A simple, assumption-free, and clinically interpretable approach for analysis of modified Rankin outcomes

BACKGROUND AND PURPOSE

There is debate regarding the approach for analysis of modified Rankin scale scores, the most common functional outcome scale used in acute stroke trials.

METHODS

We propose to use tests to assess treatment differences addressing the metric, "if a patient is chosen at random from each treatment group and if they have different outcomes, what is the chance the patient who received the investigational treatment will have a better outcome than will the patient receiving the standard treatment?" This approach has an associated statement of treatment efficacy easily understood by patients and clinicians, and leads to statistical testing of treatment differences by tests closely related to the Mann-Whitney U test (Wilcoxon Rank-Sum test), which can be tested precisely by permutation tests (randomization tests).

RESULTS

We show that a permutation test is as powerful as are other approaches assessing ordinal outcomes of the modified Rankin scores, and we provide data from several examples contrasting alternative approaches.

DISCUSSION

Whereas many approaches to analysis of modified Rankin scores outcomes have generally similar statistical performance, this proposed approach: captures information from the ordinal scale, provides a powerful clinical interpretation understood by both patients and clinicians, has power at least equivalent to other ordinal approaches, avoids assumptions in the parameterization, and provides an interpretable parameter based on the same foundation as the calculation of the probability value.

Treatment of fever after stroke: conflicting evidence

Approximately 50% of patients hospitalized for stroke develop fever. In fact, experimental evidence suggests that high body temperature is significantly correlated to initial stroke severity, lesion size, mortality, and neurologic outcome. Fever occurring after stroke is associated with poor outcomes. We investigated the etiology of fever after stroke and present evidence evaluating the efficacy and safety of interventions used to treat stroke-associated fever. Oral antipyretics are only marginally effective in lowering elevated body temperature in this population and may have unintended adverse consequences. Nonpharmacologic approaches to cooling have been more effective in achieving normothermia, but whether stroke outcomes can be improved remains unclear. We recommend using body temperature as a biomarker and a catalyst for aggressive investigation for an infectious etiology. Care must be taken not to exceed the new standard of a maximum acetaminophen dose of 3 g/day to avoid patient harm.

Abstract 3744: Brain's High Constitutive Background Autophagy Level Is Disrupted by Stroke Injury and Post-stroke Pharmacological Induction of Autophagy Reduces Lesion Size

Background: Autophagy is a highly regulated and dynamic process that allows cells to recycle aging organelles, bulk proteins and lipids for nutritional reuse. Autophagy occurs in all cell types and body tissues and is induced by oxidative stress or lack of nutrients to promote survival. Excessive autophagy, however, can lead to cell death, including apoptotic (PCD type I) and autophagic cell death (PCD Type II). Recent literature reports that autophagy is disregulated during stroke and other brain injuries. We hypothesized that the normally high innate level of autophagy in the brain undergoes aberrant regulation during stroke injury and this aberrant regulation correlates to changes in stroke lesion size.

Methods: We induced ischemia in C57BL/6J mice using a permanent MCA ligation model, with sacrifice 48 hours after stroke. For time course analysis mice were sacrificed at 3, 6, 12, 24, 48, or 72 hours after stroke. Mice were treated i.p. with chloroquine (30, 60, or 90 mg/K/d for 2 days), an autophagy inhibitor, rapamycin (1.25 or 2.5 mg/K/d for 2 days), an autophagy activator via inhibition of mTOR, or treated with vehicle (saline or 10% DMSO in 100 ul). The autophagy markers LC3, p62 and Beclin-1 were analyzed by Western blot and immunohistochemistry and infarct size was measured by TTC staining.

Results: Brain showed consistently higher baseline levels of LC3II than other tissues. Chloroquine and rapamycin both reduced lesion size, the former between 28 & 34% and the later, in a dose dependent fashion, between 60 and 65%. Beclin-1 is decreased in the infarct side of the brain and treatment with rapamycin enhanced this depletion while treatment with chloroquine increased Beclin-1 levels. LC3II is decreased in the infarct side and does not increase with chloroquine treatment on the infarct side, suggesting that stroke injury may inhibit the high innate baseline level of autophagy in the brain. Rapamycin led to increased LC3II and p62, consistent with increased induction of autophagy. Time course analysis of stroked brains showed that LC3II and Beclin-1 are initially decreased at 3 to 6 hours post injury, then increased above non-injured between 12 and 24 hours before it falls below baseline at 48 to 72 hours.

