Alteplase at 0.6 mg/kg for Acute Ischemic Stroke Within 3 Hours of Onset

Intravenous thrombolysis for acute stroke: current standards and future directions

OPINION STATEMENT

Intravenous thrombolysis with the recombinant tissue plasminogen activator alteplase is the standard of care for patients with acute ischaemic stroke presenting within 4.5 h of symptom onset. The odds of independent survival decline steeply with longer time to treatment delivery, reflecting progressive ischaemic damage to the brain. Standards accordingly emphasise optimisation of patient pathways to minimise treatment delays. Observational data and international clinical guidelines support the safety and efficacy of alteplase in many patient groups currently excluded from treatment (e.g. seizure at onset, concomitant diabetes and previous stroke) on the basis of historical clinical trial criteria. Future evolution of thrombolysis will optimise dosing, apply advanced imaging to extend treatment to groups currently excluded and investigate novel drugs, and adjunctive drug and device therapies. To date, trials of novel therapeutic approaches that have been applied at later time points have failed to demonstrate benefit, suggesting that the future gains are likely to arise from applications within current time windows.

Impact of time-to-reperfusion on outcome in patients with poor collaterals

BACKGROUND AND PURPOSE

The relationship between reperfusion and clinical outcome is time-dependent, and the effect of reperfusion on outcome can vary on the basis of the extent of collateral flow. We aimed to identify the impact of time-to-reperfusion on outcome relative to baseline angiographic collateral grade in patients successfully treated with endovascular revascularization for acute large-vessel anterior circulation stroke.

MATERIALS AND METHODS

Two hundred seven patients were selected for analysis from our prospectively maintained registry. Inclusion criteria were M1 MCA ± ICA occlusions, onset-to-puncture time within 8 hours, and successful endovascular reperfusion. Baseline angiographic collateral grades were independently evaluated and dichotomized into poor (0-1) versus good (2-4). Multivariable analyses were performed to identify the effect of collateral-flow adequacy on favorable outcome on the basis of onset-to-reperfusion time and puncture-to-reperfusion time.

RESULTS

In the poor collateral group, the odds of favorable outcome significantly dropped for patients with onset-to-reperfusion time of >300 minutes or puncture-to-reperfusion time of >60 minutes (onset-to-puncture time: ≤300, 59% versus >300, 32%; OR, 0.24; P = .011; puncture-to-reperfusion time: ≤60, 73% versus >60, 32%; OR, 0.21, P = .011), whereas the probability of favorable outcome in the good collateral group was not significantly influenced by onset-to-reperfusion time or puncture-to-reperfusion time. In the subgroup lesion-volume growth analysis by using DWI, the effect of puncture-to-reperfusion time of >60 minutes was significantly greater compared with the effect of puncture-to-reperfusion time of <60 minutes in the poor collateral group (β = 41.6 cm(3), P = .001).

CONCLUSIONS

Time-to-reperfusion including onset-to-reperfusion time and puncture-to-reperfusion time in patients with poor collaterals is an important limiting factor for favorable outcome in a time-dependent fashion. Future trials may benefit from a noninvasive imaging technique to detect poor collaterals along with a strategy for rapid reperfusion.

Comparative effectiveness of standard care with IV thrombolysis versus without IV thrombolysis for mild ischemic stroke

Background

One third of patients presenting with initially mild strokes have unfavorable outcomes, and the efficacy of intravenous thrombolysis (IVT) in this population has not been proven. This study aimed to evaluate the comparative effectiveness of standard care with IVT versus without IVT in mild stroke patients.

Methods and Results

Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial National Institutes of Health Stroke Scale scores ≤5. Multivariable logistic analysis and propensity score matching were used to adjust for baseline imbalances between the patients who did and did not receive IVT. Adjusted odds ratios and 95% CIs of IVT were estimated for 3‐month modified Rankin Scale scores of 0 to 1 and symptomatic. Of 13 117 patients with stroke who were hospitalized between April 2008 and May 2012, 1386 met the eligibility criteria, and 194 (14.0%) were treated with IVT. For a modified Rankin Scale of 0 to 1 at 3 months, the adjusted odds ratios were 1.96 (95% CI, 1.28 to 3.00; P=0.002) by multivariable logistic analysis and 1.68 (1.10 to 2.56; P=0.02) by propensity score matching analysis, respectively. There was a statistically nonsignificant excess of symptomatic hemorrhagic transformation (odds ratios=3.76 [0.95 to 16.42; P=0.06] and 4.81 [0.84 to 49.34; P=0.09]), respectively.

Conclusions

In this observational registry‐based study, standard care with IVT is more effective than not receiving IVT in mild ischemic stroke patients, and there is a statistically nonsignificant risk of symptomatic hemorrhagic transformation.

Correlation between the Occlusion Site and Clinical Outcome after Acute Ischemic Stroke

OBJECTIVE

The significance of early mild clinical improvement after intravenous tissue plasminogen activator (IVtPA) treatment is unclear. Therefore, we examined whether the timing of clinical improvement after IVtPA predicted the clinical outcome at 3 months.

METHODS

Consecutive patients with acute cerebral infarction in the anterior circulation who received IVtPA treatment within 3 hours of the onset of symptoms were enrolled in the study. Patients were classified according to the timing of clinical improvement [early responder (ER), National Institutes of Health Stroke Scale (NIHSS) score improved ≥4 points or who had a score of 0 within 2 hours after IVtPA; late responder (LR), a similar improvement between 2 and 24 hours; and non-responder (NR)] and according to the arterial occlusion site (P group, internal carotid artery and proximal middle cerebral artery M1 region; and D group, distal M1 and M2).

RESULTS

Ninety-three patients [median age, 74 (67-79) years; 54 men (58%); median NIHSS score, 11 (7-16)] were enrolled in the study. The P group consisted of 48 (52%) patients and the D group consisted of 45 (48%) patients. Thirty-eight patients (41%) were classified as ERs, 20 (22%) as LRs, and 35 (38%) as NRs. On a multivariate regression analysis, the P group [odds ratio (OR), 3.24; 95% confidence interval (CI), 1.08-10.45; p=0.036] and NR (OR, 4.04; 95% CI, 1.29-14.27; p=0.016) were independent predictors of a poor outcome. ER (47%, p=0.01) and LR (45%, p=0.01) patients showed fewer poor outcomes than NR (77%) patients, but the rate did not differ significantly between the ER and LR patients.

CONCLUSION

Early mild clinical recovery did not predict a good outcome. The occlusion site was a stronger predictor of clinical improvement after IVtPA administration.

