify these variables.

METHODS

We included a cohort of 828 patients with acute proximal carotid arterial occlusions imaged with a whole-brain CTP within 8 h from stroke onset. pIC was computed on CTP Maps (cerebral blood flow < 30%), and poor clinical outcome was defined as a 90-day modified Rankin Scale score > 2. Potential mediators of the association between pIC and clinical outcome were evaluated through first-order and advanced interaction analyses in the derivation cohort (n = 654) for obtaining a prediction model. The derived model was further validated in an independent cohort (n = 174).

RESULTS

The volume of pIC was significantly associated with poor clinical outcome (OR = 2.19, 95% CI = 1.73 - 2.78, p < 0.001). The strength of this association depended on baseline National Institute of Health Stroke Scale, glucose levels, the use of thrombectomy, and the interaction of age with thrombectomy. The model combining these variables showed good discrimination for predicting clinical outcome in both the derivation cohort and validation cohorts (area under the receiver operating characteristic curve 0.780 (95% CI = 0.746-0.815) and 0.782 (95% CI = 0.715-0.850), respectively).

CONCLUSIONS

In patients imaged within 8 h from stroke onset, the association between pIC and clinical outcome is significantly modified by baseline and therapeutic variables. These variables deserve consideration when evaluating the prognostic relevance of pIC.

KEY POINTS

•The volume of CT perfusion (CTP) predicted infarct core (pIC) is associated with poor clinical outcome in acute ischemic stroke imaged within 8 h of onset. •The relationship between pIC and clinical outcome may be modified by baseline clinical severity, glucose levels, thrombectomy use, and the interaction of age with thrombectomy. •CTP pIC should be evaluated in an individual basis for predicting clinical outcome in patients imaged within 8 h from stroke onset.

Efficacy and safety of spot heating and ultrasound irradiation on in vitro and in vivo thrombolysis models

The feasibility of transcranial sonothrombolysis has been demonstrated, although little is known about the relationships between thermal or mechanical mechanisms and thrombolytic outcomes. Therefore, the present study aims to reveal the effect and safety of temperature and ultrasound through in vitro and in vivo thrombolysis models. Artificial clots in microtubes were heated in a water bath or sonicated by ultrasound irradiation, and then clots weight decrease with rising temperature and sonication time was confirmed. In the in vitro thrombotic occlusion model, based on spot heating, clot volume was reduced and clots moved to the distal side, followed by recanalization of the occlusion. In the in vivo study, the common carotid artery of rats was exposed to a spot heater or to sonication. No brain infarct or brain blood barrier disruption was shown, but endothelial junctional dysintegrity and an inflammatory response in the carotid artery were detected. The present spot heating and ultrasound irradiation models seem to be effective for disintegrating clots in vitro, but the safety of the in vivo model was not fully supported by the data. However, the data indicates that a shorter time exposure could be less invasive than a longer exposure.

Thrombolysis experience in Costa Rica compared against individual patient data from two randomized controlled trials

OBJECTIVES

We sought to compare thrombolysis outcomes from the Costa Rican Stroke Registry Program (CRSRP) with published individual patient data from NINDS and CLOTBUST-ER trials using matching and outcome modeling from randomized clinical trials (RCTs).

MATERIALS AND METHODS

A retrospective observational study matching subjects on baseline characteristics, from the CRSRP, the control arm of CLOTBUST-ER, and the interventional arm of NINDS trials. Day 7-10/discharge modified Rankin Score (mRS), and early mortality was compared between matched subjects. A mortality model derived from RCTs was developed, and outcomes were compared at similar baseline NIHSS scores. CRSRP symptomatic hemorrhage (SICH) rate was compared with an Ibero-American cohort (IAC).

RESULTS

Of 540 CRSRP patients, 351 received rt-PA under 3 hours and were matched with NINDS subjects yielding 292 pairs; 161 CRSRP subjects treated within 4.5 hours were matched with CLOTBUST-ER subjects resulting in 151 pairs. The proportion of patients achieving excellent outcomes (mRS 0-1) did not differ between CRSRP and either NINDS or CLOTBUST-ER (CRSRP vs NINDS: 36.6% vs 32.9%, p=0.3; CRSRP vs CLOTBUST-ER: 26.5% vs 24.5%, p=0.8). Mortality was higher for CRSRP vs CLOTBUST-ER (7.3% vs 0.7%, p=0.006), but not vs NINDS (6.5% vs 4.5%, p=0.4). A pooled mortality model derived from 15 RCTs representing 4410 patients (R²=0.39) showed CRSRP and NINDS within expected mortality, while CLOTBUST-ER showed lower than expected mortality. CRSRP SICH rate equaled IAC (5.7% vs 5.7%; p=0.9).

CONCLUSIONS

Functional outcomes and SICH of thrombolysed Costa Rican patients compared favorably with published datasets, with a potential increase in early mortality.

Contemporary Practice Patterns and Outcomes of Systemic Thrombolysis in Acute Pulmonary Embolism

OBJECTIVE

While systemic thrombolysis (ST) is standard of care in treatment of high-risk pulmonary embolism, large variation in real world usage exists, including use in intermediate-risk pulmonary embolism. There is a paucity of data defining the outcomes, practice patterns of ST dose, duration, and treatment in presumed or imaging confirmed pulmonary embolism.

METHODS

We performed a multicenter retrospective study evaluating real world practice patterns of systemic thrombolysis use in the setting of acute pulmonary embolism (presumed versus imaging confirmed intermediate- and high-risk). Patients who received tissue plasminogen activator for pulmonary embolism between 2017 and 2019 were included. We compared baseline clinical characteristics, tissue plasminogen activator practice patterns, and outcomes in those with confirmed versus presumed pulmonary embolism.

RESULTS

104 patients received systemic thrombolysis for pulmonary embolism; 52 patients had confirmed pulmonary embolism and 52 patients had presumed pulmonary embolism. Significantly more patients treated for presumed pulmonary embolism experienced cardiac arrest (n=47, 90%) than those with confirmed pulmonary embolism (n=23, 44%, p<0.01). Survival to hospital discharge was 65% in patients with confirmed pulmonary embolism versus 6% for those with presumed pulmonary embolism (p<0.01). Systemic thrombolysis was contraindicated in 56% of patients with confirmed pulmonary embolism, with major bleeding in 26% but no intracranial hemorrhage.

CONCLUSIONS

The in-hospital mortality of confirmed acute pulmonary embolism remains high (35%) in contemporary practice in those treated with systemic thrombolysis. A large proportion of these patients had contraindications to systemic thrombolysis and major bleeding rates were significant. Confirmed pulmonary embolism had higher survival rate compared to presumed, including those with cardiac arrest. This observation suggests a limited role of empiric thrombolysis in cardiac arrest situations.

Intravenous thrombolysis and endovascular thrombectomy for acute ischaemic stroke in patients with Moyamoya disease - a systematic review and meta-summary of case reports

BACKGROUND AND AIMS

Patients with Moyamoya disease (MMD) can present with ischaemic or haemorrhagic stroke. There is no good evidence for treatment strategies in MMD-associated acute ischaemic stroke (AIS), particularly for treatments like intravenous thrombolysis (IVT) and endovascular thrombectomy (ET). As the intracranial vessels are friable in MMD, and the risk of bleeding is high, the use of IVT and ET is controversial. To clarify the safety and efficacy of IVT/ET in the treatment of MMD-associated AIS, we performed a systematic review and meta-summary to examine this issue.

METHODS

A systematic search was performed from four electronic databases: PubMed (MEDLINE), Cochrane Library, EMBASE and Scopus, profiling data from inception till 21 November 2021, as well as, manually on Google Scholar.