Conclusions: 1) Stroke appears to inhibit the high innate baseline levels of autophagy in the brain after the injury. 2) Since chloroquine and rapamycin both decreased lesion size, this suggests cross-talk between autophagy and other programmed cell death pathways and/or direct effects of the drugs on these and other pathways. 3) The rapid decrease in autophagy markers post injury indicates that modulation of autophagy may offer a new therapeutic avenue for stroke.

Abstract 3549: Sex-Independent Down-regulation of MMP-9 with Minocycline after Experimental Embolic Stroke

Background and Purpose - Minocycline provides neurovascular protection reducing acute cerebral injury. However, it is unclear whether minocycline is effective in females. We tested minocycline in both sexes and aged animals using an embolic stroke model in mice that closely mimics acute thromboembolic stroke in humans. The aim was to determine if there is a sex-specific change in MMP-9 levels.

Methods - In the context of the revised preclinical STAIR criteria call for testing of neuroprotective agents in female mice and aged mice, minocycline was tested in five groups of mice subjected to thromboembolic stroke: adult males, aged males, adult females, aged females, and adult ovariectomized females (n=9-23 animals/group). Behavioral outcomes, infarct volumes, and cerebral blood flow as well as expression and activity of MMP-9 were assessed. Statistical ANOVA analyses were performed using SAS® 9.2.

Results - The model resulted in reproducible infarct in the experimental groups. As expected, adult females were significantly more resistant to cerebral ischemic injury than males. This advantage was abolished by aging and ovariectomy. Minocycline significantly reduced the infarct volume (P=0.0001) and also improved neurologic score (P<0.0001) in all groups. Moreover, minocycline treatment significantly reduced mortality at 24 hours post stroke (P=0.037) for aged mice (25% versus 54%). Stroke up-regulated MMP-9 level in the brain and acute minocycline treatment reduced its expression in both genders (P<0.0001).

Conclusion - In a thromboembolic stroke model minocycline is neuroprotective inhibiting MMP-9 irrespective of mouse sex and age.

Abstract 2752: Incomplete Reversal of Anticoagulation Following Intracranial Hemorrhage with Three-Factor Prothrombin Complex Concentrate

Introduction: Warfarin-associated intracranial hemorrhage (wICH) is common and associated with worse outcomes than spontaneous intracranial hemorrhages. National guidelines for treatment are vague and consensus-driven. Prothrombin complex concentrates (PCC) have been advocated as a safe and rapid means for reversing anticoagulation but the effectiveness of formulations with low levels of factor VII (three-factor PCC) have not been tested. The purpose of this study was to determine the safety and effectiveness of a three-factor PCC (Profilnine) to reverse anticoagulation in the setting of wICH.

Methods: In November, 2007, a protocol for reversal of anticoagulation in wICH using Profilnine was instituted at our instituion. All patients with wICH received 10 mg IV vitamin K and 50 IU/kg of PCC. If the INR remained >1.4 after 30 minutes, a second dose of PCC of 25 IU/kg was infused. Additional treatment with plasma was at the discretion of the treating physician. Charts of all patients receiving PCC between November 1, 2007 and May 31, 2010 were reviewed. Patient demographics, hemorrhage subtype [intracerebral (ICH), subarachnoid (SAH) or subdural (SDH)], plasma usage, complications, and clinical outcome were determined from the chart review. Adequate correction of the INR was defined as an INR <1.4. Kaplan-Meier survival analysis examined the time to INR correction.

Results: Fifty-one wICH patients were treated with Profilnine including 28 (55%) with ICH, 21 (41%) with SDH and 2 (4%) with SAH. The mean age was 70.3 (SD 12.7), 32 (63%) were male, 37 (74%) patients were white and the remaining African-American. The mean INR was 3.56 (SD 2.71) at baseline [30 (61%) <3.0, 11 (23%) 3.0-4.9, 8 (16%) >4.9]. Seventeen (33%) patients received plasma along with the first dose of PCC. Mean INR was 2.13 post-PCC and only 33 (67.4%; 95% CI, 54.3% - 80.5%) were corrected to an INR <1.4. Eleven (22%) patients received a second dose of PCC and 22 (43%) received subsequent plasma. The likelihood of correction was not increased by concomitant plasma (p=0.77). However, those with INRs <3.0 and those with INRs between 3.0-4.9 were more likely to have an INR that corrected to <1.4 than those with and INR >4.9 before PCC dosing (p=0.02). The median time to INR correction following initial PCC dose was 11.5 hours. If a second dose of PCC was needed, the median time to INR correction was 17.6 hours. No arterial and one (2%) venous thromboembolic adverse events occurred. Twenty-four (47%) patients died or were discharged to hospice.