Intravenous tissue plasminogen activator for an ischemic stroke with occult double primary cancer

Background

In patients with advanced-stage cancer, systemic thrombolysis with tissue plasminogen activator (tPA) for hyperacute ischemic stroke is not strictly off-label, but it is at higher risk of complications (including bleeding).

Case Report

A 71-year-old male with unrecognizable malignancy developed a hemispheric ischemic stroke and received intra-venous tPA within 4.5 h of onset, followed by anticoagulation treatment after 24 h of throm-bolysis. Two days later, the patient had tarry stool and progressive anemia, receiving a blood transfusion. The systemic workup documented the presence of double primary cancers with advanced stage gastric and rectal cancers, and the patient subsequently received palliative care. The outcome at 3 months was a modified Rankin Scale of 5, and the patient died 6 months after the stroke.

Discussion

Although systemic thrombolysis with tPA for ischemic stroke in patients with advanced-stage cancer may be performed relatively safely, optimal post-thrombolysis management is important to prevent the complications.

Intravenous thrombolysis with recombinant tissue plasminogen activator for ischemic stroke patients over 80 years old: the Fukuoka Stroke Registry

Objectives

The benefit of intravenous recombinant tissue plasminogen activator (rt-PA) therapy for very old patients with acute ischemic stroke remains unclear. The aim of this study was to elucidate the efficacy and safety of intravenous rt-PA therapy for patients over 80 years old.

Methods

Of 13,521 stroke patients registered in the Fukuoka Stroke Registry in Japan from June 1999 to February 2013, 953 ischemic stroke patients who were over 80 years old, hospitalized within 3 h of onset, and not treated with endovascular therapy were included in this study. Among them, 153 patients were treated with intravenous rt-PA (0.6 mg/kg). For propensity score (PS)-matched case-control analysis, 148 patients treated with rt-PA and 148 PS-matched patients without rt-PA therapy were selected by 1∶1 matching with propensity for using rt-PA. Clinical outcomes were neurological improvement, good functional outcome at discharge, in-hospital mortality, and hemorrhagic complications (any intracranial hemorrhage [ICH], symptomatic ICH, and gastrointestinal bleeding).

Results

In the full cohort of 953 patients, rt-PA use was associated positively with neurological improvement and good functional outcome, and negatively with in-hospital mortality after adjustment for multiple confounding factors. In PS-matched case-control analysis, patients treated with rt-PA were still at lower risk for unfavorable clinical outcomes than non-treated patients (neurological improvement, odds ratio 2.67, 95% confidence interval 1.61–4.40; good functional outcome, odds ratio 2.23, 95% confidence interval 1.16–4.29; in-hospital mortality, odds ratio 0.30, 95% confidence interval 0.13–0.65). There was no significant association between rt-PA use and risk of hemorrhagic complications in the full and PS-matched cohorts.

Conclusions

Intravenous rt-PA therapy was associated with improved clinical outcomes without significant increase in risk of hemorrhagic complications in very old patients (aged>80 years) with acute ischemic stroke.

Simultaneous administration of recombinant tissue plasminogen activator and edaravone in acute cerebral ischemic stroke patients

Among the 1052 patients admitted to our hospital because of cerebral infarction between January 1, 2007, and December 31, 2010, we report the treatment outcomes of 48 patients (4.6% of all patients) who received recombinant tissue plasminogen activator (rt-PA) therapy (simultaneously combined with edaravone) within 3 hours after the onset of infarction. Twenty (41.7%) patients started receiving edaravone before rt-PA administration, and 28 patients (58.3%) started receiving rt-PA and edaravone simultaneously. The patients had an average age of 73.5 years (range, 55-93 years; male:female, 32:16). Medical histories included hypertension, diabetes mellitus, dyslipidemia, arterial fibrillation, and a smoking history in 23 (47.8%), 7 (14.6%), 8 (16.7%), 29 (60.4%), and 8 (16.7%) of patients, respectively. Regarding the treatment outcome of the therapy, the National Institutes of Health Stroke Scale score, which was 15 points before rt-PA administration, showed a statistically significant improvement to 8 points after rt-PA administration (P < .001). The modified Rankin Scale scores at 90 days after treatment were as follows: 0 in 12 patients (25.0%), 1 in 11 patients (22.9%), 2 in 7 patients (14.6%), 3 in 5 patients (10.4%), 4 in 6 patients (12.5%), 5 in 5 patients (10.4%), and 6 in 2 patients (4.2%). The occluded blood vessel reopened completely in 30 patients (62.5%) and partially in 5 patients (10.4%). Asymptomatic hemorrhage over the entire brain developed in 2 patients (4.2%). Thus, rt-PA therapy in combination with edaravone improved the recanalization rate, reduced the incidence of intracranial hemorrhage, and improved functional prognosis.

Thrombolysis for Acute Ischaemic Stroke with Alteplase in an Asian Population: Results of the Multicenter, Multinational Safe Implementation of Thrombolysis in Stroke-Non-European Union World (SITS-NEW)

Background

Safe Implementation of Thrombolysis in Stroke-Non-European Union World was a multinational, prospective, open, monitored, observational study of intravenous alteplase as thrombolytic therapy in clinical practice. Safe Implementation of Thrombolysis in Stroke-Non-European Union World was required to assess the safety of alteplase in an Asian population by comparison with results from the European Safe Implementation of Thrombolysis in Stroke-Monitoring Study and pooled results from randomized controlled trials.

Aims and/or hypothesis

To evaluate the efficacy and safety of intravenous alteplase (0·9 mg/kg) as thrombolytic therapy within three-hours of onset of acute ischaemic stroke in an Asian population.

Methods

The 591 patients included were treated at 48 centers in four countries (South Korea, China, India, and Singapore) between 2006 and 2008. Primary outcomes were symptomatic (deterioration in National Institutes of Health Stroke Scale score ≥4 or death within the first 24 h) intracerebral haemorrhage type 2 22–36 h after the thrombolysis and mortality at three-month follow-up. The secondary outcome was functional independence (modified Rankin Scale score 0–2) at three-months. Results were compared with those from Safe Implementation of Thrombolysis in Stroke-Monitoring Study ( n = 6483) and pooled results of patients ( n = 415) who received intravenous alteplase (0·9 mg/kg) zero- to three-hours from onset of stroke symptoms in four randomized controlled trials (National Institute of Neurological Disorders and Stroke A and B, Altephase Thrombolysis for Acute Noninterventional Therapy in Ischaemic Stroke, and European Cooperative Acute Stroke Study II).