RESULTS

Ten case reports detailing 10 MMD patients presenting with AIS and undergoing IVT or ET, or both, were included in the analysis. The median National Institute of Health Stroke Scale score at presentation was 10 (Interquartile Range [IQR] = 6.0-16.5). IVT alone was instituted in 6 patients, primary ET was attempted in 2, and 2 had received bridging IVT with ET. Of the 4 patients who underwent ET, 2 patients achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction scale [mTICI] ≥ 2b). In terms of functional outcomes, One patient achieved complete recovery (modified Rankin Scale 0), 4 patients attained improvement in neurological status, and 4 had no improvement, whilst functional outcome was unreported in 1 patient. No patient experienced symptomatic intracranial haemorrhage.

CONCLUSIONS

In this systematic review and meta-summary, the utility of IVT and ET in MMD-associated AIS appears feasible in selected cases. Further larger cohort studies are required to evaluate these treatment approaches.

HIGHLIGHTS

· AIS in MMD was typically managed with bypass surgery but not via thrombolysis or thrombectomy. · In this meta-summary, all patients treated with thrombolysis and/or thrombectomy survived and some experienced symptomatic and/or functional improvement. · Further larger cohort studies are necessary for investigating the role of thrombolysis and/or thrombectomy as treatment of AIS in MMD.

Thrombosis origin identification of cardioembolism and large artery atherosclerosis by distinct metabolites

BACKGROUND

The diagnosis of cerebral thrombosis origin is challenging and remains unclear. This study aims to identify thrombosis due to cardioembolism (CE) and large artery atherosclerosis (LAA) from a new perspective of distinct metabolites.

METHODS

Distinct metabolites between 26 CE and 22 LAA origin thrombi, which were extracted after successful mechanical thrombectomy in patients with acute ischemic stroke in the anterior circulation, were analyzed with a ultra performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UPLC-QTOF-MS) system. Enriched metabolic pathways related to the metabolites were identified. Least absolute shrinkage selection operator regression analyses and a filtering method were used to select potential predictors. Furthermore, four machine learning classifiers, including decision tree, logistic regression, random forest (RF), and k means unsupervised classification model, were used to evaluate the predictive ability of the selected metabolites.

RESULTS

UPLC-QTOF-MS analysis revealed that levels of 88 and 55 metabolites were elevated in LAA and CE thrombi, respectively. Kyoto Encyclopedia of Genes and Genomes analysis revealed a significant difference between the pathways enriched in the two types of thrombi. Six metabolites (diglyceride (DG, 18:3/24:0), DG (22:0/24:0), phytosphingosine, galabiosylceramide (18:1/24:1), triglyceride (15:0/16:1/o-18:0), and glucosylceramide (18:1/24:0)) were finally selected to build a predictive model. The predictive RF model was confirmed to be the best, with a satisfactory stability and prediction capacity (area under the curve=0.889).

CONCLUSIONS

Six metabolites as potential predictors for distinguishing between cerebral thrombi of CE and LAA origin were identified. The results are useful for understanding the pathogenesis and for secondary stroke prevention.

Thrombolysis in stroke patients with elevated inflammatory markers

Objective

To investigate the prognostic value of white blood cell count (WBC) on functional outcome, mortality and bleeding risk in stroke patients treated with intravenous thrombolysis (IVT).

Methods

In this prospective multicenter study from the TRISP registry, we assessed the association between WBC on admission and 3-month poor outcome (modified Rankin Scale 3–6), mortality and occurrence of symptomatic intracranial hemorrhage (sICH; ECASS-II-criteria) in IVT-treated stroke patients. WBC was used as continuous and categorical variable distinguishing leukocytosis (WBC > 10 × 10⁹/l) and leukopenia (WBC < 4 × 10⁹/l). We calculated unadjusted/ adjusted odds ratios with 95% confidence intervals (OR [95% CI]) with logistic regression models. In a subgroup, we analyzed the association of combined leukocytosis and elevated C-reactive protein (CRP > 10 mg/l) on outcomes.

Results

Of 10,813 IVT-treated patients, 2527 had leukocytosis, 112 leukopenia and 8174 normal WBC. Increasing WBC (by 1 × 10⁹/l) predicted poor outcome (OR_adjusted 1.04[1.02–1.06]) but not mortality and sICH. Leukocytosis was independently associated with poor outcome (OR_adjusted 1.48[1.29–1.69]) and mortality (OR_adjusted 1.60[1.35–1.89]) but not with sICH (OR_adjusted 1.17[0.94–1.45]). Leukopenia did not predict any outcome. In a subgroup, combined leukocytosis and elevated CRP had the strongest association with poor outcome (OR_adjusted 2.26[1.76–2.91]) and mortality (OR_adjusted 2.43[1.86–3.16]) when compared to combined normal WBC and CRP.

Conclusion

In IVT-treated patients, leukocytosis independently predicted poor functional outcome and death. Bleeding complications after IVT were not independently associated with leukocytosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11173-0.

Statistical analysis plan for the randomized controlled trial Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST)

BACKGROUND

Patients with wake-up ischemic stroke are frequently excluded from thrombolytic treatment due to unknown symptom onset time and limited availability of advanced imaging modalities. The Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST) is a randomized controlled trial of intravenous tenecteplase 0.25 mg/kg and standard care versus standard care alone (no thrombolysis) in patients who wake up with acute ischemic stroke and can be treated within 4.5 h of wakening based on non-contrast CT findings.

OBJECTIVE

To publish the detailed statistical analysis plan for TWIST prior to unblinding.

METHODS

The TWIST statistical analysis plan is consistent with the Consolidating Standard of Reporting Trials (CONSORT) statement and provides clear and open reporting.

DISCUSSION

Publication of the statistical analysis plan serves to reduce potential trial reporting bias and clearly outlines the pre-specified analyses.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03181360 . EudraCT Number 2014-000096-80 . WHO ICRTP registry number ISRCTN10601890 .

"No Time to Die" - Saving the Neurons

How to cite this article: Sapra H. "No Time to Die" - Saving the Neurons. Indian J Crit Care Med 2022;26(5):539-540.

The effect of heparin administration time on thrombolysis in myocardial infarction flow grade in patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND

In the clinical setting of patients with ST-elevation myocardial infarction (STEMI), there are controversies about the role of early heparin administration on the patients' outcome and the patency of the infarct-related artery (IRA). In this randomized clinical trial, we sought to investigate the effect of heparin administration time on the thrombolysis in myocardial infarction (TIMI) flow grade of patients with STEMI treated with primary percutaneous coronary intervention (PPCI).

METHODS

Eligible individuals were randomly assigned to two groups: early heparin administration (90 IU/kg) in the emergency department (group A, n = 92) and late heparin administration in the Cath lab (group B, n = 77). All demographic and clinical information and on admission examinations were documented. Clinical outcomes, 40-day mortality, and left ventricular (LV) function improvement in follow-up were also collected.

RESULTS

The mean age of patients was 57.1 ± 8.8 and 57.5 ± 7.5 years in groups A and B, respectively (P = 0.232). The history of hypertension (HTN) (34.8% vs. 53.2%, P = 0.016) and diabetes (14.1% vs. 29.9%, P = 0.013) was significantly lower in group A. The LV ejection fraction (LVEF) changes were significant before and after the intervention within each group. However, this change was not significantly different between the groups (P = 0.592). Post-intervention complications did not differ between the two groups (P > 0.05). In the proportion of cases with TIMI flow grade less than 2 in the IRA, no significant differences were observed between the groups. [P = 0.092 for left anterior descending (LAD) and P = 0.086 for left circumflex artery (LCX)].