Conclusions: A three-factor PCC (Profilnine) was incompletely effective in INR correction in wICH presumably due to the relatively low concentration of factor VII. The addition of plasma to PCC did not reduce the time to effective INR correction. Presumed superiority of three-factor PCC to plasma for wICH appears premature.

Sex-independent neuroprotection with minocycline after experimental thromboembolic stroke

Background

Minocycline provides neurovascular protection reducing acute cerebral injury. However, it is unclear whether minocycline is effective in females. We tested minocycline in both sexes and aged animals using a novel embolic stroke model in mice that closely mimics acute thromboembolic stroke in humans.

Methods

Five groups of mice were subjected to thromboembolic stroke: adult males, aged males, adult females, aged females, and adult ovariectomized females. They were treated with phosphate saline (vehicle) or minocycline (6 mg/kg) immediately after stroke onset. Behavioral outcomes, infarct volumes and cerebral blood flow were assessed. The effect of minocycline on expression and activity of MMP-9 was analyzed.

Results

The model resulted in reproducible infarct in the experimental groups. As expected, adult females were significantly more resistant to cerebral ischemic injury than males. This advantage was abolished by aging and ovariectomy. Minocycline significantly reduced the infarct volume (P < 0.0001) and also improved neurologic score (P < 0.0001) in all groups. Moreover, minocycline treatment significantly reduced mortality at 24 hours post stroke (P = 0.037) for aged mice (25% versus 54%). Stroke up-regulated MMP-9 level in the brain, and acute minocycline treatment reduced its expression in both genders (P < 0.0001).

Conclusion

In a thromboembolic stroke model minocycline is neuroprotective irrespective of mouse sex and age.

Recent advances in basic and translational stroke research

Since 1998, the biannual International Symposium on Neuroprotection and Neurorepair, also known as the Magdeburg Meeting series, has provided a platform for the discussion of recent advances in basic and translational stroke research. The 2010 meeting reviewed highly relevant topics, including astrogliosis and microgliosis, neuroimmunological processes, cell-based therapies, novel imaging approaches, mechanisms of poststroke regeneration and metabolic phenomena in neuroprotection. It further focused on common pitfalls and opportunities in the translational process, from preclinical research to clinical application.

Dibucaine mitigates spreading depolarization in human neocortical slices and prevents acute dendritic injury in the ischemic rodent neocortex

Background

Spreading depolarizations that occur in patients with malignant stroke, subarachnoid/intracranial hemorrhage, and traumatic brain injury are known to facilitate neuronal damage in metabolically compromised brain tissue. The dramatic failure of brain ion homeostasis caused by propagating spreading depolarizations results in neuronal and astroglial swelling. In essence, swelling is the initial response and a sign of the acute neuronal injury that follows if energy deprivation is maintained. Choosing spreading depolarizations as a target for therapeutic intervention, we have used human brain slices and in vivo real-time two-photon laser scanning microscopy in the mouse neocortex to study potentially useful therapeutics against spreading depolarization-induced injury.

Methodology/Principal Findings

We have shown that anoxic or terminal depolarization, a spreading depolarization wave ignited in the ischemic core where neurons cannot repolarize, can be evoked in human slices from pediatric brains during simulated ischemia induced by oxygen/glucose deprivation or by exposure to ouabain. Changes in light transmittance (LT) tracked terminal depolarization in time and space. Though spreading depolarizations are notoriously difficult to block, terminal depolarization onset was delayed by dibucaine, a local amide anesthetic and sodium channel blocker. Remarkably, the occurrence of ouabain-induced terminal depolarization was delayed at a concentration of 1 µM that preserves synaptic function. Moreover, in vivo two-photon imaging in the penumbra revealed that, though spreading depolarizations did still occur, spreading depolarization-induced dendritic injury was inhibited by dibucaine administered intravenously at 2.5 mg/kg in a mouse stroke model.

