1
|
Lei Z, Li S, Feng H, Wu X, Hu S, Li J, Xu G, Ren L, Pan S. Effects of intravenous rtPA in patients with minor stroke. Ann Med 2024; 56:2304653. [PMID: 38289926 PMCID: PMC10829835 DOI: 10.1080/07853890.2024.2304653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/29/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Whether minor ischemic stroke (MIS) patients can benefit from intravenous thrombolysis (IVT) remains controversial. The association between the efficacy of IVT and baseline National Institute of Health Stroke Scale (NIHSS) score is unclear in MIS, while the association in moderate and severe stroke is known. This study aimed to explore the effect of IVT in patients with MIS and analyze its efficacy in patients with different baseline NIHSS scores. METHODS Patients with a NIHSS score ≤5 within 4.5 h of stroke onset were screened in 32 centers. Patients with and without IVT were matched to a ratio of 1:1 with propensity scores. An excellent outcome was defined as a modified Rankin Scale (mRS) score ≤1 at three months after stroke onset. Safety outcomes included mortality and symptomatic intracranial hemorrhage (sICH). Multivariate analysis was used to compute the adjusted odds ratio (OR) for excellent outcomes. The effect of IVT was further analyzed in subgroups according to the baseline NIHSS score. RESULTS Of the 23,853 screened, 3336 patients with MIS who arrived at the hospital within 4.5 h of onset were included. The 1163 patients treated with IVT were matched with 1163 patients without IVT. IVT in minor strokes generated an adjusted OR of 1.38 (95% CI: 1.09-1.75, p = 0.009) for excellent outcomes. There were no significant differences in mortality (0.17% vs. 0.09%, p = 1.000) and sICH (0.69% vs. 0.86%, p = 0.813) between patients with and without IVT. Subgroup analysis showed that there was no significant effect of IVT in the baseline NIHSS 0-1 or 2-3 subgroups, with adjusted OR of 0.816 (95% CI 0.437-1.53, p = 0.525) and1.22 (95% CI 0.845-1.77, p = 0.287), respectively. In patients with NIHSS score of 4-5, IVT was significantly effective, with an adjusted OR of 1.53 (95% CI 1.02-2.30, p = 0.038). CONCLUSION IVT can improve MIS outcomes. The risks of sICH and mortality did not increase, especially in patients with NIHSS scores 4 to 5, who could benefit from IVT significantly.
Collapse
Affiliation(s)
- Zhihao Lei
- Department of Neurology, Nanfang Hospital, Southern Medical University/The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Shuanglin Li
- Department of Anatomy and Histology, School of Basic Medical Sciences, Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China
| | - Hongye Feng
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Xiaohong Wu
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Shiyu Hu
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Jun Li
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Gelin Xu
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Lijie Ren
- Department of Neurology, Shenzhen Second People’s Hospital, First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Shenzhen Cerebrovascular Disease Treatment and Quality Control Center, Shenzhen, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University/The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| |
Collapse
|
2
|
Alhazzani A, Al-Ajlan FS, Alkhiri A, Almaghrabi AA, Alamri AF, Alghamdi BA, Salamatullah HK, Alharbi AR, Almutairi MB, Chen HS, Wang Y, Abdalkader M, Turc G, Khatri P, Nguyen TN. Intravenous alteplase in minor nondisabling ischemic stroke: A systematic review and meta-analysis. Eur Stroke J 2024; 9:521-529. [PMID: 38465589 DOI: 10.1177/23969873241237312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Minor ischemic stroke, defined as National Institute of Health Stroke Scale score of 0-5 on admission, represents half of all acute ischemic strokes. The role of intravenous alteplase (IVA) among patients with minor stroke is inconclusive; therefore, we evaluated clinical outcomes of these patients treated with or without IVA. MATERIALS AND METHODS We searched Medline, Embase, Scopus, and the Cochrane library until August 1, 2023. Inclusion was restricted to the English literature of studies that reported on minor nondisabling stroke patients treated with or without IVA. Odds ratios (ORs) with their corresponding 95% CIs were utilized using a random-effects model. Efficacy outcomes included rates of excellent (modified Rankin scale [mRS] of 0-1) and good (mRS of 0-2) functional outcome at 90 days. The main safety outcome was symptomatic intracerebral hemorrhage (sICH). RESULTS Five eligible studies, two RCTs and three observational studies, comprising 2764 patients (31.8% female) met inclusion criteria. IVA was administered to 1559 (56.4%) patients. Pooled analysis of the two RCTs revealed no difference between the two groups in terms of 90-days excellent functional outcomes (OR 0.76 [95% CI, 0.51-1.13]; I2 = 0%) and sICH rates (OR 3.76 [95% CI, 0.61-23.20]). No significant differences were observed between the groups in terms of good functional outcomes, 90-day mortality, and 90-day stroke recurrence. CONCLUSION This meta-analysis of minor nondisabling stroke suggests that IVA did not prove more beneficial compared to no-IVA.
Collapse
Affiliation(s)
- Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah R Alharbi
- Department of Neurology, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Maher B Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | | | | | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | | |
Collapse
|
3
|
Wang D, Wen Q, Liu K, Ding Y, Xiao L, Li W, Lei X, Zhang S, Du P, Zhou H, Chen Y, Zhang H, Zhao Y, Nguyen TN, Xu A, Xiao J, Meng H. Intravenous thrombolysis versus dual antiplatelet therapy in minor ischemic stroke within the thrombolytic window (TAMIS): a multicenter cohort study. J Thromb Thrombolysis 2024:10.1007/s11239-024-03032-8. [PMID: 39179951 DOI: 10.1007/s11239-024-03032-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Abstract
Intravenous thrombolysis (IVT) and dual antiplatelet therapy (DAPT) have been widely used in minor ischemic stroke (MIS) treatment. However, the clinical outcomes and safety of these two treatments have not been compared within the early thrombolytic time window. Here, we conducted a multicenter, ambispective cohort study involving patients with MIS presenting within 4.5 h of symptom onset at 3 affiliated hospitals of Jinan University from 2018-2022. The patients were divided into the IVT group and DAPT group. The primary outcome was a 90-day excellent outcome (mRS ≤ 1). A total of 1,026 patients were enrolled, of whom 492 were assigned to the IVT group and 534 were assigned to the DAPT group. The IVT group had better 90-day excellent outcomes (mRS ≤ 1) than the DAPT group (OR 1.69, 95% CI 1.14-2.52, P = 0.010). Among the 623 patients with nondisabling stroke, the proportion of mRS ≤ 1 in the IVT group was higher than the DAPT group (P = 0.009). In the subtypes of MIS with large vessel occlusion/stenosis and with isolated symptoms, the 90-day outcomes of the IVT group and DAPT group were not different (P > 0.05). In conclusion, compared with DAPT, IVT was associated with better 90-day clinical outcomes in patients with MIS (in particular, for those with mRS > 1), including earlier clinical improvement.IVT also benefited the early neurological improvement of patients with severe stenosis/occlusion of intracranial large vessels, nondisabling mild stroke, nondisabling mild stroke with isolated symptoms.