CONCLUSION

Although heparin administration in patients with STEMI undergoing PPCI is safe and effective, the effect appears not to be time-dependent.

Dependence of the Rate and Completeness of Fibrin Clot Destruction on the Acoustic Dose and Ultrasound Intensity

The kinetics of fibrin clot destruction under catheter-delivered 32- to 45-kHz ultrasound (US) has been studied at 36°C-38°C in isotonic saline solution. A pseudo-first-order rate constant increased linearly from 0.06/min to 0.57/min with increasing US intensity I₀ from 21.6 to 51.2 W/cm². At I₀ = 4.4 and 11.4 W/cm², the degree of clot destruction did not exceed 11%-15% regardless of the time of US exposure. Starting from I₀ = 21.6 W/cm², the maximum achievable level of clot destruction increased linearly with US intensity, reaching 68% at I₀ = 51.2 W/cm² after 3 min of US exposure. Thus, US intensity is a key parameter determining the maximum achievable level of clot destruction. However, an increase in US intensity above 30 W/cm² is limited by the intensified negative sonochemical effect on the enzymatic system of hemostasis caused by an increase in inertial cavitation. The best effect can be achieved with ultrasound of a sufficiently high intensity that ensures a large contribution of stable cavitation, generating microstreaming flows, and a minimum contribution of inertial cavitation, generating microjets and shock waves.

Nomogram to predict hemorrhagic transformation for acute ischemic stroke in Western China: a retrospective analysis

Background and purpose

Hemorrhagic transformation (HT) is the most alarming complication of acute ischemic stroke. We aimed to identify risk factors for HT in Chinese patients and attempted to develop a nomogram to predict individual cases.

Methods

A retrospective study was used to collect the demographic and clinical characteristics of ischemic stroke patients at the Second Affiliated Hospital of Chongqing Medical University (development cohort) and Chongqing Sanbo Changan Hospital (validation cohort) from October 2013 to August 2020. Univariate analysis and multivariate analysis were used to identify the risk factors of patients in the development cohort. The nomogram was generated, and internal validation was performed. We used the area under the receiver-operating characteristic curve (AUC-ROC) to assess the discrimination and used the Hosmer–Lemeshow test to calibrate the model. To further verify the predictability and accuracy of the model, we performed an external validation of the patients in the validation cohort.

Results

A total of 570 patients were used to generate the nomogram. After univariate analysis and multivariate logistic regression, the remaining 7 variables (diabetes mellitus, atrial fibrillation, total cholesterol, fibrous protein, cerebral infarction area, NIHSS score and onset-to-treatment) were independent predictors of HT and used to compose the nomogram. The area under the receiver-operating characteristic curve of the model was 0.889 (95% CI, 0.841–0.938), and the calibration was good (P = 0.487 for the Hosmer–Lemeshow test). The model was validated externally with an AUC-ROC value of 0.832 (95% CI, 0.727–0.938).

Conclusions

The nomogram prediction model in this study has good predictive ability, accuracy and discrimination, which can improve the diagnostic efficiency of HT in patients with acute ischemic stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02678-2.

A Chilean Experience of Telestroke in a COVID-19 Pandemic Year

Background and Purpose

Telemedicine for stroke patients' care (telestroke [TS]) has grown notably in recent decades and may offer advantages during health crisis. Hospital admissions related to stroke have decreased globally during the COVID-19 pandemic, but scarce information is available regarding the effect of COVID-19 in TS. Using a population-based TS registry, we investigated the impact of the first year of the COVID-19 pandemic throughout our TS network in Santiago, Chile.

Methods

Stroke codes evaluated after the onset of COVID-19 restrictions in Chile (defined as March 15, 2020) were compared with those evaluated in 2019. We analyzed differences between number of stroke codes, thrombolysis rate, stroke severity, and time from the stroke onset to hospital admission.

Results

We observed that the number of stroke codes and the number of patients undergoing reperfusion therapy did not change significantly (p = 0.669 and 0.415, respectively). No differences were found with respect to the median time from the stroke onset to admission (p = 0.581) or in National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.055). The decision-making-to-needle time was significantly shorter in the COVID-19 period (median 5 min [IQR 3–8], p < 0.016), but no significant changes were found at the other times.

Conclusions

This study demonstrates the potential of adapting TS to extreme situations such as the COVID-19 pandemic, as well as the importance of establishing networks that facilitate patient access to quality treatments.

Interhospital Transfer for the Management of Acute Pulmonary Embolism

BACKGROUND

There are increasing treatment options for the management of acute pulmonary embolism (PE), though many are only available at tertiary care centers. Patients with acute pulmonary embolism with high-risk features are often transferred for consideration of such therapies. There are limited data describing outcomes in patients transferred with acute pulmonary embolism.

METHODS

We evaluated patients with acute pulmonary embolism at our tertiary care center from August 2012 through August 2018 and compared clinical characteristics, pulmonary embolism features, management, and outcomes in those transferred for acute pulmonary embolism to those that were not transferred.

RESULTS

Of 2050 patients with pulmonary embolism included in the study, 432 (21.1%) were transferred from an outside hospital with a known diagnosis of pulmonary embolism. Patients transferred had a lower rate of malignancy (22.2% vs 33.3%; P < .001) and median Charlson comorbidity index (3 vs 4; P < .001). A higher percentage of patients transferred were classified as intermediate- or high-risk pulmonary embolism (62.5% vs 43.0%; P <.001) and more frequently received advanced therapy beyond anticoagulation alone (12.5% vs 3.2%, P < .001). Overall survival to discharge was similar between groups, though definite pulmonary embolism-related mortality was higher in the transferred group (38.5% vs 9.4%, P = .004).

CONCLUSION

More than 1 in 5 patients treated for acute pulmonary embolism at a tertiary care center were transferred from an outside facility. Transferred patients had higher risk pulmonary embolism features, more often received advanced therapy, and had higher definite pulmonary embolism-related mortality. There are opportunities to further optimize outcomes of patients transferred for management of acute pulmonary embolism.

Endovascular treatment of ischemic stroke due to isolated internal carotid artery occlusion: ETIS registry data analysis

BACKGROUND

The best treatment for acute ischemic stroke (AIS) due to isolated cervical internal carotid artery occlusion (CICAO) (i.e., without associated occlusion of the circle of Willis) is still unknown. In this study, we aimed to describe EVT safety and clinical outcome in patients with CICAO.

METHODS

We analyzed data of all consecutive patients, included in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry between 2013 and 2020, who presented AIS and proven CICAO on angiogram and underwent EVT. We assessed carotid recanalization, procedural complications, National Institutes of Health Stroke Scale (NIHSS) at 24 h post-EVT, and 3-month favorable outcome (modified Rankin Scale, mRS ≤ 2 or equal to the pre-stroke value).

RESULTS

Forty-five patients were included (median age: 70 years; range: 62-82 years). The median NIHSS before EVT was 14 (9-21). Carotid stenting was performed in 23 (51%) patients. Carotid recanalization at procedure end and on control imaging was observed in 37 (82%) and 29 (70%) patients, respectively. At day 1 post-EVT, the NIHSS remained stable or decreased in 25 (60%) patients; 12 (29%) patients had early neurologic deterioration (NIHSS ≥ 4 points). The rate of procedural complications was 36%, including stent thrombosis (n = 7), intracranial embolism (n = 7), and symptomatic intracranial hemorrhage (n = 1). At 3 months, 18 (40%) patients had a favorable outcome, and 10 (22%) were dead.