Results

Results are presented as Safe Implementation of Thrombolysis in Stroke-Non-European Union World vs. Safe Implementation of Thrombolysis in Stroke-Monitoring Study vs. pooled randomized controlled trials. Median age was 64 vs. 68 vs. 70 years, National Institutes of Health Stroke Scale score at baseline was 12 vs. 12 vs. 13, time from stroke onset to treatment was 130 vs. 140 vs. 135 mins, and females were 36·4% vs. 39·8% vs. 41·2%. Main outcomes (proportion of patients and 95% confidence intervals) were symptomatic intracerebral haemorrhage: 1·9% (1·1–3·3) vs. 1·7% (1·4–2·0) vs. 3·1% (1·8–5·3); mortality: 10·2% (8·0–12·9) vs. 11·3% (10·5–12·1) vs. 16·4% (13·1–20·3); and functional independence: 62·5% (58·5–66·4) vs. 54·8% (53·5–56·0) vs. 50·1% (45·3–54·9) at three-months. Adjusted odds ratio (95% confidence intervals) between Safe Implementation of Thrombolysis in Stroke-Non-European Union World and Safe Implementation of Thrombolysis in Stroke-Monitoring Study, and between Safe Implementation of Thrombolysis in Stroke-Non-European Union World and the pooled trials were 1·83 (0·89–3·77; P = 0·1156) and 0·63 (0·19–2·07; P = 0·4470) for symptomatic intracerebral haemorrhage, 0·90 (0·64–1·25; P = 0·5092) and 0·93 (0·52–1·64; P = 0·7915) for mortality at three-months, and 1·57 (1·25–1·96; P < 0·0001) and 1·35 (0·91–2·00; P = 0·1325) for functional independence.

Conclusions

These data demonstrate the safety and efficacy of the standard dose of intravenous alteplase (0·9 mg/kg) in an Asian population, as previously observed in the European population studied in Safe Implementation of Thrombolysis in Stroke-Monitoring Study and the populations in pooled randomized controlled trials, when used in routine clinical practice within three-hours of stroke onset. The findings should encourage wider use of thrombolytic therapy in Asian countries for suitable patients treated in stroke centers.

[Contribution of neurologists to emergent stroke medicine in Japan]

Although the demand for emergent stroke management has been increasing, stroke specialists are undersupplied in Japan. Neurosurgeons, not neurologists, often perform acute stroke care. Since medical management is the mainstream of stroke care, neurologists should be fully aware of their role as a commander of the stroke care unit. Neurologists have to confront wide-ranging areas of neurological diseases including neurological emergency and intractable chronic diseases, and such diversity should be respected. Nevertheless, neurological departments in the medical schools and hospitals over Japan should constantly train a certain number of stroke specialists to meet the demands of patients, since stroke is the largest neurological disease in Japan.

Hemothorax after the intravenous administration of tissue plasminogen activator in a patient with acute ischemic stroke and rib fractures

A 79-year-old man experienced sudden-onset left hemiparesis and disturbance of consciousness. Diffusion-weighted magnetic resonance imaging showed an acute ischemic stroke in the territory of the right middle cerebral artery. He underwent systemic thrombolysis via the intravenous administration of tissue plasminogen activator (t-PA). Chest radiography and computed tomography performed the following day showed severe hemothorax with atelectasis of the left lung and multiple rib fractures; the initial chest radiogram had revealed rib fractures but we did not recognize them at the time. Conservative treatment with the placement of chest tubes was successful, and the patient recovered without further deterioration. Although systemic thrombolysis with t-PA is an accepted treatment for acute cerebral ischemic stroke, posttreatment intracranial hemorrhage has a negative effect on prognosis. Extracranial bleeding is a rare complication, and our search of the literature found no reports of hemothorax after treatment with t-PA in patients with cerebral ischemic stroke. We have reported a rare case of severe hemothorax after systemic thrombolysis with t-PA. This important complication indicates the need to rule out thoracic trauma with radiography and computed tomography of the chest.

THrombolysis for Acute Wake-up and unclear-onset Strokes with alteplase at 0·6 mg/kg (THAWS) Trial

Rationale

Because of lack of information regarding timing of stroke, patients who suffer stroke during sleep are generally ineligible for intravenous thrombolysis, although many of these patients could potentially recover with this treatment. Magnetic resonance image findings with positive diffusion-weighted imaging and no marked parenchymal hyperintensity on fluid-attenuated inversion recovery (negative pattern) can identify acute ischemic stroke patients within 4·5 h from symptom onset.

Aims

The THrombolysis for Acute Wake-up and unclear-onset Strokes with alteplase at 0·6 mg/kg trial aims to determine the efficacy and safety of intravenous thrombolysis with alteplase at 0·6 mg/kg body weight, the approved dose for Japanese stroke patients, using magnetic resonance image-based selection in ischemic stroke patients with unclear time of symptom onset, and compare findings with standard treatment.

Design

This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-end-point clinical trial. The design is similar to the Efficacy and Safety of MRI-based Thrombolysis in Wake-up Stroke trial. Patients with unclear-onset time of stroke symptoms beyond 4·5 h and within 12 h after the time of the last-known-well period and within 4·5 h after symptom recognition, who showed a negative fluid-attenuated inversion recovery pattern, are randomized to either intravenous thrombolysis or standard treatment.

Study outcomes

The primary efficacy end-point is modified Rankin Scale 0–1 at 90 days. The safety outcome measures are symptomatic intracranial hemorrhage at 22–36 h, and major bleeding and mortality at 90 days.

Discussion

This trial may help determine if low-dose alteplase at 0·6 mg/kg should be recommended as a routine clinical strategy for ischemic stroke patients with unclear-onset time.

Thrombolysis for acute ischaemic stroke

BACKGROUND

Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009.

OBJECTIVES

To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists.

SELECTION CRITERIA

Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available.

MAIN RESULTS

We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke.

AUTHORS' CONCLUSIONS

Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.

Relationship between hospital volume and early outcomes in acute ischemic stroke patients treated with recombinant tissue plasminogen activator

BACKGROUND

There is controversy whether the annual number of acute ischemic stroke patients receiving stroke thrombolysis per hospital (hospital volume) is associated with outcomes in these patients.

AIMS

The study aims to assess the relationship between hospital volume and early outcomes in acute ischemic stroke patients treated with recombinant tissue plasminogen activator.

METHODS

Patients with acute ischemic stroke treated with recombinant tissue plasminogen activator from July 1, 2010 to March 31, 2012 were identified in the Japanese Diagnosis Procedure Combination database. Hospital volume was categorized into three levels (low, medium, and high volume) to obtain approximately equal numbers of patients in each group. Primary outcomes were seven-day mortality and functional independence (modified Rankin Scale score of 0 to 2) at discharge. Univariate analyses and multivariate logistic regression analyses fitted with generalized estimating equations were performed.