Collapse
Affiliation(s)
- Dan Wang
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Qianru Wen
- Department of Neurology, The Sixth Affiliated Hospital of Jinan University, Dongguan, 523573, China
| | - Kewei Liu
- Department of Neurology, Longmen County People's Hospital Affiliated to Jinan University, Huizhou, 516800, China
| | - Yan Ding
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Lu Xiao
- Clinical Medicine Research Institute: Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Wei Li
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Xiaoyun Lei
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Siqi Zhang
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Peijie Du
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Huan Zhou
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, 528100, China
| | - Hong Zhang
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
- Department of Neurology, The Sixth Affiliated Hospital of Jinan University, Dongguan, 523573, China
| | - Ying Zhao
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China
| | - Thanh N Nguyen
- Department of Neurology: Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Anding Xu
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China.
| | - Jia Xiao
- Department of Neurology, The Sixth Affiliated Hospital of Jinan University, Dongguan, 523573, China.
- Clinical Medicine Research Institute: Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China.
| | - Heng Meng
- Department of Neurology, The First Affiliated Hospital of Jinan University, No. 612 Huangpu Avenue West, Guangzhou, 510632, China.
| |
Collapse
|
4
|
Qin B, Fu L, Qin H, Liang Y, Qin C, Zhang J, Gao W. Intravenous thrombolysis versus dual antiplatelet therapy for patients with acute minor ischaemic stroke: a systematic review and meta-analysis. Front Pharmacol 2024; 15:1377475. [PMID: 38915465 PMCID: PMC11194400 DOI: 10.3389/fphar.2024.1377475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
Background and purpose The efficacy of intravenous thrombolysis (IVT) in patients with acute minor ischaemic stroke (AMIS) remains unclear. We performed a meta-analysis to compare the efficacy and safety of IVT and dual antiplatelet therapy (DAPT) in patients with AMIS. Methods The Embase, Cochrane Library, PubMed, and Web of Science databases were searched up to 10 October, 2023. Prospective and retrospective studies comparing the clinical outcomes of IVT and DAPT were included. Odds ratios (ORs) and 95% confidence intervals (CIs) for early neurological deterioration (END), excellent and favourable functional outcomes, recurrent ischaemic stroke at 3 months, mortality at 3 months, and symptomatic intracranial haemorrhage (ICH) were pooled using a random-effects model. Results Of the five included studies, 6,340 patients were included. In patients with AMIS, IVT was not significantly associated with excellent and favourable functional outcomes, recurrent ischaemic stroke, or all-cause mortality at 3 months compared to early DAPT. However, a higher risk of symptomatic ICH (OR, 9.31; 95% CI, 3.39-25.57) and END (OR, 2.75; 95% CI, 1.76-4.30) were observed with IVT. Conclusion This meta-analysis indicated that IVT was not superior to DAPT in patients with AMIS, especially in those with nondisabling AIS. However, these findings should be interpreted with caution and have some limitations. Further, well-designed randomised controlled trials are warranted.
Collapse
Affiliation(s)
- Bin Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lin Fu
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Huixun Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Yuming Liang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Cheng Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Jiede Zhang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Wen Gao
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| |
Collapse
|
5
|
Li N, Zhang J, Li SJ, Du Y, Zhou Q, Gu HQ, Zhao XQ. Multidimensional Outcomes of IV Thrombolysis in Minor Ischemic Stroke: Motor, Psychocognitive, and Dependence. Neuropsychiatr Dis Treat 2023; 19:2341-2351. [PMID: 37936866 PMCID: PMC10625889 DOI: 10.2147/ndt.s434296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/24/2023] [Indexed: 11/09/2023] Open
Abstract
Background The presence of mild deficit is the most common reason for nonuse of intravenous alteplase in ischemic stroke. We analyzed within a national prospective cohort on whether patients with minor stroke can benefit from intravenous alteplase. Methods This observational study included patients with acute ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score 0 to 5 at admission. The short-term outcomes at discharge and 3-month were analyzed including the modified Rankin Scale score, gait speed, Montreal Cognitive Assessment, Patient Health Questionnaire-9, General Anxiety Disorder-7 and Stroke Impact Scale-16. Multivariate regression models were performed to evaluate the association between intravenous thrombolysis and clinical outcomes. Results A total of 1876 consecutive patients were included in the current analyses with 102 patients (5.4%) received alteplase and 1774 patients (94.5%) were in non-alteplase group. We found that 10.9% patients presented unfavorable functional outcome with a mRS ≥ 2 at 3-month. Patients with alteplase treatment had a more favorable outcome in SIS-16 at discharge (OR, 5.45; 95% CI, 2.22-8.68) and 3-month after stroke (OR, 2.34; 95% CI, 0.17-4.50). There was an association of alteplase with better gait speed in the restricted sample of age >60 (OR,0.14; 95% CI, 0.02-0.25), while an unfavorable effect was found in anxiety (OR, 2.23; 95% CI, 2.23, 0.91-3.55) and depression (OR, 1.54; 95% CI, 0.17-2.91) in female. Conclusion Alteplase showed a suggestive benefit in function and motor outcomes in patients with low NIHSS score of 0-5. Meanwhile, female seemed more inclined to post-stroke emotional problems after alteplase treatment, which should be further explored in the future.