CONCLUSION

Our study suggests that EVT in AIS patients with moderate/severe initial deficit due to CICAO led to high rate of recanalization at day 1, and a 40% rate of favorable outcome at 3 months. There was a high rate of procedural complication which is of concern. Randomized controlled trials assessing the superiority of EVT in patients with CICAO and severe deficits are needed.

Breaking Down Barriers: Easter Island's First Telestroke Thrombolysis Experience and Case Report

Easter Island (Rapa Nui), Chile, is remote, located in the Polynesian Triangle in Oceania. The closest continental point is Chile, 3,512 km east. It has a population of 7,750 inhabitants, who are Chilean citizens, and receives more than 60,000 tourists a year. For this entire population, there is a medium complexity hospital without a neurology specialist. In 2019, local professionals were trained in a Telestroke program with remote clinical support conducted by neurologists located on mainland Chile. We present a 50-year-old native male, with unknown medical history, who suddenly presented right-half-body weakness and aphasia. He was evaluated via Telestroke consultation, and thrombolysis with tenecteplase was indicated. The patient improved rapidly and 45 min later the NIHSS score was 0 points. To our knowledge, this is the first reported case of Telestroke treatment in such a remote area, highlighting the importance of telemedicine to overcome geographical and technological stroke care barriers and to improve patients' outcome, no matter where they live.

Impact of poly-arginine peptides R18D and R18 on alteplase and tenecteplase thrombolysis in vitro, and neuroprotective stability to proteolysis

The poly-arginine peptides R18D and R18 represent novel potential neuroprotective treatments for acute ischaemic stroke. Here we examined whether R18D and R18 had any significant effects on the thrombolytic activity of alteplase (tPA) and tenecteplase (TNK) on clots formed from whole blood in an in vitro thrombolysis plate assay. R18D and R18 were examined at concentrations of 0.25, 0.5, 1, 2, 4, 8 and 16 µM during the 1-h thrombolytic assay. We also included the well-characterised neuroprotective NA-1 peptide as a control. R18D, R18 and NA-1 all reduced tPA or TNK percentage clot lysis by 0-9.35%, 0-3.44% and 0-4.8%, respectively. R18D, R18 and NA-1 had a modest and variable effect on the lag time, increasing the time to the commencement of thrombolysis by 0-9.9 min, 0-5.53 min and 0-7.16 min, respectively. Lastly, R18 and NA-1 appeared to increase the maximal activity of the thrombolysis reaction. In addition, the in vitro anti-excitotoxic neuroprotective efficacy of R18D and R18 was not affected by pre-incubation for 1-2 h or overnight with tPA or TNK, whereas only R18D retained high anti-excitotoxic neuroprotective efficacy when pre-incubated in a synthetic trypsin (TrypLE Express). The present in vitro findings suggest that neither R18D or R18 when co-administered with the thrombolytic inducing agents tPA or TNK are likely to have a significant impact when used clinically during clot thrombolysis and confirm the superior proteolytic stability of the R18D peptide.

Interventional recanalization therapy in patients with non-cirrhotic, non-malignant portal vein thrombosis: comparison between transjugular versus transhepatic access

Purpose

To compare the safety and outcome of transjugular versus percutaneous technique in recanalization of non-cirrhotic, non-malignant portal vein thrombosis.

Methods

We present a retrospective bicentric analysis of 21 patients with non-cirrhotic, non-malignant PVT, who were treated between 2016 and 2021 by interventional recanalization via different access routes (percutaneous [PT] vs. transjugular in transhepatic portosystemic shunt [TIPS] technique). Complication rates with a focus on periprocedural bleeding and patency as well as outcome were compared.

Results

Of the 21 patients treated (median age 48 years, range of 19–78), seven (33%) patients had an underlying prothrombotic condition. While 14 (57%) patients were treated for acute PVT, seven (43%) patients had progressive thrombosis with known chronic PVT. Nine patients underwent initial recanalization via PT access and twelve via TIPS technique. There was no significant difference in complete technical success rate according to initial access route (55.5% in PT group vs. 83.3% in TIPS group, p = 0.331). However, creation of an actual TIPS was associated with higher technical success in restoring portal venous flow (86.6% vs. 33.3%, p = 0.030). 13 (61.9%) patients received thrombolysis. Nine (42.8%) patients experienced hemorrhagic complications. In a multivariate analysis, thrombolysis (p = 0.049) and PT access as the first procedure (p = 0.045) were significant risk factors for bleeding.

Conclusion

Invasive recanalization of the portal vein in patients with PVT and absence of cirrhosis and malignancy offers a good therapeutic option with high recanalization and patency rates. Bleeding complications result predominantly from a percutaneous access and high amounts of thrombolytics used; therefore, recanalization via TIPS technique should be favored.

A case report of COVID-19-associated acute hand ischaemia in a young professional volleyball player

Background

Several coronavirus disease-19 (COVID-19)-associated complications are being increasingly reported, including arterial and venous thrombo-embolic events that may lead to amputation of the affected limbs. So far, acute upper limb ischaemia (ULI) has been reported only in critically ill patients.

Case summary

Herein, we aimed to present a case of a 29-year-old, otherwise healthy male volleyball player, with acute ischaemic signs in the upper extremity who was diagnosed with COVID-19 1 month before the ischaemic event. It has been shown that volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow that can lead to pain and cold digits, but never acute ULI.

Discussion

To our knowledge, this is the first case of such a hypercoagulable synergistic mechanism that leads to a high thrombus burden. Intra-arterial local thrombolysis and percutaneous transluminal angioplasty failed to succeed, and percutaneous large-bore embolectomy with the Indigo Aspiration System (Penumbra Inc., CA, USA) was deemed necessary.

Evaluation of stroke prognostication using age and NIH Stroke Scale index (SPAN-100 index) in delayed intravenous thrombolysis patients (beyond 4.5 hours)

OBJECTIVES

the efficacy of delayed intravenous tissue plasminogen activator (tPA), beyond the 4.5 h window, is evolving. Advanced age and high admission National Institutes of Health Stroke Scale (NIHSS) score are proposed to adversely affect the outcome of delayed thrombolysis and limit the inclusion criteria. The summation of patient age and admission NIHSS score was introduced as the SPAN-100 index as a tool of prediction of the clinical outcome after acute ischemic stroke (AIS). We aimed to assess the SPAN-100 index in AIS thrombolysed patients after 4.5 h.

MATERIALS AND METHODS

The SPAN-100 index was applied to AIS patients receiving delayed IV thrombolysis (IVT) after 4.5 h. Patients demographics, risk factors, clinical, laboratory and radiological data, mismatch evidence, treatment onset and modality, NIHSS score at baseline and at discharge, and 3 months follow-up modified Rankin Scale (mRS) were reviewed. SPAN-100 score ≥ 100 is classified as SPAN-100 positive while score < 100 is SPAN-100 negative. Clinical outcomes, death and intracerebral hemorrhage (ICH) incidences were compared between SPAN-100 positive and negative groups.

RESULTS

SPAN-100-positive delayed IVT-patients (11/136) had a 6-fold increased risk for unfavorable outcome compared to SPAN-negative patients (OR 6.34; 95% CI 1.59-25.24 p=0.004), however there was no relation between the SPAN-100 positivity and mortality or ICH.

CONCLUSION

SPAN-100-positive patients are more likely to achieve non-favorable outcome with delayed IVT in comparison to the SPAN-100-negative patients. SPAN-100 index may influence the eligibility criteria of delayed thrombolysis.

Association of Elevated Body Mass Index with Functional Outcome and Mortality following Acute Ischemic Stroke: The Obesity Paradox Revisited

BACKGROUND

Previous literature has identified a survival advantage in acute ischemic stroke (AIS) patients with elevated body mass indices (BMIs), a phenomenon termed the "obesity paradox."