RESULTS

We identified 7476 eligible patients, including 2339 (31·3%) treated in low-volume hospitals (1-7 patients annually), 2670 (35·7%) in medium-volume hospitals (8-16 patients annually), and 2467 (33·0%) in high-volume hospitals (17-48 patients annually). Seven-day mortality and functional independence at discharge were comparable among the three hospital volume groups (P = 0·17 for seven-day mortality; P = 0·22 for functional independence at discharge). The comparability between groups persisted after multivariate adjustment.

CONCLUSION

Hospital volume was not significantly associated with seven-day mortality or functional independence at discharge in acute ischemic stroke patients treated with recombinant tissue plasminogen activator in Japan.

Effects of edaravone on early outcomes in acute ischemic stroke patients treated with recombinant tissue plasminogen activator

BACKGROUND

We investigated whether edaravone could improve early outcomes in acute ischemic stroke patients treated with recombinant tissue plasminogen activator (rtPA).

METHODS

We conducted a retrospective cohort study using the Japanese Diagnosis Procedure Combination database. We identified patients admitted with a primary diagnosis of ischemic stroke from 1 July 2010 to 31 March 2012 and treated with rtPA on the same day of stroke onset or the following day. Thereafter, we selected those who received edaravone on the same day of rtPA administration (edaravone group), and those who received rtPA without edaravone (control group). The primary outcomes were modified Rankin Scale (mRS) scores at discharge. One-to-one propensity-score matching was performed between the edaravone and control groups. An ordinal logistic regression analysis for mRS scores at discharge was performed with adjustment for possible variables as well as clustering of patients within hospitals using a generalized estimating equation.

RESULTS

We identified 6336 eligible patients for inclusion in the edaravone group (n=5979; 94%) and the control group (n=357; 6%) as the total population. In 356 pairs of the propensity-matched population, the ordinal logistic regression analysis showed that edaravone was significantly associated with lower mRS scores of patients at discharge (adjusted odds ratio: 0.74; 95% confidence interval: 0.57-0.96).

CONCLUSIONS

Edaravone may improve early outcomes in acute ischemic stroke patients treated with rtPA.

Recanalization therapy for internal carotid artery occlusion presenting as acute ischemic stroke

BACKGROUND

We aimed to describe the current status and clinical outcomes of recanalization therapy for internal carotid artery occlusion (ICAO) presenting as acute ischemic stroke.

METHODS

Using a nationwide stroke registry database in Korea, we identified consecutive ischemic stroke patients with ICAO hospitalized within 12 hours of onset between March 2010 and November 2011.

RESULTS

ICAO accounted for 10.6% (322 of 3028) of acute ischemic strokes within 12 hours of onset. Among the 322 ICAO patients, 53% underwent recanalization therapy, 41% intravenous thrombolysis (IVT) alone, and 59% endovascular treatment (EVT). Twenty-two percent of those with mild deficits (National Institutes of Health Stroke Scale <4) and 50% of those 80 years of age or more received recanalization therapy. Compared with no treatment, recanalization therapy was not significantly associated with a favorable outcome (3-month modified Rankin scale, 0-2) (adjusted odds ratio [OR], 1.77; 95% confidence interval [CI], .80-3.91; P = .16). However, compared with IVT, EVT significantly improved the odds of favorable outcome (OR, 2.86; 95% CI, 1.19-6.88; P = .02) without significant increase of symptomatic intracranial hemorrhage (OR, 2.18; 95% CI, .42-11.43; P = .36) and 3-month mortality (OR, .53; 95% CI, .23-1.18; P = .12). Successful recanalization rate (Thrombolysis in Cerebral Infarction ≥2a) by EVT was 76%.

CONCLUSIONS

In Korea, one tenth of acute ischemic stroke was caused by ICAO, and about 50% were treated by recanalization therapy. EVT was widely used as a recanalization modality (about 60% of cases) despite lack of evidence. However, its effectiveness and safety were acceptable.

Different doses of recombinant tissue-type plasminogen activator for acute stroke in Chinese patients

BACKGROUND AND PURPOSE

The relationship between the dose of recombinant tissue-type plasminogen activator (r-tPA) and its safety/efficacy for ischemic stroke has not been well evaluated in the East Asian population. We assessed the safety/efficacy of different doses of r-tPA for acute ischemic stroke in Chinese patients.

METHODS

A total of 1004 eligible patients were classified according to the dose of r-tPA received for managing acute ischemic stroke: 0.9 mg/kg (n=422), 0.8 mg/kg (n=202), 0.7 mg/kg (n=199), and 0.6 mg/kg (n=181). The safety outcome was symptomatic intracerebral hemorrhage and death within 3 months. The efficacy outcome was good functional outcome (modified Rankin Scale ≤1) at 3 months.

RESULTS

There was a significant trend for symptomatic intracerebral hemorrhage with age (P=0.002). With multivariate logistic regression analysis, a dose of 0.9 mg/kg was a predictor of symptomatic intracerebral hemorrhage (P=0.0109), and a dose ≤0.65 mg/kg was a predictor of good functional outcome (P=0.0369). In patients aged 71 to 80 years, there was a significant trend of increasing symptomatic intracerebral hemorrhage (P=0.0130) and less good functional outcome (P=0.0179) with increasing doses of r-tPA. There was also a trend of increasing mortality (P=0.0971) at 3 months in these patients.

CONCLUSIONS

These results did not support the dose of 0.9 mg/kg of r-tPA being optimal for all patients in the East Asian population. In elderly patients (71-80 years), a lower dose of 0.6 mg/kg is associated with a better outcome. Confirmation of the results through randomized trial is required.

The safety and effectiveness of low-dose recombinant tissue plasminogen activator (0.6 mg/kg) therapy for elderly acute ischemic stroke patients (≥ 80 years old) in the pre-endovascular era

There are still few studies of low-dose recombinant tissue plasminogen activator (rtPA) therapy (0.6 mg/kg) for acute ischemic stroke (AIS) patients ≥ 80 years old, though most strokes occur in elderly people. The safety and effectiveness of this form of thrombolysis without endovascular therapy were evaluated in AIS patients ≥ 80 years old at our hospital. The data were collected from August 2006 to April 2010, before approval of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) retriever in Japan. Intravenous rtPA was administered to patients within 3 hours of stroke onset. The incidence of intracerebral hemorrhage (ICH), the recanalization rate of the occluded artery, and the modified Rankin Scale (mRS) score 3 months after stroke were examined. The patients who received rtPA therapy were stratified into two age groups: a younger group (< 80 years) and an older group (≥ 80 years). Of the 87 patients who received rtPA therapy, 17 (19.5%) were ≥ 80 years old. The incidence of symptomatic ICH was not significantly different between the younger (4.3%) and older (0%) groups (p = 0.61). The recanalization rate of the occluded artery was not significantly different between the younger (54%) and older (50%) groups (p = 0.78). The rate of an mRS score of 0-2, 3 months after stroke was significantly higher in the younger (44.3%) than in the older group (11.8%) (p = 0.013). Low-dose rtPA therapy appears to be as safe and feasible for AIS patients ≥ 80 years old as it is for younger people. This therapy should not be withheld because of age.