Conclusions/Significance

Dibucaine mitigated the effects of spreading depolarization at a concentration that could be well-tolerated therapeutically. Hence, dibucaine is a promising candidate to protect the brain from ischemic injury with an approach that does not rely on the complete abolishment of spreading depolarizations.

Use of telemedicine and helicopter transport to improve stroke care in remote locations

OPINION STATEMENT

Intravenous recombinant tissue plasminogen activator is the only medication approved by the US Food and Drug Administration for treatment of acute stoke. Despite established efficacy, less than 3% of stroke patients receive treatment, and that number is even smaller for patients living in remote locations. This is in part due to a lack of neurologists and stroke specialists in these rural communities. The traditional model of "ship and drip" wastes crucial time, resulting in delays or loss of treatment. In this review, we discuss strategies to overcome geographic disparities in stroke care and improve acute treatment in remote locations. Helicopter transport from field to stroke center is one option to rapidly deliver patients to stroke centers. However, geography, weather, and unnecessary transport are potential drawbacks. Alternatively, "telestroke" facilitates remote evaluation of acute stroke patients via an audiovisual link and transmission of computerized tomography images. Despite the physical separation, stroke specialists are able to examine patients, review brain imaging and make correct treatment decisions; transfer to a stroke center can then be performed as appropriate. A cost-benefit analysis of telestroke is needed, although the recent proliferation of telestroke networks suggests an economic asset to some hospital systems.

Carotid stenosis: endarterectomy or angioplasty and stenting?

Atherosclerotic narrowing of the proximal internal carotid artery is an important mechanism in ischemic stroke. Optimal medical management of internal carotid stenosis includes antiplatelet agent and statin administration, blood pressure reduction, weight control, and smoking cessation. Decisions regarding the use of invasive procedures to treat carotid disease--specifically carotid endarterectomy and carotid angioplasty and stenting--must weigh the long-term risk reduction in ipsilateral ischemic stroke against the immediate intervention risks. Clinical trials evaluating the benefits of carotid endarterectomy were conducted before widespread use of statins and newer blood pressure-lowering agents such as angiotensin-receptor blockers; it is unclear what impact this may have had on trial results. Regardless, carotid endarterectomy is clearly superior to medical therapy for patients with symptomatic severe stenosis. Conversely, the benefit from endarterectomy is muted in individuals with symptomatic moderate stenosis or asymptomatic stenosis, and decisions regarding surgical intervention must incorporate surgeon proficiency and patient comorbidity. Currently, there is a lack of evidence to support the use of carotid artery angioplasty and stenting in the routine management of carotid disease. Selected patients with severe symptomatic stenosis for whom endarterectomy cannot be safely performed may still benefit from endovascular management. However, it is unlikely that asymptomatic patients or symptomatic patients with moderate stenosis considered at high risk for endarterectomy would benefit from any intervention.

Matrix metalloproteinase-9 in an exploratory trial of intravenous minocycline for acute ischemic stroke

BACKGROUND AND PURPOSE

Plasma matrix metalloproteinase-9 levels predict posttissue plasminogen activator (tPA) hemorrhage.

METHODS

The authors investigated the effect of minocycline on plasma matrix metalloproteinase-9 in acute ischemic stroke in the Minocycline to Improve Neurological Outcome in Stroke (MINOS) trial and a comparison group.

RESULTS

Matrix metalloproteinase-9 level decreased at 72 hours compared with baseline in MINOS (tPA, P=0.0022; non-tPA, P=0.0066) and was lower than in the non-MINOS comparison group at 24 hours (tPA, P<0.0001; non-tPA, P=0.0019).

CONCLUSIONS

Lower plasma matrix metalloproteinase-9 was seen among tPA-treated subjects in the MINOS trial. Combining minocycline with tPA may prevent the adverse consequences of thrombolytic therapy through suppression of matrix metalloproteinase-9 activity.

Simplified modified rankin scale questionnaire: reproducibility over the telephone and validation with quality of life

BACKGROUND AND PURPOSE

The simplified modified Rankin Scale questionnaire (smRSq) enables a reliable and rapid determination of the modified Rankin Scale score after stroke. We test the reliability and validity of a slightly revised smRSq.