Collapse
Affiliation(s)
- Ning Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Si-Jia Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yang Du
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Qi Zhou
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| |
Collapse
|
6
|
Merlino G, Nesi L, Vergobbi P, Scanni MD, Pez S, Marziali A, Tereshko Y, Sportelli G, Lorenzut S, Janes F, Gigli GL, Valente M. The use of alteplase, although safe, does not offer clear clinical advantages when mild stroke is non-disabling. Front Neurol 2023; 14:1212712. [PMID: 37528859 PMCID: PMC10390232 DOI: 10.3389/fneur.2023.1212712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/19/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction It is unknown whether alteplase is effective and safe in patients with mild acute ischemic stroke (AIS). Determining whether symptoms are "disabling" or not is a crucial factor in the management of these patients. This study aimed to investigate the efficacy and safety of alteplase in patients with mild, non-disabling AIS. Methods We included all consecutive patients admitted for AIS at our institution from January 2015 to May 2022 who presented a baseline NIHSS score of 0-5 and fit the criteria to receive intravenous thrombolysis. In order to select only subjects with non-disabling AIS, we excluded patients who scored more than 1 point in the following NIHSS single items: vision, language, neglect, and single limb. Patients who scored at least 1 point in the NIHSS consciousness item were excluded as well. This study is a retrospective analysis of a prospectively collected database. Results After the application of the exclusion criteria, we included 319 patients, stratified into patients receiving and not receiving alteplase based on non-disabling symptoms. The two groups were comparable regarding demographic and clinical data. Rates of a 3-month favorable outcome, defined as a 3-month mRS score of 0-1, were similar, being 82.3% and 86.1% in the treated and untreated patients, respectively. Hemorrhagic complications and mortality occurred infrequently and were not affected by alteplase treatment. Discussion This observational study suggests that the use of alteplase, although safe, is not associated with a better outcome in highly selected patients with non-disabling AIS.
Collapse
Affiliation(s)
- Giovanni Merlino
- Stroke Unit, Department of Head-Neck and Neuroscience, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Lorenzo Nesi
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | | | | | - Sara Pez
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | | | - Yan Tereshko
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | | | - Simone Lorenzut
- Stroke Unit, Department of Head-Neck and Neuroscience, Udine University Hospital, Udine, Italy
| | - Francesco Janes
- Stroke Unit, Department of Head-Neck and Neuroscience, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology, Udine University Hospital, Udine, Italy
- Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| |
Collapse
|
7
|
Cao X, Luo J, Xu B, Xiao Y, Yang T, Sun X, Sui Y. Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study. J Neurol Sci 2023; 451:120706. [PMID: 37379725 DOI: 10.1016/j.jns.2023.120706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES The efficacy and safety of intravenous thrombolysis uncertain in patients with non-disabling mild ischemic stroke. Our aim was to investigate whether best medical management only is noninferior to intravenous thrombolysis plus best medical management therapy for achieving favorable functional outcome at 90 days. MATERIALS AND METHODS In a prospective acute ischemic stroke registry from 2018 through 2020, 314 non-disabling mild ischemic stroke patients received best medical management only and 638 underwent intravenous thrombolysis plus best medical management. The primary outcome was modified Rankin Scale ≤1 at Day 90. The noninferiority margin was -5%. Secondary outcomes of hemorrhagic transformation, early neurologic deterioration and mortality were also evaluated. RESULTS The best medical management only was noninferior to the combined therapy of intravenous thrombolysis and best medical management with regard to the primary outcome (unadjusted risk difference, 1.16%; 95% CI, -3.48% ∼ 5.8%; p = 0.0046 for noninferiority; adjusted risk difference, 3.01%; 95% CI, -3.39% ∼ 9.41%). After propensity score matching, p < 0.0001 for noninferiority. RD, 4.03%; 95% CI, -1.59% ∼ 9.69%. p < 0.0001 for noninferiority. Adjusted RD, 5.23%; 95% CI, -1.88% ∼ 9.97%. The occurrence of hemorrhagic transformation was significantly increased in the group of combination therapy (OR, 4.26; 95% CI, 1.30 to 13.99; p = 0.008), while no significant difference was detected in early neurologic deterioration (OR, 1.11; 95% CI, 0.49-2.52; p = 0.808) and mortality (OR, 0.57; 95% CI, 0.20 to 1.69; p = 0.214) between groups. CONCLUSIONS In the present study, we found the best medical management only was noninferior to the combination therapy of intravenous thrombolysis plus best medical management for non-disabling mild ischemic stroke within 4.5 h after onset. Best medical management may be a treatment of choice for non-disabling mild ischemic stroke patients. Further randomized controlled studies are warranted.
Collapse
Affiliation(s)
- Xiaopan Cao
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China; Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, 223 Handan Road, Yangpu District, Shanghai 200436, China.
| | - Bing Xu
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Ying Xiao
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Tuo Yang
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China
| | - Xiaohong Sun
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China.
| | - Yi Sui
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
| |
Collapse
|
8
|
Zafar M, McCafferty Y, Sarwar A, Thielemans L, Davies B. A Stroke of Vision as One-and-a-Half Syndrome: Is It Time to Update the FAST Criteria and ABCD2 Score? Cureus 2022; 14:e29370. [PMID: 36159351 PMCID: PMC9489031 DOI: 10.7759/cureus.29370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
FAST (Face, Arm, Speech, Time) is the most commonly used acronym to identify a possible acute stroke. However, it fails to include visual or vestibular changes as potential hallmarks of an acute event. In this case report, we discuss a patient presenting with visual disturbances and internuclear ophthalmoplegia, with a resulting diagnosis of acute ischaemia. We discuss the associated causes, syndromes, and acute management. Though FAST is an important tool for early recognition of a possible stroke, we want to highlight the consideration of visual changes as an increasing phenomenon in an acute cerebrovascular event.
Collapse
|
9
|
Holguin JA, Margetis JL, Narayan A, Yoneoka GM, Irimia A. Vascular Cognitive Impairment After Mild Stroke: Connectomic Insights, Neuroimaging, and Knowledge Translation. Front Neurosci 2022; 16:905979. [PMID: 35937885 PMCID: PMC9347227 DOI: 10.3389/fnins.2022.905979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Contemporary stroke assessment protocols have a limited ability to detect vascular cognitive impairment (VCI), especially among those with subtle deficits. This lesser-involved categorization, termed mild stroke (MiS), can manifest compromised processing speed that negatively impacts cognition. From a neurorehabilitation perspective, research spanning neuroimaging, neuroinformatics, and cognitive neuroscience supports that processing speed is a valuable proxy for complex neurocognitive operations, insofar as inefficient neural network computation significantly affects daily task performance. This impact is particularly evident when high cognitive loads compromise network efficiency by challenging task speed, complexity, and duration. Screening for VCI using processing speed metrics can be more sensitive and specific. Further, they can inform rehabilitation approaches that enhance patient recovery, clarify the construct of MiS, support clinician-researcher symbiosis, and further clarify the occupational therapy role in targeting functional cognition. To this end, we review relationships between insult-derived connectome alterations and VCI, and discuss novel clinical approaches for identifying disruptions of neural networks and white matter connectivity. Furthermore, we will frame knowledge translation efforts to leverage insights from cutting-edge structural and functional connectomics research. Lastly, we highlight how occupational therapists can provide expertise as knowledge brokers acting within their established scope of practice to drive substantive clinical innovation.