Surgical embolectomy for middle cerebral artery occlusion after thrombolytic therapy: A report of two cases

Background:

Occlusion of the intracranial main trunk results in a poor functional outcome and a high mortality rate. Accordingly, some revascularization procedures such as intravenous administration of recombinant tissue plasminogen activator (rt-PA), endovascular surgery, or surgical embolectomy in the very acute stage have been attempted.

Case Description:

We describe two patients with middle cerebral artery occlusion due to cardiogenic embolism. One patient was subjected to surgical embolectomy shortly after intravenous rt-PA and the other was subjected to same after intra-arterial urokinase. Complete recanalization without new cerebral infarction territory was achieved in both patients.

Conclusion:

Based on our experience, we think that surgical embolectomy is an effective and safe procedure and should be attempted when no response to early thrombolytic therapy is obtained.

Trimming the fat in acute ischemic stroke: an assessment of 24-h CT scans in tPA patients

BACKGROUND

International management of acute ischemic stroke patients treated with intravenous tissue plasminogen activator frequently includes 24-h head imaging. These recommendations stem from the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial protocol regarding the risk of intracerebral hemorrhage post-tissue plasminogen activator administration. Follow-up computed tomography scans on select patients, however, may not effect clinical management, resulting in unnecessary radiation exposure and healthcare costs.

AIMS

Our study questions the utility of routine 24-h computed tomography imaging and looks at the National Institute of Health Stroke Scale as a possible clinical screen for selecting candidates for 24-h imaging. Such a tool would result in decreased radiation exposure to the patient and decreased cost to the hospital.

METHODS

Consecutive patients with acute ischemic stroke given intravenous tissue plasminogen activator between June 2008 and December 2011 were retrospectively identified and dichotomized based on change in 24-h National Institute of Health Stroke Scale from baseline. Initial analysis compared patients with National Institute of Health Stroke Scale worsening to those without worsening. Subsequent analysis was limited to patients with a baseline National Institute of Health Stroke Scale ≤10. Baseline demographics and medical history, baseline and 24-h computed tomography findings, medical and/or surgical orders within six-hours of imaging, and antithrombotic administration within 24-48-h postintravenous tissue plasminogen activator were compared between the two groups.

RESULTS

Two-hundred patients met inclusion criteria: No 24-h National Institute of Health Stroke Scale worsening (n = 167) vs. 24-h National Institute of Health Stroke Scale worsening (n = 33). No baseline demographic or admission data differed significantly between the two groups. Patients without 24-h National Institute of Health Stroke Scale worsening had significantly lower incidence of hemorrhagic infarction (10·8% vs. 31·3%, P = 0·0014) on follow-up imaging. Less than 2% of all patients without 24-h National Institute of Health Stroke Scale worsening had a parenchymal hematoma. No patient with baseline National Institute of Health Stroke Scale ≤10 and without 24-h National Institute of Health Stroke Scale worsening had parenchymal hematoma. Patients with 24-h worsening were significantly less likely to receive timely antithrombotic therapy (60·6% vs. 77·8%, odds ratio 0·44, 95% confidence interval 0·20-0·96).

CONCLUSIONS

Our results demonstrate that routine 24-h computed tomography scan in patients without 24-h National Institute of Health Stroke Scale worsening (especially those with baseline National Institute of Health Stroke Scale ≤10) is less likely to yield information that results in a deviation from standard acute stroke care. No patient without worsening and baseline National Institute of Health Stroke Scale ≤10 had parenchymal hematoma on 24-h computed tomography. Application of the National Institute of Health Stroke Scale to distinguish patients who should have 24-h follow-up imaging from those who will not benefit is a potential avenue for improving utilization of resources and warrants further study.

Stroke education using an animated cartoon and a manga for junior high school students

BACKGROUND

We investigated whether junior high school students could be educated regarding stroke with an animated cartoon and a Manga that we produced for the purpose of dissemination of this knowledge.

METHODS

We produced a 10-minute animated cartoon and a Manga that provided information regarding stroke risk factors, stroke signs and symptoms, and awareness to immediately contact emergent medical service (EMS) on identification of stroke signs and symptoms. From December 2011 to March 2012, 493 students in 15 classes of the first grade (age 12-13 years) of 3 junior high schools were enrolled in the study. Each subject watched the animated cartoon and read the Manga; this was referred to as "training." Lessons about stroke were not given. Questionnaires on stroke knowledge were evaluated at baseline, immediately after the training, and 3 months after the training.

RESULTS

The proportion of correct answers given immediately after the training was higher for all questions, except those related to arrhythmia, compared with baseline. Percentage of correct answers given at 3 months was higher than that at baseline in questions related to facial palsy (75% versus 33%), speech disturbance (91% versus 60%), hemiplegia (79% versus 52%), numbness of 1 side (58% versus 51%), calling for EMS (90% versus 85%), alcohol intake (96% versus 72%), and smoking (69% versus 54%). At 3 months after the training, 56% of students answered the FAST (facial droop, arm weakness, speech disturbance, time to call for EMS) mnemonic correctly.

CONCLUSIONS

Stroke education using these teaching aids of the animated cartoon and the Manga improved stroke knowledge in junior high school students.

Acute ischemic stroke: comparison of low-dose and standard-dose regimes of tissue plasminogen activator

Intravenous tissue plasminogen activator (IV-TPA), administered within 4.5 h of symptom onset, is the only therapeutic agent approved for achieving arterial recanalization in acute ischemic stroke. Current major guidelines recommend the use of a standard dose (0.9 mg/kg bodyweight; maximum 90 mg) of IV-TPA. However, comparable efficacy of IV-TPA was demonstrated in the observational studies from Japan when a lower dose (0.6 mg/kg bodyweight; maximum 60 mg) was used and later approved by the regulatory authorities. Although limited in numbers, considerable variations in the dose of IV-TPA are noted in recent publications from Asia, with variable results and optimal dose of TPA in Asia remains controversial. The authors present a systemic review of the existing literature and compare the efficacy and safety of standard-versus the low-dose IV-TPA therapy in acute ischemic stroke.