OBJECTIVE

The aim of this study was to evaluate the independent association between obesity and clinical outcomes following AIS.

METHODS

Weighted discharge data from the National Inpatient Sample were queried to identify AIS patients from 2015 to 2018. Multivariable logistic regression and Cox proportional hazards modeling were performed to evaluate associations between obesity (BMI ≥ 30) and clinical endpoints following adjustment for acute stroke severity and comorbidity burden.

RESULTS

Among 1,687,805 AIS patients, 216,775 (12.8%) were obese. Compared to nonobese individuals, these patients were younger (64 vs. 72 mean years), had lower baseline NIHSS scores (6.9 vs. 7.9 mean score), and a higher comorbidity burden. Multivariable analysis demonstrated independent associations between obesity and lower likelihood of mortality (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI]: 0.71, 0.82, p < 0.001; hazard ratio 0.84, 95% CI: 0.73, 0.97, p = 0.015), intracranial hemorrhage (aOR 0.87, 95% CI: 0.82, 0.93, p < 0.001), and routine discharge to home (aOR 0.97, 95% CI: 0.95, 0.99; p = 0.015). Mortality rates between obese and nonobese patients were significantly lower across stroke severity thresholds, but this difference was attenuated among high severity (NIHSS > 20) strokes (21.6% vs. 23.2%, p = 0.358). Further stratification of the cohort into BMI categories demonstrated a "U-shaped" association with mortality (underweight aOR 1.58, 95% CI: 1.39, 1.79; p < 0.001, overweight aOR 0.64, 95% CI: 0.42, 0.99; p = 0.046, obese aOR 0.77, 95% CI: 0.71, 0.83; p < 0.001, severely obese aOR 1.18, 95% CI: 0.74, 1.87; p = 0.485). Sub-cohort assessment of thrombectomy-treated patients demonstrated an independent association of obesity (BMI 30-40) with lower mortality (aOR 0.79, 95% CI: 0.65, 0.96; p = 0.015), but not with routine discharge.

CONCLUSION

This cross-sectional analysis demonstrates a lower likelihood of discharge to home as well as in-hospital mortality in obese patients following AIS, suggestive of a protective effect of obesity against mortality but not against all poststroke neurological deficits in the short term which would necessitate placement in acute rehabilitation and long-term care facilities.

Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability and coverage

BACKGROUND

Major disparities have been reported in recombinant tissue Plasminogen Activator (rtPA) availability among countries of different socioeconomic status.

AIMS

To characterize variability of rtPA price, its availability, and its association with and impact on each country's health expenditure (HE) resources.

METHODS

We conducted a global survey to obtain information on rtPA price (50mg vial, 2020 US Dollars) and availability. Country-specific data, including Low, Lower Middle (LMIC), Upper Middle (UMIC) and High-Income Country (HIC) classifications, and Gross Domestic Product (GDP) and HE, both nominally and adjusted for purchasing power parity (PPP), were obtained from World Bank Open Data. To assess the impact of rtPA cost, we computed the rtPA price as percentage of per capita GDP and HE and examined its association with the country income classification.

RESULTS

rtPA is approved and available in 109 countries. We received surveys from 59 countries: 27 (46%) HIC, 20 (34%) UMIC and 12 (20%) LMIC. Although HIC have significantly higher per capita GDP and HE compared to UMIC and LMIC (p<0.0001), the median price of rtPA is non-significantly higher in LMICs [USD 755, IQR (575-1300)] compared to UMICs [USD 544, IQR (400-815)] and HIC [USD 600, IQR (526-1000)]. In LMIC, rtPA cost accounts for 217.4% (IQR (27.1-340.6%) of PPP-adjusted per capita HE, compared to 17.6% (IQR [11.2-28.7%], p<0.0001) for HICs.

CONCLUSIONS

We documented significant rtPA availability and variability in its price among countries. Relative costs are higher in lower income countries, exceeding the available HE. Concerted efforts to improve rtPA affordability in low-income settings are necessary.

Improved Stroke Care in a Primary Stroke Centre Using AI-Decision Support

BACKGROUND

Patient selection for reperfusion therapies requires significant expertise in neuroimaging. Increasingly, machine learning-based analysis is used for faster and standardized patient selection. However, there is little information on how such software influences real-world patient management.

AIMS

We evaluated changes in thrombolysis and thrombectomy delivery following implementation of automated analysis at a high volume primary stroke centre.

METHODS

We retrospectively collected data on consecutive stroke patients admitted to a large university stroke centre from two identical 7-month periods in 2017 and 2018 between which the e-Stroke Suite (Brainomix, Oxford, UK) was implemented to analyse non-contrast CT and CT angiography results. Delivery of stroke care was otherwise unchanged. Patients were transferred to a hub for thrombectomy. We collected the number of patients receiving intravenous thrombolysis and/or thrombectomy, the time to treatment; and outcome at 90 days for thrombectomy.

RESULTS

399 patients from 2017 and 398 from 2018 were included in the study. From 2017 to 2018, thrombolysis rates increased from 11.5% to 18.1% with a similar trend for thrombectomy (2.8-4.8%). There was a trend towards shorter door-to-needle times (44-42 min) and CT-to-groin puncture times (174-145 min). There was a non-significant trend towards improved outcomes with thrombectomy. Qualitatively, physician feedback suggested that e-Stroke Suite increased decision-making confidence and improved patient flow.

CONCLUSIONS

Use of artificial intelligence decision support in a hyperacute stroke pathway facilitates decision-making and can improve rate and time of reperfusion therapies in a hub-and-spoke system of care.

Endovascular Management of Venous Thromboembolic Disease in the Oncologic Patient Population

PURPOSE OF REVIEW

Venous thromboembolic disease causes significant mortality and morbidity in the oncologic patient population. Recently, minimally invasive endovascular technologies have been developed as an adjunct to antithrombotic therapy for the management of DVT and PE. The current and potential roles for endovascular treatment of cancer-associated venous thromboembolism (VTE) will be reviewed in this article.

RECENT FINDINGS

The recent NCCN guidelines recommend endovascular therapy in patients eligible for therapeutic anticoagulation who present with life-, organ-, or limb-threatening thrombosis. However, symptomatic non-life-threatening VTE can negatively affect QOL and physical function, both of which have prognostic implications in the cancer population. Endovascular therapies have been shown to improve physical function and QOL in prospective trials performed in a non-oncologic patient population as well as small retrospective studies in the cancer population. In addition to treating life- and limb-threatening thrombosis, endovascular therapy for VTE can improve QOL and physical function in comparison to anticoagulation alone. Prospective trials are warranted to assess the benefit of endovascular therapy for quality of life-years, performance status, and overall survival in the oncologic patient population.