Collapse
Affiliation(s)
- Jess A. Holguin
- T.H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, United States
| | - John L. Margetis
- T.H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, United States
| | - Anisha Narayan
- Tulane University School of Medicine, Tulane University, New Orleans, LA, United States
| | - Grant M. Yoneoka
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI, United States
| | - Andrei Irimia
- Leonard Davis School of Gerontology, Ethel Percy Andrus Gerontology Center, University of Southern California, Los Angeles, CA, United States
- Corwin D. Denney Research Center, Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
10
|
Ferrari J, Reynolds A, Knoflach M, Sykora M. Acute Ischemic Stroke With Mild Symptoms-To Thrombolyse or Not to Thrombolyse? Front Neurol 2021; 12:760813. [PMID: 34867745 PMCID: PMC8637329 DOI: 10.3389/fneur.2021.760813] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/15/2021] [Indexed: 12/01/2022] Open
Abstract
Management of stroke with minor symptoms may represent a therapeutical dilemma as the hemorrhage risk of acute thrombolytic therapy may eventually outweigh the stroke severity. However, around 30% of patients presenting with minor stroke symptoms are ultimately left with disability. The objective of this review is to evaluate the current literature and evidence regarding the management of minor stroke, with a particular emphasis on the role of IV thrombolysis. Definition of minor stroke, pre-hospital recognition of minor stroke and stroke of unknown onset are discussed together with neuroimaging aspects and existing evidence for IV thrombolysis in minor strokes. Though current guidelines advise against the use of thrombolysis in those without clearly disabling symptoms due to a paucity of evidence, advanced imaging techniques may be able to identify those likely to benefit. Further research on this topic is ongoing.
Collapse
Affiliation(s)
- Julia Ferrari
- Department of Neurology, St John's Hospital, Vienna, Austria
| | - Audrey Reynolds
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marek Sykora
- Department of Neurology, St John's Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria
| |
Collapse
|
11
|
Meng X, Ji J. Infarct volume and outcome of cerebral ischaemia, a systematic review and meta-analysis. Int J Clin Pract 2021; 75:e14773. [PMID: 34478602 DOI: 10.1111/ijcp.14773] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Multiple studies have evaluated the accuracy of infarct volume (IV) as a predictor of outcome in patients with ischaemic stroke; however, no study has systematically reviewed the results of these studies. AIM This systematic review and meta-analysis aim to sum up the results of the studies evaluating IV as the prognostic criteria for patients with cerebral ischaemia. METHODS Human studies that reported the infarction volume and any prognostic outcome in patients with ischaemic stroke were collected from PubMed, Scopus, Embase and Cochrane library databases. Newcastle-Ottawa Quality Assessment Checklist was applied to evaluate the quality of the included articles. 90-day modified Rankin Scale (mRS) score was used as a meta-analysis outcome. The area under the curve, sensitivity and specificity among included studies was evaluated. The heterogeneity of the studies was assessed by Cochran test Egger and Begg test was used for assessing publication bias. RESULTS Among the included studies, nine studies assessed the association between IV and outcome (90-day mRS score). The results of the meta-analysis revealed a significant association between IV with the unfavourable functional outcome (mRS score of 3-6) (OR = 0.80; 95% CI: 0.74-0.86 per 10 mL, P < .001; I2 = 98.1%, P < .001). The infarction volume cut of point between 20 and 50 mL showed the best sensitivity and specificity for the prediction of poor clinical outcomes in patients with ischaemic stroke. CONCLUSION The results of the meta-analysis revealed a significant association between IV and unfavourable functional outcomes in patients with ischaemic stroke.
Collapse
Affiliation(s)
- Xianbing Meng
- Department of Neurosurgery, The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Jianwen Ji
- Neurological Center, The Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), Chongqing, China
| |
Collapse
|
12
|
Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
Collapse
Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| |
Collapse
|
13
|
Xiong Y, Yan R, Gu H, Wang S, Fisher M, Zhao X, Yang X, Wang C, Qi Z, Meng X, Li Z, Wang Y. Intravenous thrombolysis in Chinese patients with mild acute ischemic stroke. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:767. [PMID: 34268380 PMCID: PMC8246215 DOI: 10.21037/atm-21-40] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/26/2021] [Indexed: 11/06/2022]
Abstract
Background Mild stroke accounts for more than a half of all stroke patients, and short-term outcomes after treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) have not been fully investigated in this group. Methods Our study investigated short-term outcomes and predictors for a favorable functional outcome at discharge in mild stroke patients with IV rtPA. 6,752 mild stroke patients in the China Stroke Center Alliance with a clinical diagnosis of acute ischemic stroke, within 4.5 hours from symptom onset, with a baseline National Institutes of Health Stroke Scale score ≤5 and received rt-PA treatment were included in this retrospective analysis. Univariable and multivariable analyses were performed to identify factors independently associated with a favorable functional outcome. Results Only 18.5% had an unfavorable functional outcome at discharge, 91.1% were discharged home, 89.9% could ambulate independently, 95.9% had a length of stay of 3 days or longer and 1.9% had sICH. A multivariable Logistic regression model identified that age >80 years [adjusted odds ratio (aOR): 1.57 (1.1–2.25)], diabetes mellitus [aOR: 1.35 (1.16–1.58)], 3–4.5 h time window [aOR: 1.43 (1.26–1.63)] and NIHSS score [3 vs. 0, aOR: 1.49 (1.05–2.11); 4 vs. 0, aOR: 2.36 (1.68–3.33); 5 vs. 0, aOR: 2.51 (1.77–3.56)] were independent risk factors for mRS >2 with hospital region, hospital level and hypertension as covariates. Conclusions Our findings suggest that tPA is safe and effective in mild stroke patients with age ≤80 within the 3 hour time window and in those without diabetes mellitus, further studies are needed to confirm the findings.