METHODS

Fifty consecutive outpatients 4.83 ± 3.00 months after stroke were scored with a slightly revised smRSq by 3 raters selected consecutively from a list of 10: 4 stroke faculty, 3 neurology residents, 2 medial students, and 1 stroke research coordinator. Two ratings were in person within 20 minutes of each other and 1 was by telephone 1 to 3 days later. The telephone rating also included a quality of life scale, the Short-Form-12v2. Each rater was blinded to the other raters' scores.

RESULTS

The average estimated time to administer the smRSq was 1.29 minutes (range, 0.50 to 2.25 minutes). The in-person raters agreed 78% (κ=0.71; CI, 0.57 to 0.86 and weighted κ [κ(w)]=0.86; CI, 0.79 to 0.94). The first in-person and telephone raters agreed 82% (κ=0.76; CI, 0.63 to 0.90 and κ(w)=0.87; CI, 0.79 to 0.95). The second in-person and telephone rates agreed 82% (κ=0.77; CI, 0.63 to 0.90 and κ(w)=0.89; CI, 0.82 to 0.96). The smRSq correlated with the physical (r=-0.50, P=0.005) than the mental (r=-0.36, P=0.048) components of the Short-Form-12v2.

CONCLUSIONS

The slightly revised smRSq appears to be useful in clinical stroke; it has excellent reliability in person and by telephone, can usually be administered in <1.5 minutes by a wide variety of raters, and correlates with quality of life.

Cell therapy for ischaemic stroke

While acute neuroprotection in acute stroke has proven difficult and ended in many failures, there is increasing interest in restorative therapies that target brain remodelling. Cell therapy (transplantation of cells) shows promise, with a growing body of pre-clinical evidence demonstrating improved functional outcomes in animal models; however, questions still remain concerning mechanisms of action. Clinical trials are already underway and will increase in the next few years; their appropriate design and execution along with continued pre-clinical work are necessary for the field to advance and satisfy a large unmet clinical need.

Impact of systems of care and blood pressure management on stroke outcomes

Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.

Minocycline to improve neurologic outcome in stroke (MINOS): a dose-finding study

BACKGROUND AND PURPOSE

Minocycline is a promising anti-inflammatory and protease inhibitor that is effective in multiple preclinical stroke models. We conducted an early phase trial of intravenous minocycline in acute ischemic stroke.

METHODS

Following an open-label, dose-escalation design, minocycline was administered intravenously within 6 hours of stroke symptom onset in preset dose tiers of 3, 4.5, 6, or 10 mg/kg daily over 72 hours. Minocycline concentrations for pharmacokinetic analysis were measured in a subset of patients. Subjects were followed for 90 days.

RESULTS

Sixty patients were enrolled, 41 at the highest dose tier of 10 mg/kg. Overall age (65±13.7 years), race (83% white), and sex (47% female) were consistent across the doses. The mean baseline National Institutes of Health Stroke Scale score was 8.5±5.8 and 60% received tissue plasminogen activator. Minocycline infusion was well tolerated with only 1 dose limiting toxicity at the 10-mg/kg dose. No severe hemorrhages occurred in tissue plasminogen activator-treated patients. Pharmacokinetic analysis (n=22) revealed a half-life of approximately 24 hours and linearity of parameters over doses.

CONCLUSIONS

Minocycline is safe and well tolerated up to doses of 10 mg/kg intravenously alone and in combination with tissue plasminogen activator. The half-life of minocycline is approximately 24 hours, allowing every 24-hour dosing. Minocycline may be an ideal agent to use with tissue plasminogen activator.

Toward cell therapy using placenta-derived cells: disease mechanisms, cell biology, preclinical studies, and regulatory aspects at the round table

Among the many cell types that may prove useful to regenerative medicine, mounting evidence suggests that human term placenta-derived cells will join the list of significant contributors. In making new cell therapy-based strategies a clinical reality, it is fundamental that no a priori claims are made regarding which cell source is preferable for a particular therapeutic application. Rather, ongoing comparisons of the potentiality and characteristics of cells from different sources should be made to promote constant improvement in cell therapies, and such comparisons will likely show that individually tailored cells can address disease-specific clinical needs. The principle underlying such an approach is resistance to the notion that comprehensive characterization of any cell type has been achieved, neither in terms of phenotype nor risks-to-benefits ratio. Tailoring cell therapy approaches to specific conditions also requires an understanding of basic disease mechanisms and close collaboration between translational researchers and clinicians, to identify current needs and shortcomings in existing treatments. To this end, the international workshop entitled "Placenta-derived stem cells for treatment of inflammatory diseases: moving toward clinical application" was held in Brescia, Italy, in March 2009, and aimed to harness an understanding of basic inflammatory mechanisms inherent in human diseases with updated findings regarding biological and therapeutic properties of human placenta-derived cells, with particular emphasis on their potential for treating inflammatory diseases. Finally, steps required to allow their future clinical application according to regulatory aspects including good manufacturing practice (GMP) were also considered. In September 2009, the International Placenta Stem Cell Society (IPLASS) was founded to help strengthen the research network in this field.