Metal ion chelation enhances tissue plasminogen activator (tPA)-induced thrombolysis: an in vitro and in vivo study

Stroke is the third leading cause of death in the United States and the leading cause of adult disability. Despite enormous research efforts including many clinical trials, tissue plasminogen activator (tPA) remains the only FDA-approved treatment for acute ischemic stroke. Unfortunately, only 1-3% of stroke patients in the US receive this therapy because of the narrow time window and severe side effects for using tPA. The most deadly and damaging side effect is the risk of intracranial bleeding or hemorrhage. For that reason, the dose of tPA and its overall administration are under tight control, which may compromise the effect of thrombolysis. Studies have been focused on improving the effectiveness of tPA for higher rate of reperfusion, and the safety for less adverse bleeding episode. We studied how metal ions (zinc & iron) affect tPA-induced thrombolysis in vitro and in vivo, and proposed a method to improve the rate of thrombolysis. The amount of hemoglobin in the blood clot lysis was measured by a spectrophotometer. The tPA-induced thrombolysis was measured in vivo in femoral artery. Our results showed that Zn²⁺, Fe³⁺ and Fe²⁺ inhibited tPA-induced thrombolysis, with Zn²⁺ and Fe²⁺ being the most effective. Metal ion chelating agent EDTA when it was co-applied with tPA significantly enhanced the tPA-induced thrombolysis. The chelation alone did not have noticeable thrombolytic effect. In in vivo study of tPA-induced thrombosis following femoral artery thrombosis, the co-application of tPA and EDTA achieved significant higher rate of reperfusion than that by tPA treatment alone, suggesting that ion chelation facilitates tPA-induced thrombolysis and potentially improves the safety of tPA application by reducing the necessary dose of tPA application. Our results suggest that the co-application of a chelator and tPA improves the efficacy and, potentially, safety of tPA application, by reducing the necessary dose of tPA for thrombolysis.

The prognostic value of time from symptom onset to thrombolysis in patients with pulmonary embolism

BACKGROUND

According to clinical practice guidelines, thrombolysis can be administered during the 14 days after the beginning of symptoms in PE. However, the role of the early thrombolysis in PE has not been comprehensively investigated. In this study we evaluated the effect of short symptom-to-thrombolysis time (STT) in these patients who received the thrombolytic therapy within the 48-h.

METHOD

A total of 456 patients with pulmonary embolism who underwent thrombolytic therapy in a tertiary center were included in the current study. The patients were stratified into three groups according to STT as: <12 h (Group 1), 12 to 24 h (Group 2) and > 24 to 48 h (Group 3). In-hospital events and long-term mortality were compared between the groups.

RESULTS

Group 3 had higher in-hospital mortality, acute kidney injury, cardiogenic shock, asystole, and the use mechanical ventilation and 3-year mortality compared to the other two groups. The 3-year overall survival for Group 1, 2 and 3 were 82.1%, 77.7% and 25.9% respectively. According to regression analysis, a STT > 24 h was independently associated with in-hospital and long-term mortality. Group 1 and 2 had similar in-hospital outcomes and long-term mortality.

CONCLUSION

A short STT has a great importance in patients with PE who treated with thrombolytic therapy. The efficacy of systemic thrombolysis significantly drops after 24 h. Because of this situation, the period between the symptom onset and thrombolytic therapy should be kept short as much as possible.

Efficacy and safety of argatroban in treatment of acute ischemic stroke: A meta-analysis

BACKGROUND

Argatroban is a novel direct thrombin inhibitor that has been used for treatment of acute ischemic stroke (AIS). To our knowledge, no systematic analysis has assessed the efficacy and safety of argatroban for treatment of AIS.

AIM

To evaluate the efficacy and safety of argatroban for treatment of AIS.

METHODS

Cochrane Library, Medline, PubMed, and Web of Science were searched to retrieve all studies associated with argatroban and AIS. Effective rate, adverse events rate, and 95% confidence intervals were calculated and pooled using meta-analysis methodology.

RESULTS

We only found four randomized controlled studies, comprising 354 cases with 213 in the argatroban group and 141 in the control group. Great heterogeneity was found in the four studies (c² = 11.44, I² = 74%, P = 0.01). Subgroup analysis could not be performed because of the absence of detailed data. The two most recent studies showed acceptable heterogeneity (c² = 1.56, I² = 36%, P = 0.21). Our analysis showed that argatroban was not more effective than the control therapy in the acute phase of ischemic stroke (Z = 0.01, P = 0.99). Argatroban did not increase the risk of bleeding compared with the control group (c² = 0.37, I² = 0%, P = 0.54, Z = 0.80, P = 0.42).

CONCLUSION

Patients with AIS might not benefit from argatroban and combination therapy with argatroban does not increase bleeding tendency.

Superior mesenteric venous thrombosis: Endovascular management and outcomes

BACKGROUND

Superior mesenteric venous thrombosis (SMVT) is a rare but fatal condition that is typically treated initially with anticoagulation therapy, and if this fails, with endovascular interventions. However, due to its rarity, there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.

AIM

To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.

METHODS

A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed. Technical success was defined as angiographic improvement in SMV flow after intervention. Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention. Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up. The adverse events were reported through Clavien-Dindo classification.

RESULTS

Twenty-four patients were included for analysis. The median age at intervention was 60 years (35-74 years) and 16 (67%) were men. Nineteen patients presented with acute thrombosis (79.2%) and 5 with chronic thrombosis with acute manifestations (20.8%). The most commonly used endovascular modalities were thrombectomy in 12 patients (50.0%) and catheter-directed thrombolysis in 10 patients (41.7%). Technical success was achieved in 18 patients (75%). The 14-d and 30-d primary patency rates were 88.9% and 83.3%, respectively. Adverse events were reported in two patients (8.3%), one marked as grade IIIB, and 1 death marked as grade V. Five-year overall survival rate was 82% (58%-100%).

CONCLUSION

Endovascular intervention with anticoagulation appears to be effective for managing SMVT. This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Pre-administration of a carboxypeptidase inhibitor enhances tPA-induced thrombolysis in mouse microthrombi: Evidence from intravital imaging analysis

INTRODUCTION

Thrombolysis using recombinant tissue-type plasminogen activator (rt-PA) is the pharmacological treatment of choice in acute thrombotic events. However, a narrow therapeutic window and bleeding complications limit its use. We describe the role of carboxypeptidase inhibitor from potato tuber (PTCI), an inhibitor of activated thrombin-activatable fibrinolysis inhibitor (TAFIa), on Glu-plasminogen accumulation and microthrombus dynamics in vivo and demonstrate its influence on rt-PA-mediated thrombolysis.

MATERIALS AND METHODS

In conjunction with real-time intravital two-photon excitation fluorescence microscopy, we produced and imaged laser-induced microthrombi in the mesenteric venules of Green Fluorescent Protein (GFP)-expressing mice. We examined microthrombus dynamics and thrombolysis patterns in vivo by measuring the changes in the fluorescence intensity of labeled Glu-plasminogen following administration of epsilon aminocaproic acid (EACA), PTCI, and rt-PA.

RESULTS

PTCI enhanced Glu-plasminogen accumulation at the core of the thrombus by inhibiting TAFIa, while EACA inhibited this process. Exogenous rt-PA effectively triggered Glu-plasminogen activation within the thrombus and promoted thrombolysis. Administration of PTCI and rt-PA together showed no significant benefit on thrombolysis compared to rt-PA administration alone. However, early-phase systemic administration of PTCI before thrombolytic therapy by rt-PA expedited clot lysis as evidenced by significantly faster time to reach peak Glu-plasminogen fluorescence intensity and shorter time to achieve near-complete clot lysis (P = 0.014 and P = 0.003, respectively).

CONCLUSIONS

PTCI potentiates rt-PA-mediated thrombolysis when administered early in acute thrombotic events. Further studies are warranted to explore the potential of TAFI inhibitors as adjunct agents in thrombolysis or thromboprophylaxis.

Long-term outcomes in inferior ST-segment elevation myocardial infarction patients with right ventricular myocardial infarction

OBJECTIVE

To evaluate the prognostic influence of the presence of right ventricular myocardial infarction (RVMI) on patients with inferior ST-segment elevation myocardial infarction (STEMI) in the contemporary reperfusion era.