Collapse
Affiliation(s)
- Yunyun Xiong
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ran Yan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Shang Wang
- Neurocardiology Center, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Marc Fisher
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Xingquan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin Yang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Chunjuan Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Zhou Qi
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China.,Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yongjun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China.,Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China
| |
Collapse
|
14
|
Garg R. Alteplase for Minor Stroke: The AAEM Clinical Practice Advisory is More Accurate Than Other National Guidelines. J Emerg Med 2020; 59:717-718. [PMID: 33248504 DOI: 10.1016/j.jemermed.2020.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Ravi Garg
- Department of Neurology, Division of Neurocritical Care, Stritch School of Medicine at Loyola University, Loyola University Medical Center, MacNeal Hospital, Maywood, Illinois
| |
Collapse
|
15
|
Wang D, Zhang L, Hu X, Zhu J, Tang X, Ding D, Wang H, Kong Y, Cai X, Lin L, Fang Q. Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion. Front Neurol 2020; 11:340. [PMID: 32431662 PMCID: PMC7214684 DOI: 10.3389/fneur.2020.00340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
Collapse
Affiliation(s)
- Dapeng Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Lulu Zhang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiaowei Hu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Longting Lin
- Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Qi Fang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| |
Collapse
|
16
|
Akhtar N, Kamran S, Elkhider H, Al-Makki S, Mhjob N, ElShiekh L, AlHussain H, Ali M, Khodair R, Wadiwala F, Salam A, Deleu D, Francis R, Shuaib A. Progression of stroke deficits in patients presenting with mild symptoms: The underlying etiology determines outcome. PLoS One 2020; 15:e0231448. [PMID: 32330144 PMCID: PMC7182193 DOI: 10.1371/journal.pone.0231448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/24/2020] [Indexed: 12/02/2022] Open
Abstract
Background and purpose Patients with acute stroke and mild or rapidly improving symptoms frequently show progression. The role of reperfusion treatment in such patients is not clear. We hypothesized that progression was most likely in patients with cortical localization and such patients may benefit from thrombolysis. Material and methods We interrogated Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Evaluation was based on localization (lacunar or cortical), multi-model imaging abnormalities and whether they received rt-PA. The 90-day mRS was used to determine outcome. Results During study period 6381 patients were admitted with acute stroke. Mild stroke within 4 hours was diagnosed in 506 [no thrombolysis: 381(lacunar: 213; cortical: 168), thrombolysis: 125 (lacunar: 45; cortical: 80)]. The rt-PA treated patients had significantly higher NIHSS (2.94±3.9 versus 1.28±2.46, p<0.0001), increased rates of complications (16.0% versus 3.9%, p<0.0001) and longer hospital stay (6.05±8.1 versus 3.78±3.6 days; p<0.001). In patients with cortical stroke, intracranial arterial occlusions (11.6% vs 3.9%, p<0.0001) and CTP mismatch (22.2% vs 4.4%, p<0.0001) were more frequent in rt-PA treated patients. Discharge mRS (33.6% versus 13.9%, p<0.001) and 90-days mRS (23.2% versus 11.8%, p = 0.002) was significantly worse in patients with cortical stroke (rt-PA-treated and untreated patients). Conclusions The outcome in patients with mild stroke depends on lesion location (lacunar versus cortical) and severity of symptoms. Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of hospital complication, explaining the poor outcome in such subjects.
Collapse
Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Elkhider
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Soha Al-Makki
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Noha Mhjob
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Lubna ElShiekh
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Hassan AlHussain
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Musab Ali
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Rola Khodair
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faisal Wadiwala
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Salam
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Reny Francis
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Stroke Program, University of Alberta, Edmonton, Canada
- * E-mail: ,
| |
Collapse
|
17
|
Lan L, Rong X, Li X, Zhang X, Pan J, Wang H, Shen Q, Peng Y. Reperfusion therapy for minor stroke: A systematic review and meta-analysis. Brain Behav 2019; 9:e01398. [PMID: 31532082 PMCID: PMC6790315 DOI: 10.1002/brb3.1398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 08/04/2019] [Accepted: 08/06/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Approximately, half of the acute stroke patients with minor symptoms were excluded from thrombolysis in some randomized controlled trials (RCTs). There is little evidence on treating minor strokes with rt-PA. Here, we performed a systematic review and meta-analysis to assess the safety and efficacy of thrombolysis in these patients. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched in July 2018. All available RCTs and retrospective comparative studies that compared thrombolysis with nonthrombolysis' for acute minor stroke (NIHSS ≤ 5) with quantitative outcomes were included. RESULTS Ten studies, including a total of 4,333 patients, were identified. The risk of intracranial hemorrhage (ICH) was higher in the rt-PA group as compared with that in the non-rt-PA group (3.8% vs. 0.6%; p = .0001). However, there is no significant difference in the rate of mortality between the two groups (p = .96). The pooled rate of a good outcome in 90 days was 67.8% in those with rt-PA and 63.3% in those without rt-PA (p = .07). Heterogeneity was 43% between the studies (p = .08). After adjusting for the heterogeneity, thrombolysis was associated with good outcome (68.3% vs. 63.0%, OR 1.47; 95% CI 1.14-1.89; p = .003). In post hoc analyses, including only RCTs, the pooled rate of good outcome had no significant differences between the two groups (86.6% vs. 85.7%, 95% CI 0.44-3.17, p = .74; 87.4% vs. 91.9%, 95% CI 0.35-1.41, p = .32; before and after adjusting separately). CONCLUSIONS Although thrombolysis might increase the risk of ICH based on existing studies, patients with acute minor ischemic stroke could still benefit from thrombolysis at 3 months from the onset.
Collapse
Affiliation(s)
- Lihuan Lan
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Xiaoming Rong
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Xiangpen Li
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Xiaoni Zhang
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Jingrui Pan
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Hongxuan Wang
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Qingyu Shen
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| | - Ying Peng
- Department of NeurologySun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouChina
| |
Collapse
|
18
|
Incidence of acute cerebral infarction or space occupying lesion among patients with isolated dizziness and the role of D-dimer. PLoS One 2019; 14:e0214661. [PMID: 30921431 PMCID: PMC6438525 DOI: 10.1371/journal.pone.0214661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
Background To determine the incidence of acute cerebral infarction or space occupying lesion (SOL) among patients with isolated vertigo or dizziness (IVD) and to evaluate the role of cerebellar function test (CFT) and D-dimer to discriminate ACI/SOL and non-ACI/SOL. Methods A retrospective study of consecutive emergency department (ED) patients with IVD during one year was conducted. ACI was based on the diffusion-weighted magnetic resonance imaging (DW-MRI), and SOL was based on the concurrent MRI sequences. A sensitivity analysis of CFT and D-dimer was also performed. Results Among the 468 patients enrolled, 13 patients (2.8%) had ACI, 11 at cerebellum, 1 at occipital lobe, and 1 at centrum semiovale. Twenty-five patients (5.3%) had SOL. Aneurysm is most frequent (n = 7), followed by meningioma (n = 4) and venous anomaly (n = 4). In total, ACI/SOL was found in 8.1% (n = 38). Abnormal findings in finger-to-nose (FN), heel-to-shin (HTS), and rapid alternative movement (RAM) tests were significantly higher in ACI or ACI/SOL group, while gait disturbance, tandem gait abnormality, and Romberg’s test were not. CFT sensitivities were low for ACI as well as for ACI/SOL, but specificities were high for ACI and ACI/SOL. D-dimer level showed a sensitivity of 100% at >0.18 mg/L for ACI and >0.15 mg/L for ACI/SOL. However, specificity was low at corresponding D-dimer level. Among the subgroup (n = 411) who did not show any abnormality in CFT, 9 patients (2.2%) had ACI, and 33 patients (8.0%) had ACI/SOL. Conclusion The present study reports a clinically significant incidence of ACI/SOL among ED patients with IVD. D-dimer showed high sensitive and low specificity, while CFT showed low sensitivity and high specificity.