Comparison of fast MRI-based individual thrombolysis therapy for patients with superacute infarction

BACKGROUND

The aim of this study is to investigate the outcomes of magnetic resonance imaging (MRI)-based individual thrombolysis therapy using recombinant tissue plasminogen activator (rt-PA) in patients with superacute infarction, comparing the outcome in 1 group of patients treated within 4.5 hours compared with 4.5- to 12-hour window treatment group.

METHODS

We studied 135 patients stratified to 2 different groups based on whether they presented with stroke symptoms within 4.5 hours (4.5-hour group, 72 patients) or between 4.5 and 12 hours (4.5- to 12-h group, 63 patients). All patients were treated with rt-PA after MRI confirmed superacute ischemic stroke (hyperintense in diffusion-weighted imaging but no hypointense change in T2-weighted image (T2WI) or fluid-attenuated inversion recovery). Clinical neurologic deficit was evaluated using the National Institutes of Health Stroke Scale on admission, at 24 hours, and 7 days later. A 90-day clinical outcome was assessed using the modified Rankin Scale (mRS).

RESULTS

There was no significant difference in the clinical outcome between the patients treated with thrombolysis within the first 4.5 hours and those treated between 4.5 and 12 hours. The 2 groups both had recanalization, mRS, and favorable outcome at 90 days (P > .05).

CONCLUSIONS

Our study suggested that fast MR-based thrombolysis using rt-PA was safe and reliable in superacute infarction within 4.5 hours and 4.5-12 hours poststroke.

The effectiveness of a stroke educational activity performed by a schoolteacher for junior high school students

BACKGROUND

The purpose of this study was to determine whether our stroke education system can help junior high school students acquire stroke knowledge when performed by a schoolteacher.

METHODS

A stroke neurologist gave a stroke lesson to 25 students (S group) and a schoolteacher through our stroke education system. After instruction, the schoolteacher performed the same lesson using the same education system to another 75 students (T group). Questionnaires on stroke knowledge were examined at baseline, immediately after the lesson (IL), and at 3 months after the lesson (3M). We analyzed the results of stroke knowledge assessment by linear mixed effects models adjusted for gender and class difference using the student number.

RESULTS

We assessed 24 students in the S group and 72 students in the T group. There were no significant differences in the changes of predicted scores of symptoms and risk factors adjusted for gender, class difference, and each student knowledge level until 3M between the 2 groups. Correct answer rates for the meaning of the FAST (facial droop, arm weakness, speech disturbance, time to call 119) at IL were 92% in the S group and 72% in the T group, respectively. At 3M, they were 83% in the S group and 84% in the T group. The correct answer rates of FAST at 3M were not significantly different adjusted for group, gender, class difference, and correct answer rate at IL.

CONCLUSIONS

A schoolteacher can conduct the FAST message lesson to junior high school students with a similar outcome as a stroke neurologist using our stroke education system.

Is renal dysfunction associated with adverse stroke outcome after thrombolytic therapy?

BACKGROUND

Renal dysfunction is a prevalent comorbidity in acute stroke patients requiring thrombolytic therapy. Reports studying the relationship between renal dysfunction and risk of postthrombolytic symptomatic intracerebral hemorrhage (SICH) are contradictory. We aimed to compare the safety and effectiveness of thrombolytic therapy in acute stroke patients with and without renal dysfunction.

METHODS

Based on the prospective stroke registries of 4 hospitals in Taiwan from 2007-2012, we identified acute stroke patients who received thrombolytic therapy. Clinically significant renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2). Renal dysfunction was further defined as stage 3 (30 ≤ eGFR < 60 ml/min/ 1.73 m(2)), stage 4 (15 ≤ eGFR < 30 ml/min/1.73 m(2)) and stage 5 (<15 ml/min/1.73 m(2)). The rates of SICH and poor outcome (defined as modified Rankin scale score ≥4) at 3 months after thrombolytic therapy were compared in patients with and without renal dysfunction. SICH was determined according to the definition of the National Institute of Neurological Disorders and Stroke. Multivariable logistic regression was used to determine the effect of renal dysfunction on outcome. Patients with different stages of renal dysfunction were further analyzed to determine the effect of disease severity on outcome.

RESULTS

Of the 657 stroke patients with thrombolysis, 239 (36%) had renal dysfunction, including 212 patients in stage 3, 17 patients in stage 4 and 10 patients in stage 5 of renal dysfunction. Patients with renal dysfunction were older and more likely to have hypertension, ischemic heart disease, congestive heart failure and prior antiplatelet use than those without. There were no differences in SICH (8 vs. 7%, p = 0.580) and poor outcome (41 vs. 39%, p = 0.758) between patients with and without renal dysfunction. After multivariable analysis, renal dysfunction was not associated with SICH (odds ratio: 1.03, 95% confidence interval: 0.55-1.92) and poor outcome. Pretreatment stroke severity was the only factor significantly associated with both SICH and poor outcome at 3 months. When stratifying renal dysfunction into stage 3 and stage ≥4, there was no significant increase in SICH as the severity of renal dysfunction increased after multivariable adjustment.

CONCLUSIONS

Renal dysfunction did not increase the risk of SICH and poor outcome at 3 months after stroke thrombolysis. Further study comparing directly the risk and benefit of thrombolytic therapy versus no therapy in stroke patients with renal dysfunction is warranted.

Thrombolytic therapy with intravenous recombinant tissue plasminogen activator in Japanese older patients with acute ischemic stroke: Fukuoka Stroke Registry

AIM

The present study aimed to determine the efficacy and safety of thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) therapy in older patients compared with younger patients.

METHODS

Using the Fukuoka Stroke Registry, a prospective multicenter study for acute stroke in Japan, we analyzed data of 401 patients with acute ischemic stroke (aged 74.5 ± 13.1 years) treated with thrombolytic therapy using rt-PA. Patients were categorized into two groups according to age: those aged ≥ 75 years (n=240) and <75 years (n=161). Neurological improvement was defined as a decrease in the National Institute of Health Stroke Scale (NIHSS) score of ≥ 4 during hospitalization or an NIHSS score of 0 at discharge. Good functional outcome was defined as a modified Rankin scale score of 0-2 at 3 months after onset.

RESULTS

Neurological symptoms at admission were more severe in older patients than in younger patients. Old age (≥ 75 years) was not associated with neurological deterioration (multivariate-adjusted odds ratio [OR] 0.90, 95% confidence interval [CI] 0.46-1.77), neurological improvement (multivariate-adjusted OR 0.91, 95% CI 0.54-1.53) and symptomatic intracranial hemorrhage (multivariate-adjusted OR 1.11, 95% CI 0.19-8.87). Old age was negatively associated with good functional outcome (multivariate-adjusted OR 0.29, 95% CI 0.16-0.52) and positively associated with in-hospital mortality (multivariate-adjusted OR 19.3, 95% CI 2.4-474.9).