METHODS

9308 patients with inferior STEMI were included from the prospective, nationwide, multicenter China Acute Myocardial Infarction Registry, including 1745 (18.75%) patients with RVMI and 7563 (81.25%) patients without RVMI. The primary outcome was two-year all-cause mortality. The secondary outcome was major adverse cardiac and cerebrovascular event (MACCE) defined as a composite of all-cause mortality, recurrent MI, revascularization, stroke, and major bleeding.

RESULTS

After two-year follow up, there were no significant differences between inferior STEMI patients with or without RVMI in all-cause mortality (12.0% vs 11.3%; adjusted HR: 1.05; 95% CI: 0.90 to 1.24; P = 0.5103). Inferior STEMI with RVMI was associated with higher risk of MACCE (25.6% vs 22.0%; adjusted HR: 1.17; 95% CI: 1.05 to 1.31; P = 0.0038), revascularization (10.3% vs 8.1%; adjusted HR: 1.23; 95% CI: 1.03 to 1.48; P = 0.0218), and major bleeding (4.6% vs 2.7%; adjusted HR: 1.56; 95% CI: 1.18 to 2.07; P = 0.0019). Primary percutaneous coronary intervention (PCI) and thrombolysis were independent predictors to decrease all-cause mortality. For patients who received timely reperfusion, RVMI involvement did not increase all-cause mortality, whereas for those who did not undergo reperfusion, RVMI increased all-cause mortality (20.3% vs 15.7%; HR: 1.34; 95% CI: 1.10 to 1.63).

CONCLUSION

RVMI did not increase all-cause mortality for inferior STEMI patients in contemporary reperfusion era, whereas the risk was increased for patients with no reperfusion treatment.

Higher baseline blood glucose is associated with reduced likelihood for successful recanalization in patients with basilar artery occlusion

Purpose

Evidence regarding the effect of mechanical thrombectomy (MT) of basilar artery occlusion (BAO) stroke is yet sparse. As successful recanalization has been suggested as major determinant of outcome, the early identification of modifiable factors associated with successful recanalization could be of importance to improve functional outcome. Hyperglycemia has been associated with enhanced thrombin generation and unfavorably altered clot features.

Objective

We hypothesized that serum baseline glucose is associated with likelihood of vessel recanalization mediated by collateral quality and clot burden in BAO stroke.

Methods

BAO stroke patients who received multimodal CT on admission were analyzed. The association of vessel recanalization defined using modified Thrombolysis in cerebral infarction scale (mTICI) scores 2b-3, and baseline imaging and clinical parameters were tested in logistic regression analyses. Collateral quality and clot burden were evaluated using the Basilar Artery on CT-Angiography (BATMAN) score.

Results

Out of 117 BAO patients, 91 patients (78%) underwent MT. In 70 patients (77%), successful recanalization could be achieved (mTICI 2b/3). In multivariable logistic regression analysis, only a higher BGL (aOR 0.97, 95% CI 0.96–0.99, p = 0.03) and higher BATMAN score (aOR 1.77, 95% CI 1.11–2.82, p = 0.02) were independently associated with vessel recanalization. Application of alteplase, or time from symptom onset-imaging revealed no independent association with recanalization status.

Conclusion

Higher BGL was significantly associated with reduced likelihood for recanalization success besides BATMAN score as a measure of collateral quality and clot burden. BGL could be tested as a modifiable parameter to increase likelihood for recanalization in BAO stroke, aiming to improve functional outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10948-1.

Shortening Door-to-Needle Time by Multidisciplinary Collaboration and Workflow Optimization During the COVID-19 Pandemic

OBJECTIVES

This study aims to evaluate shortening door-to-needle time of intravenous recombinant tissue plasminogen activator of acute ischemic stroke patients by multidisciplinary collaboration and workflow optimization based on our hospital resources.

MATERIALS AND METHODS

We included patients undergoing thrombolysis with intravenous recombinant tissue plasminogen activator from January 1, 2018, to September 30, 2020. Patients were divided into pre- (January 1, 2018, to December 31, 2019) and post-intervention groups (January 1, 2020, to September 31, 2020). We conducted multi-department collaboration and process optimization by implementing 16 different measures in prehospital, in-hospital, and post-acute feedback stages for acute ischemic stroke patients treated with intravenous thrombolysis. A comparison of outcomes between both groups was analyzed.

RESULTS

Two hundred and sixty-three patients received intravenous recombinant tissue plasminogen activator in our hospital during the study period, with 128 and 135 patients receiving treatment in the pre-intervention and post-intervention groups, respectively. The median (interquartile range) door-to-needle time decreased significantly from 57.0 (45.3-77.8) min to 37.0 (29.0-49.0) min. Door-to-needle time was shortened to 32 min in the post-intervention period in the 3rd quarter of 2020. The door-to-needle times at the metrics of ≤ 30 min, ≤ 45 min, ≤ 60 min improved considerably, and the DNT> 60 min metric exhibited a significant reduction.

CONCLUSIONS

A multidisciplinary collaboration and continuous process optimization can result in overall shortened door-to-needle despite the challenges incurred by the COVID-19 pandemic.

Acute ischemic stroke in childhood: a comprehensive review

This review provides an updated analysis of the main aspects involving the diagnosis and the management of children with acute ischemic stroke. Acute ischemic stroke is an emergency of rare occurrence in children (rate of incidence of 1/3500 live birth in newborns and 1-2/100,000 per year during childhood with peaks of incidence during the perinatal period, under the age of 5 and in adolescence). The management of ischemic stroke in the paediatric age is often challenging because of pleomorphic age-dependent risk factors and aetiologies, high frequency of subtle or atypical clinical presentation, and lacking evidence-based data about acute recanalization therapies. Each pediatric tertiary centre should activate adequate institutional protocols for the optimization of diagnostic work-up and treatments.Conclusion: The implementation of institutional standard operating procedures, summarizing the steps for the selection of candidate for neuroimaging among the ones presenting with acute neurological symptoms, may contribute to shorten the times for thrombolysis and/or endovascular treatments and to improve the long-term outcome. What is Known: •Acute ischemic stroke has a higher incidence in newborns than in older children (1/3500 live birth versus 1-2/100,000 per year). •Randomized clinical trial assessing safety and efficacy of thrombolysis and/or endovascular treatment were never performed in children What is New: •Recent studies evidenced a low risk (2.1% of the cases) of intracranial haemorrhages in children treated with thrombolysis. •A faster access to neuroimaging and hyper-acute therapies was associated with the implementation of institutional protocols for the emergency management of pediatric stroke.

Thrombolysis: Observations and numerical models

This perspective paper considers thrombolysis in the context of ischemic strokes, intending to build eventually a numerical model capable of simulating the thrombolytic treatment and predicting patient outcomes. Numerical modeling is a scientific methodology based on an abstraction of a system but requires understanding their spatio-temporal interactions. However, although important, the current knowledge on thrombolysis is fragmented in contributions from which it is difficult to obtain a complete picture of the process, especially in a clinically relevant setup. This paper discusses, from a general point of view, how to develop a numerical model to describe the evolution of a patient clot under the action of a thrombolytic drug. We will present critical, yet fundamental, open questions that have emerged during this elaboration and discuss original experimental observations that challenge some of our current knowledge of thrombolysis.

Cardiac MRI for Evaluation of Right Heart Function before and after Catheter-directed Therapy in Submassive Pulmonary Embolism: A Prospective Study of Feasibility and Potential Utility

Cardiac MRI is clinically feasible in the setting of submassive pulmonary embolism and is able to demonstrate measurable differences of right heart function before and after catheter-directed therapy.