Collapse
|
19
|
Nalleballe K, Sharma R, Kovvuru S, Brown A, Sheng S, Gundapaneni S, Ranabothu S, Veerapaneni P, Joiner R, Kapoor N, Culp W, Onteddu S. Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network? J Telemed Telecare 2019; 26:317-321. [PMID: 30741084 DOI: 10.1177/1357633x18824518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to determine reasons for not giving intravenous tissue plasminogen activator to eligible patients with acute ischemic stroke in a telestroke network. METHODS We performed a retrospective analysis of prospectively collected data of patients who were seen as a telestroke consultation during 2015 and 2016 with the Arkansas Stroke Assistance through Virtual Emergency Support programme for possible acute ischemic stroke. RESULTS Total consultations seen were 809 in 2015 and 744 in 2016, out of which 238 patients in 2015 and 247 patients in 2016 received intravenous tissue plasminogen activator. In 2015 and 2016, out of the remaining 571 and 497 patients, 294 and 200 patients respectively were thought to be cases of acute stroke based on clinical evaluation. The most common reasons for not being treated in 2015 and 2016, respectively, were; (a) minimal deficits in 42.17% and 49.5% cases, (b) falling out of the 4.5-hour time window in 22.44% and 22% cases, (c) patient/next of kin refusal in 18.02% and 16.5% cases. Less common reasons included limited functional status, abnormal labs (thrombocytopenia, elevated international normalised ratio (INR)/prothrombin time (PT)/partial thromboplastin time (PTT), hypo or hyperglycemia etc), recent surgery and symptoms being too severe etc. CONCLUSION 'Minimal deficits' and 'out of time window' continue to be the major causes for not receiving thrombolysis during acute ischemic stroke in both traditional and telestroke systems. Patient/next of kin refusal was high in our telestroke system when compared to traditional practices. Considering the increasing utility of telestroke this needs to be further looked into, along with the ways to address it.
Collapse
Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Sukanthi Kovvuru
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, USA.,Department of Radiology, University of Arkansas for Medical Sciences, USA
| | - Sen Sheng
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | | | - Saritha Ranabothu
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | | | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - William Culp
- Department of Radiology, University of Arkansas for Medical Sciences, USA
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| |
Collapse
|
20
|
King M, Kelly LP, Wallack EM, Hasan SMM, Kirkland MC, Curtis ME, Chatterjee T, McCarthy J, Ploughman M. Serum levels of insulin-like growth factor-1 and brain-derived neurotrophic factor as potential recovery biomarkers in stroke. Neurol Res 2019; 41:354-363. [PMID: 30620251 DOI: 10.1080/01616412.2018.1564451] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Our objectives were: 1) to determine whether maximal aerobic exercise increased serum neurotrophins in chronic stroke and 2) to determine the factors that predict resting and exercise-dependent levels. METHODS We investigated the potential predictors of resting and exercise-dependent serum insulin-like growth factor-1 and brain-derived neurotrophic factor among 35 chronic stroke patients. Predictors from three domains (demographic, disease burden, and cardiometabolic) were entered into 4 separate stepwise linear regression models with outcome variables: resting insulin-like growth factor, resting brain-derived neurotrophic factor, exercise-dependent change in insulin-like growth factor, and exercise-dependent change brain-derived neurotrophic factor. RESULTS Insulin-like growth factor decreased after exercise (p = 0.001) while brain-derived neurotrophic factor did not change (p = 0.38). Greater lower extremity impairment predicted higher resting brain-derived neurotrophic factor (p = 0.004, r2 = 0.23). Higher fluid intelligence predicted greater brain-derived neurotrophic factor response to exercise (p = 0.01, r2 = 0.18). There were no significant predictors of resting or percent change insulin-like growth factor-1. DISCUSSION Biomarkers have the potential to characterize an individual's potential for recovery from stroke. Neurotrophins such as insulin-like growth factor-1 and brain-derived neurotrophic factor are thought to be important in neurorehabilitation; however, the factors that modulate these biomarkers are not well understood. Resting brain-derived neurotrophic factor and percent change in brain-derived neurotrophic factor were related to physical and cognitive recovery in chronic stroke, albeit weakly. Insulin-like growth factor-1 was not an informative biomarker among chronic stroke patients. The novel finding that fluid intelligence positively correlated with exercise-induced change in brain-derived neurotrophic factor warrants further research.
Collapse
Affiliation(s)
- Michael King
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Liam P Kelly
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Elizabeth M Wallack
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - S M Mahmudul Hasan
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Megan C Kirkland
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Marie E Curtis
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Tanaya Chatterjee
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Jason McCarthy
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| | - Michelle Ploughman
- a Recovery and Performance Laboratory, Faculty of Medicine , Memorial University , St. John's , Canada
| |
Collapse
|
21
|
Liberman AL, Pinto D, Rostanski SK, Labovitz DL, Naidech AM, Prabhakaran S. Clinical Decision-Making for Thrombolysis of Acute Minor Stroke Using Adaptive Conjoint Analysis. Neurohospitalist 2019; 9:9-14. [PMID: 30671158 PMCID: PMC6327243 DOI: 10.1177/1941874418799563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION There is practice variability in the treatment of patients with minor ischemic stroke with thrombolysis. We sought to determine which clinical factors physicians prioritize in thrombolysis decision-making for minor stroke using adaptive conjoint analysis. METHODS We conducted our conjoint analysis using the Potentially All Pairwise RanKings of all possible Alternatives methodology via the 1000Minds platform to design an online preference survey and circulated it to US physicians involved in stroke care. We evaluated 6 clinical attributes: language/speech deficits, motor deficits, other neurological deficits, history suggestive of increased risk of complication from thrombolysis, age, and premorbid disability. Survey participants were asked to choose between pairs of treatment scenarios with various clinical attributes; scenarios automatically adapted based on participants' prior responses. Preference weights representing the relative importance of each attribute were compared using unadjusted paired t tests. Statistical significance was set at α = .05. RESULTS Fifty-four participants completed the survey; 61% were vascular neurologists and 93% worked in academic centers. All neurological deficits were ranked higher than age, premorbid status, or potential contraindications to thrombolysis. Differences between each successive mean preference weight were significant: motor (31.7%, standard deviation [SD]: 9.5), language/speech (24.1%, SD: 9.6), other neurological deficits (16.6%, SD: 6.4), premorbid status (12.9%, SD: 6.6), age (10.1%, SD: 6.3), and potential thrombolysis contraindication (4.7%, SD: 4.4). CONCLUSION In a conjoint analysis, surveyed US physicians in academic practice assigned greater weight to motor and speech/language deficits than other neurological deficits, patient age, relative contraindications to thrombolysis, and premorbid disability when deciding to thrombolyse patients with minor stroke.