Improving modified Rankin Scale assessment with a simplified questionnaire

BACKGROUND AND PURPOSE

The modified Rankin Scale (mRS) is a popular primary stroke outcome measure, but its usefulness is limited by suboptimal reliability (inter-rater agreement).

METHODS

We developed and tested the reliability of a simplified mRS questionnaire (smRSq) in 50 patients after stroke seen in outpatient clinics. Randomly chosen paired raters administered the smRSq within 20 minutes of each other and the ratings were blinded until the end of this study.

RESULTS

Agreement among the raters was 78%, the kappa statistic was 0.72 (95% CI, 0.58-0.86), and the weighted kappa(w) statistic taking into account the extent of disagreement was 0.82 (95% CI, 0.72-0.92). The average time to administer the smRSq was 1.67 minutes.

CONCLUSIONS

The smRSq appears to have very good reliability that is similar to that of a structured interview mRS and is considerably less time-consuming.

A telestroke network enhances recruitment into acute stroke clinical trials

BACKGROUND AND PURPOSE

Acute stroke clinical trials are conducted primarily at academic medical centers. As a result, patients living in rural areas are excluded from participation, results may not be generalizable to nonacademic settings, and studies may be slow to recruit subjects. Telemedicine can provide rural patients with emergency neurovascular consultation. We sought to determine whether telemedicine facilitates enrollment into acute stroke trials.

METHODS

We have an established rural "hub and spoke" telestroke network. From 2005 to 2009, we participated in 2 time-sensitive acute stroke trials: Factor Seven for Acute Hemorrhagic Stroke and Minocycline to Improve Neurological Outcome. Candidates for the 2 trials could be identified at either the hub or at the spokes, with patients presenting to the latter transferred to the hub for enrollment. We analyzed the times from symptom onset to consultation via telemedicine, arrival at the hub, and to initiation of a study drug to determine the impact of telemedicine on study enrollment.

RESULTS

Nineteen of 28 subjects enrolled in the 2 trials were identified initially at an outside facility via a telemedicine link. An additional 9 candidates identified by telemedicine could not be enrolled because of transportation time. Arrival at the hub was 127 minutes later (median, 207 [95% CI, 145 to 255] versus 80 [95% CI, 55 to 142]; P=0.0002), and study drug was started 74 minutes later (median, 298 [95% CI, 218 to 352] versus 225 [95% CI, 147 to 330]; P=0.05) for subjects who were identified via telemedicine and required transport to the hub compared with local subjects who presented directly to the hub.

CONCLUSIONS

Telemedicine can enhance enrollment into time-sensitive acute stroke trials. However, transfer of subjects to the hub results in delays in study initiation for some and precludes enrollment for others similar to the weaknesses of "ship and drip" thrombolytic strategies. To save time, efforts are needed to enroll clinical trial subjects and begin the research drug at the remote site under telemedicine guidance.

Repurposing an old drug to improve the use and safety of tissue plasminogen activator for acute ischemic stroke: minocycline

There is only 1 US Food and Drug Administration-approved drug for acute ischemic stroke: tissue plasminogen activator (tPA). Due to a short time window and fear of intracerebral hemorrhage (ICH), tPA remains underutilized. There is great interest in developing combination drugs to use with tPA to improve the odds of a favorable recovery and to reduce the risk of ICH. Minocycline is a broad-spectrum antibiotic that has been found to be a neuroprotective agent in preclinical ischemic stroke models. Minocycline inhibits matrix metalloproteinase-9, a biomarker for ICH associated with tPA use. Minocycline is also an anti-inflammatory agent and inhibits poly (ADP-ribose) polymerase-1. Minocycline has been safe and well tolerated in the clinical trials conducted to date.