CONCLUSIONS

In patients treated with rt-PA, old age is associated with poor functional outcome and in-hospital mortality. However, the probability of neurological improvement and symptomatic intracranial hemorrhage in older patients is comparable with that in younger patients.

[Intravenous rt-PA therapy: current status and extending therapeutic time window in Japan]

Several clinical studies carried out in Japan demonstrated that 0.6 mg/kg of intravenous alteplase within 3 hours of stroke onset could be safe and effective in routine clinical practice for Japanese patients. Since the approval, it has become the golden standard for acute ischemic stroke therapy, although there are huge gaps in frequency of use between various areas of Japan.Pooled analyses of randomized controlled trials in USA and Europe and the ECASS III clinical trial indicated the efficacy and safety of rt-PA therapy when expanding therapeutic time window (TTW) from 3 to 4.5 hours. The Japanese Government approved the 4.5 hour time-window in August 2012, and the Japan Stroke Society published the 2nd version of guidelines of rt-PA therapy in October 2012. The author discussed on clinical implications of shortening the door-to-needle time and extending TTW of this therapy.

Brush sign on 3-T T2*-weighted MRI as a potential predictor of hemorrhagic transformation after tissue plasminogen activator therapy

BACKGROUND AND PURPOSE

The brush sign (BS) is the enlargement of medullary veins on 3-T T2*-weighted MRI seen in patients with ischemic stroke because of major cerebral artery occlusion. However, the clinical relevance of BS in patients with acute stroke remains unclear. We assessed the correlation between detecting BS with the development of hemorrhagic transformation after intravenous thrombolysis.

METHODS

We enrolled consecutive patients with M1 or M2 occlusion treated with intravenous tissue plasminogen activator. We classified the patients into 2 groups: the group positive for BS (P-BS) and the group negative for BS (N-BS). We investigated the differences in MRI findings and the clinical outcome between the 2 groups.

RESULTS

The subjects consisted of 36 patients (19 men; mean age, 74.7 years). Twenty-one patients (58%) had M1 occlusion, and 15 (42%) had M2 occlusion. Twenty-five patients (69%) were classified into the P-BS group and 11 (31%) into the N-BS group. Recanalization was observed in 15 (60%) and 10 (90%) patients in the P-BS and N-BS groups, respectively (P=0.116). Hemorrhagic transformation on MRI was observed more frequently in the P-BS group than in the N-BS group (64% versus 18%; P=0.027). A good outcome (mRS, 0-1) at discharge was found in 24% of patients in the P-BS group and in 45% of patients in the N-BS group (P=0.152). A multivariate logistic regression analysis revealed that the presence of BS (odds ratio, 9.08; 95% confidence interval, 1.4-59.8; P=0.022) was independently associated with hemorrhagic transformation.

CONCLUSIONS

BS may predict the development of hemorrhagic transformation in patients with acute stroke treated with intravenous tissue plasminogen activator.

Neurothrombectomy in the treatment of acute ischaemic stroke

Major ischaemic stroke is a leading cause of morbidity and mortality in industrialized countries. For patients with acute stroke, fast and effective vessel recanalization is important for successful treatment. Neurothrombectomy--that is, angiographically performed mechanical thrombus removal from intracranial arteries--results in higher recanalization rates than with pharmaceutical thrombolysis alone, but the value of this treatment in terms of clinical outcome remains to be established. This article summarizes the history of intra-arterial stroke treatment, outlines the recent developments and the different techniques used, and discusses the results of current studies on neurothrombectomy. Owing to the high morphological and clinical variability of stroke, careful patient selection in future randomized controlled trials will be crucial for assessment of the true potential of neurothrombectomy.

Low-dose tissue plasminogen activator and standard-dose tissue plasminogen activator in acute ischemic stroke in Asian populations: a review

BACKGROUND

The burden of stroke is becoming an important issue in Asian countries, where half of the world's population lives. In Western populations, standard-dose intravenous tissue plasminogen activator (tPA) at a dose of 0.9 mg/kg administered up to 4.5 h following acute ischaemic stroke has been shown to improve clinical outcomes. However, the dosage of tPA in Asian populations varies, partly influenced by treatment costs in developing countries and the perceived racial differences in treatment response. Furthermore, no randomized controlled trial of intravenous tPA thrombolysis has been carried out in Asia with the exceptions of observational and multicentre registries in Japan. SUMMARY OF THE REVIEW: This review aims to examine the current use of low-dose tPA in Asian populations with particular emphasis on its clinical benefits. Historically, the findings of 2-chain tPA (duteplase) trials in the early 1990s were the basis of low-dose tPA in Japan, and standard-dose tPA was chosen taking into account a pilot dose escalation study. Most of the trials incorporating low-dose tPA suggested that low-dose tPA has clinical efficacy comparable with the standard dose and that it is associated with a lower incidence of symptomatic haemorrhage. It follows that consensus regarding the dosage of tPA is wanting.

CONCLUSIONS

Standard-dose tPA would be a reasonable choice in Asian populations until the results are available from randomized controlled studies comparing low-dose with standard-dose tPA.

Stroke education program of act FAST for junior high school students and their parents

BACKGROUND

We produced a stroke education program using the FAST (facial droop, arm weakness, speech disturbance, time to call an ambulance) mnemonic.

AIMS

The aim of this study is to examine efficacy of our education program for junior high school students and their parents.

METHODS

One hundred ninety students of 3 junior high schools (aged 12-13 years) and their parents were enrolled. Students received a 45-minute lesson of stroke enlightenment using the FAST mnemonic. Enlightenment items, such as a magnet poster, were distributed. Parents were educated indirectly from their child. Surveys of stroke knowledge were examined at baseline, immediately after the lesson, and at 3 months after the lesson.

RESULTS

For the students, correct answers at 3 months were significantly higher than those at baseline in questions of facial palsy (98% versus 33%), speech disturbance (98% versus 54%), numbness on one side (64% versus 42%), weakness on one side (80% versus 51%), calling an ambulance (88% versus 60%), alcohol drinking (85% versus 65%), smoking (70% versus 43%), dyslipidemia (58% versus 46%), hyperglycemia (59% versus 48%), and obesity (47% versus 23%). At 3 months, the parents answered more correctly questions of facial palsy (93% versus 66%), calling an ambulance (95% versus 88%), and alcohol drinking (65% versus 51%) than at baseline. At 3 months, 96% of students and 78% of parents answered the FAST mnemonic correctly.