Collapse
Affiliation(s)
- Ava L. Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College
of Medicine, Bronx, NY, USA
| | - Daniel Pinto
- Department of Physical Therapy, College of Health Sciences, Marquette
University, Milwaukee, WI, USA
| | - Sara K. Rostanski
- Department of Neurology, New York University School of Medicine, New York,
NY, USA
| | - Daniel L. Labovitz
- Department of Neurology, Montefiore Medical Center, Albert Einstein College
of Medicine, Bronx, NY, USA
| | - Andrew M. Naidech
- Department of Neurology, Northwestern University Feinberg School of
Medicine, Chicago, IL, USA
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University Feinberg School of
Medicine, Chicago, IL, USA
| |
Collapse
|
22
|
Yeatts SD, Broderick JP, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Khatri P. Alteplase for the treatment of acute ischemic stroke in patients with low National Institutes of Health Stroke Scale and not clearly disabling deficits (Potential of rtPA for Ischemic Strokes with Mild Symptoms PRISMS): Rationale and design. Int J Stroke 2018; 13:654-661. [PMID: 29570044 DOI: 10.1177/1747493018765269] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale Over half of acute ischemic stroke patients have a low National Institutes of Health Stroke Scale of 0-5 and up to two-thirds may not appear clearly disabled at presentation. The efficacy of intravenous alteplase for the latter group is not known. Aim Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) was designed to evaluate the safety and efficacy of intravenous alteplase for the treatment of acute ischemic stroke with National Institutes of Health Stroke Scale 0-5 and without clearly disabling deficits. Sample size estimates A maximum of 948 subjects were required to test the superiority hypothesis with 80% power, according to a one-sided 0.025 level of significance. Methods and design PRISMS was a multicenter, randomized, double-blind, placebo-controlled phase 3b clinical trial. Patients were randomized to the active arm (intravenous alteplase standard dose of 0.9 mg/kg, up to a maximum of 90 mg, plus oral aspirin placebo) or the control arm (intravenous alteplase placebo plus active oral aspirin dose of 325 mg). Study outcome The primary efficacy endpoint was favorable functional outcome, defined as a modified Rankin Scale score 0 or 1 assessed at 90-day postrandomization.
Collapse
Affiliation(s)
| | | | - Anjan Chatterjee
- 3 Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Steven R Levine
- 4 The State University of New York - Downstate Medical Center, Kings County Hospital Cente, Brooklyn, USA
| | - Jose G Romano
- 5 Miller School of Medicine, University of Miami, Miami, USA
| | | | | | | | | | | |
Collapse
|
23
|
Frank RA, Chakraborty S, McGrath T, Mungham A, Ross J, Dowlatshahi D, Shamy M, Stotts G. Diagnostic accuracy of whole-brain computed tomography perfusion for detection of ischemic stroke in patients with mild neurological symptoms. Neuroradiol J 2018; 31:464-472. [PMID: 29720033 DOI: 10.1177/1971400918770898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Mild and minor acute neurological symptoms may lead to diagnostic uncertainty, resulting in a heterogeneous group of patients with true ischemic events and stroke mimics with a potential for poor outcomes. More than half of ischemic stroke patients present as minor strokes (National Institutes of Health Stroke Scale score <6). Whole-brain computed tomography perfusion can be used as a diagnostic test for minor stroke, offering a potential method of reducing diagnostic uncertainty in these patients. We hypothesize that whole-brain computed tomography perfusion imaging features could accurately predict infarction in patients with minor neurological deficits. This retrospective chart review enrolled consecutive patients suspected of acute ischemic stroke with a National Institutes of Health Stroke Scale score <6, who underwent whole-brain computed tomography perfusion and follow-up diffusion-weighted magnetic resonance imaging at our institution. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for whole-brain computed tomography perfusion, using follow-up diffusion-weighted magnetic resonance imaging as a reference standard. A total of 524 patients (mean age: 67 years; range: 17-96 years; 56% men) met the inclusion criteria. Patients were excluded for non-diagnostic ( n = 25) or missing maps ( n = 8) scans, non-ischemic findings ( n = 7), and lack of follow-up magnetic resonance imaging ( n = 336). The final analysis included 148 patients who underwent diffusion-weighted magnetic resonance imaging. Whole-brain computed tomography perfusion has a sensitivity of 0.57 (95% CI: 0.45-0.69) and a specificity of 0.82 (95% CI: 0.71-0.90). The positive and negative predictive values and positive and negative likelihood ratios were 75%, 67%, 3.09, and 0.53, respectively. Our analysis suggests that although whole-brain computed tomography perfusion may offer some value as an adjunctive test for improving confidence in offering stroke treatment, it is not sufficiently sensitive or specific to accurately predict cerebral infarcts in patients with minor neurological symptoms.
Collapse
Affiliation(s)
- Robert A Frank
- 1 Department of Medical Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, ,University of Ottawa, Canada
| | - Santanu Chakraborty
- 2 Department of Diagnostic Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Trevor McGrath
- 1 Department of Medical Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, ,University of Ottawa, Canada
| | - Alexander Mungham
- 2 Department of Diagnostic Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - James Ross
- 2 Department of Diagnostic Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Dar Dowlatshahi
- 3 Department of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Michel Shamy
- 3 Department of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Grant Stotts
- 4 Department of Neurology, The Ottawa Hospital, Canada
| |
Collapse
|
24
|
Chang BP, Rostanski S, Willey J, Kummer B, Miller E, Elkind M. Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department. J Emerg Med 2018; 54:636-644. [PMID: 29321107 PMCID: PMC6446571 DOI: 10.1016/j.jemermed.2017.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/05/2017] [Accepted: 12/01/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions. OBJECTIVE OF THE REVIEW The goal of this clinical review was to summarize and present recommendations regarding the disposition of TIAMS patients in the ED (e.g., admission vs. discharge). DISCUSSION An estimated 250,000 to 300,000 TIA events occur each year in the United States, with an estimated near-term risk of subsequent stroke ranging from 3.5% to 10% at 2 days, rising to 17% by 90 days. While popular and easy to use, reliance solely on risk-stratification tools, such as the ABCD2, should not be used to determine whether TIAMS patients can be discharged safely. Additional vascular imaging and advanced brain imaging may improve prediction of short-term neurologic risk. We also review various disposition strategies (e.g., inpatient vs. outpatient/ED observation units) with regard to their association with neurologic outcomes, such as 30-day or 90-day stroke recurrence or new stroke, in addition to other outcomes, such as hospital length of stay and health care costs. CONCLUSIONS Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.