Up-regulated miR-204-5p promoted the migration, invasion, and angiogenesis of endothelial progenitor cells to enhance the thrombolysis of rats with deep venous thrombosis by targeting SPRED1

Deep venous thrombosis (DVT) endangers human health. Endothelial progenitor cells (EPCs) were proven to promote thrombolysis and miR-204-5p was discovered to be low-expressed in DVT patients. This study concentrated on exploring whether miR-204-5p had a regulatory effect on EPCs and DVT. Concretely, the expression of miR-204-5p in DVT patients' blood was detected by qRT-PCR. The target of miR-204-5p was predicted by bioinformatics and verified by dual-luciferase reporter assay. After rat EPCs were isolated, identified, and transfected with miR-204-5p agomiR, antagomiR, or SPRED1 plasmids, the viability, migration, invasion, and tube formation of EPCs were detected by MTT, wound healing, Transwell, and tube formation assays, respectively. MiR-204-5p, SPRED1, p-PI3K, PI3K, p-AKT, AKT, VEGFA, and Ang1 expressions in EPCs were measured by qRT-PCR or Western blot. EPCs transfected with miR-204-5p overexpression lentivirus plasmid were injected into the DVT rat model. The histopathology of the thrombus and the homing of EPCs to thrombus in the DVT rats were observed by hematoxylin-eosin staining and confocal microscopy, respectively. We found that miR-204-5p was low-expressed in DVT patients and SPRED1 was a target gene of miR-204-5p. MiR-204-5p agomiR promoted the viability, migration, invasion, and tube formation of EPCs, the levels of VEGFA and Ang1 and the activation of PI3K/AKT pathway in EPCs, while miR-204-5p antagomiR and SPRED1 worked oppositely. SPRED1 reversed the effect of miR-204-5p agomiR on EPCs. Up-regulated miR-204-5p inhibited thrombosis and promoted EPCs homing to thrombus in DVT rats. Collectively, up-regulated miR-204-5p enhanced the angiogenesis of EPCs and thrombolysis in DVT rats by targeting SPRED1.

Differences between surviving and non-surviving venous thromboembolism COVID-19 patients: a systematic review

BACKGROUND

To our knowledge, the treatment, outcome, clinical presentation, risk stratification of patients with venous thromboembolism and COVID-19 have not been well characterized.

METHODS

We searched for systematic reviews, cohorts, case series, case reports, editor letters, and venous thromboembolism COVID-19 patients' abstracts following PRISMA and PROSPERO statements. We analyzed therapeutic approaches and clinical outcomes of venous thromboembolism COVID-19 patients. Inclusion: COVID-19 patients with venous thromboembolism confirmed by an imaging method (venous doppler ultrasound, ventilation-perfusion lung scan, computed tomography pulmonary angiogram, pulmonary angiography). We assessed and reported the original Pulmonary Embolism Severity Index for each pulmonary embolism patient. In addition, we defined major bleedings according to the International Society of Thrombosis and Haemostasis criteria.

RESULTS

We performed a systematic review from August 9 to August 30, 2020. We collected 1,535 papers from PubMed, Scopus, Web of Science, Wiley, and Opengrey. We extracted data from 89 studies that describe 143 patients. Unfractionated and low-molecular-weight heparin was used as parenteral anticoagulation in 85/143 (59%) cases. The Food and Drug Administration-approved alteplase regimen guided the advanced treatment in 39/143 (27%) patients. The mortality was high (21.6%, CI 95% 15.2-29.3). The incidence of major bleeding complications was 1 (0.9%) in the survival group and 1 (3.2%) in the death group. Pulmonary Embolism Severity Index was class I in 11.6% and II in 22.3% in survivors compared to 0% and 6.5% in non-survivors, respectively. Patients who experienced venous thromboembolism events at home were more likely to live than in-hospital events.

CONCLUSIONS

We determined a high mortality incidence of pulmonary embolism and a low rate of bleeding. Unfractionated and low-molecular-weight heparin drove parenteral anticoagulation and alteplase the advanced treatment in both groups. The original Pulmonary Embolism Severity Index could be helpful in the risk stratification.

Aspects of ischemic stroke biomechanics derived using ex-vivo and in-vitro methods relating to mechanical thrombectomy

Establishing the underlying biomechanics of acute ischemic stroke (AIS) and its treatment is fundamental to developing more effective clinical treatments for one of society's most impactful diseases. Recent changes in AIS management, driven by clinical evidence of improved treatments, has already led to a rapid rate of innovation, which is likely to be sustained for many years to come. These unprecedented AIS triage and treatment innovations provide a great opportunity to better understand the disease. In this article we provide a perspective on the recreation of AIS in the laboratory to inform contemporary device design and procedural techniques in mechanical thrombectomy. Presentation of these findings, which have been used to solve the applied problem of designing mechanical thrombectomy devices, is intended to help inform the development of basic biomechanics solutions for AIS.

Thrombolysis with Systemic Recombinant Tissue Plasminogen Activator in Children: A Multicenter Retrospective Study

Objective

This study aimed to evaluate systemic thrombolysis experiences with recombinant tissue plasminogen activator (rtPA).

Materials and Methods

Retrospective data were collected from 13 Turkish pediatric hematology centers. The dose and duration of rtPA treatment, concomitant anticoagulant treatment, complete clot resolution (CCR), partial clot resolution (PCR), and bleeding complications were evaluated. Low-dose (LD) rtPA treatment was defined as 0.01-0.06 mg/kg/h and high-dose (HD) rtPA as 0.1-0.5 mg/kg/h.

Results

Between 2005 and 2019, 55 thrombotic episodes of 54 pediatric patients with a median age of 5 years (range: 1 day to 17.75 years) were evaluated. These patients had intracardiac thrombosis (n=16), deep vein thrombosis (DVT) (n=15), non-stroke arterial thrombosis (n=14), pulmonary thromboembolism (PE) (n=6), and stroke (n=4). The duration from thrombus detection to rtPA initiation was a median of 12 h (range: 2-504 h) and it was significantly longer in cases of DVT and PE compared to stroke, non-stroke arterial thrombosis, and intracardiac thrombosis (p=0.024). In 63.6% of the episodes, heparin was initiated before rtPA treatment. LD and HD rtPA were administered in 22 and 33 of the episodes, respectively. Concomitant anticoagulation was used in 90% and 36% of the episodes with LD and HD rtPA, respectively (p=0.0001). Median total duration of LD and HD rtPA infusions was 30 h (range: 2-120 h) and 18 h (2-120 h), respectively (p=0.044). Non-fatal major and minor bleeding rates were 12.5% and 16.7% for LD and 3.2% and 25.8% for HD rtPA, respectively. At the end of the rtPA infusions, CCR and PCR were achieved in 32.7% and 49.0% of the episodes, respectively. The most successful site for thrombolysis was intracardiac thrombosis. HD versus LD rtPA administration was not correlated with CCR/PCR or bleeding (p>0.05).

Conclusion

Systemic thrombolytic therapy may save lives and organs effectively if it is used at the right indications and the right times in children with high-risk thrombosis by experienced hematologists with close monitoring of recanalization and bleeding.

Seizures and epilepsy in patients with ischaemic stroke

BACKGROUND

With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy.

CONCLUSION

PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.

Changing the Landscape of Stroke in Egypt

Egypt, a low-middle-income country, is the most populated nation in the Middle East with a high overall crude prevalence rate of stroke (963/100,000 inhabitants), accounting for 6.4% of all deaths. In this article, we discuss how, through a corrective plan, we could change the landscape of stroke services in Egypt, in a relatively short time, raising thrombolysis rate from <1% to 12.3%, with shortening of door-to-needle time. We could build a database that now exceeds 5,000 patients, our centers received international accreditation and several awards, and we developed tele-stroke service.