CONCLUSIONS

Our stroke education program improved stroke knowledge, especially the FAST message, for junior high school students and their parents.

New Appearance of Extraischemic Microbleeds on T2*-Weighted Magnetic Resonance Imaging 24 Hours After Tissue-type Plasminogen Activator Administration

Background and Purpose—

It is unknown whether new-extraischemic microbleeds (new-EMBs) develop rapidly after tissue-type plasminogen activator (tPA) infusion. We hypothesized that new-EMBs may develop rapidly after tPA infusion using T2*-weighted MRI (T2*) and investigated the frequency and clinical factors associated with new-EMBs.

Methods—

Patients with acute stroke within 3 hours of onset who were treated with tissue-type plasminogen activator (tPA) were studied prospectively. T2* was performed before and 24 hours after tPA therapy. Independent clinical factors associated with new-EMBs development were examined using multivariate logistic regression analysis.

Results—

A total of 224 patients (121 men; mean age, 76.2±10.6 years) were enrolled in the present study. MBs before tPA infusion were observed in 72 (32.1%) patients. Within 24 hours after tPA infusion, 6 (2.7%) patients had symptomatic intracranial hemorrhage (extraischemic [n=4], and hemorrhagic transformation [n=2]). Follow-up T2* revealed asymptomatic new-EMBs in 11 (4.9%) patients and hemorrhagic transformation in the infarcted area in 65 (29.0%). The total and mean number of new-EMBs were 23 and 1.6±1.3, respectively. Patients with new-EMBs more frequently had symptomatic extraischemic hemorrhage than those without new-EMBs (27.3% [3/11] versus 0.5% [1/213]; P =0.0003). However, the frequency of hemorrhagic transformation was not different between patients with and without new-EMBs (27.3% versus 29.1%; P =0.9999). Multivariate logistic regression demonstrated that the presence of MBs before tPA infusion was the only independent factor associated with new-EMBs (odds ratio, 10.6; 95% confidence interval, 20.68–54.279; P =0.0046).

Conclusions—

New-EMBs occurred rapidly after tPA infusion in 4.9% of patients. The presence of MBs before tPA therapy was associated with new-EMBs. Patients with new-EMBs are likely to have symptomatic extraischemic hemorrhage.

Effects of Intensive and Moderate Public Education on Knowledge of Early Stroke Symptoms Among a Japanese Population

Background and Purpose—

To assess the effects of intensive and moderate public education on knowledge of early stroke symptoms among a general Japanese population.

Methods—

Information on early stroke symptoms was distributed by leaflet 12× and by booklet twice in an intensive intervention area >22 months, and by leaflet and booklet once each in a moderate intervention area. No distribution occurred in the control area. Before and after the intervention, a mailed survey was conducted in the 3 areas. A total of 2734 individuals, aged 40 to 74 years, who did not select all 5 correct symptoms of stroke in the preintervention survey were eligible for our analysis.

Results—

The numbers of correct answers selected about stroke symptoms did not differ significantly among the 3 areas in the preintervention survey ( P =0.156). In the postintervention survey, the proportions of participants who selected sudden 1-sided numbness or weakness (94.2% in the intensive intervention area, 88.3% in the moderate intervention area, and 89.2% in the control area; P <0.001) and sudden severe headache (76.8%, 70.1%, and 70.4%, respectively; P <0.001) differed significantly among the 3 areas. After adjustment for confounding factors, the multivariable-adjusted odds ratios (95% confidence intervals) for correctly choosing all 5 symptoms were 1.35 (1.07–1.71) in the intensive intervention area and 0.96 (0.74–1.24) in the moderate intervention area compared with the control area.

Conclusions—

Our findings suggest that frequent distribution of leaflets and booklets significantly improved the short-term knowledge of community residents about early symptoms of stroke.

Location of the Susceptibility Vessel Sign on T2*-Weighted MRI and Early Recanalization within 1 Hour after Tissue Plasminogen Activator Administration

Background

We have recently reported that the susceptibility vessel sign (SVS) at the proximal portion of the horizontal (M1) middle cerebral artery (MCA) on T2*-weighted MRI is a strong predictor for no early recanalization after intravenous recombinant tissue plasminogen activator (t-PA) therapy. However, it is unclear whether the presence of the SVS at other locations, such as distal M1, the vertical portion (M2) of the MCA, and distal branches (MCA distal), is a predictor for no early recanalization in acute ischemic stroke patients.

Methods

The SVS was defined as a hypointense signal of the MCA on T2*-weighted MRI on admission. The locations of the SVS were classified as M1 proximal, M1 distal, and MCA distal. M1 proximal SVS was defined as an SVS at the origin of the M1. M1 distal SVS was any M1 SVS not including the origin of the M1. MCA distal SVS was an SVS further away from M1. Early recanalization was defined as a new appearance of at least one of the distal branches on MRA within 1 h after t-PA therapy. A good outcome at 3 months was defined as a modified Rankin Scale (mRS) score of 0-1.

Results

Consecutive acute stroke patients admitted to our stroke center and treated with t-PA between October 2005 and October 2012 were enrolled. There were 158 patients [median age, 78 (71-84) years; 84 (53%) males; median National Institutes of Health Stroke Scale score, 16 (10-20)]. Internal carotid artery occlusion was seen in 18 (72%) of the 25 patients with M1 proximal SVS, in 3 (14%) of the 22 patients with M1 distal SVS, in 4 (9%) of the 44 patients with MCA distal SVS, and in 18 (27%) of the 67 patients with No SVS (p < 0.001). Twenty-four (96%) of the 25 patients with M1 proximal SVS had no early recanalization, while 16 (73%) of the 22 patients with M1 distal SVS, 25 (57%) of the 44 patients with MCA distal SVS, and 36 (54%) of the 67 patients with No SVS had no early recanalization (p < 0.001, 0.140, and 0.846, respectively, compared to the patients with No SVS). Multivariate analysis showed that only M1 proximal SVS was significantly associated with no early recanalization (odds ratio 16.80, 95% confidence interval 2.04-138.17, p = 0.009). Among the 95 patients with a premorbid mRS score of 0-1, none (0%) of the 16 patients with M1 proximal SVS, 5 (36%) of the 14 patients with M1 distal SVS, 12 (48%) of the 25 patients with MCA distal SVS, and 13 (33%) of the 40 patients with No SVS achieved a good outcome (p = 0.011, 1.000, and 0.295, respectively, compared to the patients with No SVS).

Conclusion

M1 proximal SVS on T2*-weighted MRI is a strong predictor for no early recanalization, and all patients with it had a poor outcome. However, M1 distal SVS and MCA distal SVS were not predictors for no early recanalization, and half of the patients had a poor outcome.