Collapse
Affiliation(s)
- Bernard P Chang
- Department of Emergency Medicine, Columbia University Medical Center, New York, New York
| | - Sara Rostanski
- Department of Neurology, New York University, New York, New York
| | - Joshua Willey
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Benjamin Kummer
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Eliza Miller
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Mitchell Elkind
- Department of Neurology, Columbia University Medical Center, New York, New York
| |
Collapse
|
25
|
Sand KM, Naess H, Thomassen L, Hoff JM. Visual field defect after ischemic stroke-impact on mortality. Acta Neurol Scand 2018; 137:293-298. [PMID: 29148038 DOI: 10.1111/ane.12870] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aimed to investigate the impact of visual field defects (VFD) on mortality in ischemic stroke patients. MATERIALS AND METHODS All patients with acute infarction and a clinically detected VFD from February 2006 to December 2013 in the NORSTROKE Registry (n = 506) were included and compared with ischemic stroke patients with normal visual fields (n = 2041). A record of patients who had died per ultimo April 2015 was obtained from the central registry at Haukeland University Hospital. RESULTS Patients with VFD were significantly older (75.0 vs 69.8, P < .001) than patients with normal visual fields. The majority of patients with VFD was male, had higher cardiovascular morbidity prestroke, and were more likely to have shorter median time from symptom onset to admission (1.7 hours vs 2.7 hours, P < .001). Baseline National Institute of Health Stroke Scale (NIHSS) score was higher (12.7 vs 3.5, P < .001) as was modified Rankin Scale (mRS) score (3.5 vs 1.9, P < .001) and Barthel Index was lower (51.9 vs 84.8, P < .001) day 7. VFD was associated with increased mortality on Kaplan-Meier plots. Hazard ratio was significantly higher for patients with VFD after adjusting for age, sex, employment prior to infarction, married prior to infarction, institutionalization prior to infarction, prior myocardial infarction, atrial fibrillation, smoking, Barthel Index score and i.v. thrombolysis with Cox regression (hazard ratios [HR] 1.30, CI 1.07-1.56, P = .007). CONCLUSIONS Having a visual field defect after ischemic stroke is independently associated with increased mortality. This should be addressed when selecting candidates for thrombolysis and in the rehabilitation process.
Collapse
Affiliation(s)
- K. M. Sand
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
| | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Centre for Age-Related Medicine; Stavanger University Hospital; Stavanger Norway
| | - L. Thomassen
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - J. M. Hoff
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| |
Collapse
|
26
|
|
27
|
You S, Saxena A, Wang X, Tan W, Han Q, Cao Y, Liu CF. Efficacy and safety of intravenous recombinant tissue plasminogen activator in mild ischaemic stroke: a meta-analysis. Stroke Vasc Neurol 2018; 3:22-27. [PMID: 29600004 PMCID: PMC5870640 DOI: 10.1136/svn-2017-000106] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 11/19/2022] Open
Abstract
The benefits and safety of intravenous recombinant tissue plasminogen activator (IV-tPA) for patients with mild ischaemic stroke (MIS) are still unclear. The objective of this meta-analysis was to evaluate the efficacy and safety of IV-tPA as treatment for patients with MIS. We performed a systematic literature search across MEDLINE, Embase, Central, Global Health and Cumulative Index to Nursing and Allied Health Literature (CINAHL), from inception to 10 November 2016, to identify all related studies. Where possible, data were pooled for meta-analysis with odds ratio (OR) and corresponding 95% confidence interval (CI) using the fixed-effects model. MIS was defined as having National Institutes of Health Stroke Scale score of ≤6. We included seven studies with a total of 1591 patients based on the prespecified inclusion and exclusion criteria. The meta-analysis indicated a high odds of excellent functional outcome based on the modified Rankin Scale or Oxfordshire Handicap Score 0–1 (OR=1.43; 95% CI 1.14 to 1.79; P=0.002, I2=35%) in patients treated with IV-tPA compared with those not treated with IV-tPA (74.8% vs 67.6%). There was a high risk of symptomatic intracranial haemorrhage (sICH) with IV-tPA treatment (OR=10.13; 95% CI 1.93 to 53.02; P=0.006, I2=0%) (1.9% vs 0.0%) but not mortality (OR=0.78; 95% CI 0.43 to 1.43; P=0.43, I2=0%) (2.4% vs 2.9%). Treatment with IV-tPA was associated with better functional outcome but not mortality among patients with MIS, although there was an increased risk of sICH. Randomised trials are warranted to confirm these findings.
Collapse
Affiliation(s)
- Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Anubhav Saxena
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - WeeYong Tan
- Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Qiao Han
- Department of Neurology, Suzhou Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Yongjun Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institutes of Neuroscience, Soochow University, Suzhou, China
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institutes of Neuroscience, Soochow University, Suzhou, China
| |
Collapse
|
28
|
Rostanski SK, Shahn Z, Elkind MS, Liberman AL, Marshall RS, Stillman JI, Williams O, Willey JZ. Door-to-Needle Delays in Minor Stroke: A Causal Inference Approach. Stroke 2017; 48:1980-1982. [PMID: 28536170 PMCID: PMC5708142 DOI: 10.1161/strokeaha.117.017386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/27/2017] [Accepted: 04/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Thrombolysis rates among minor stroke (MS) patients are increasing because of increased recognition of disability in this group and guideline changes regarding treatment indications. We examined the association of delays in door-to-needle (DTN) time with stroke severity. METHODS We performed a retrospective analysis of all stroke patients who received intravenous tissue-type plasminogen activator in our emergency department between July 1, 2011, and February 29, 2016. Baseline characteristics and DTN were compared between MS (National Institutes of Health Stroke Scale score ≤5) and nonminor strokes (National Institutes of Health Stroke Scale score >5). We applied causal inference methodology to estimate the magnitude and mechanisms of the causal effect of stroke severity on DTN. RESULTS Of 315 patients, 133 patients (42.2%) had National Institutes of Health Stroke Scale score ≤5. Median DTN was longer in MS than nonminor strokes (58 versus 53 minutes; P=0.01); fewer MS patients had DTN ≤45 minutes (19.5% versus 32.4%; P=0.01). MS patients were less likely to use emergency medical services (EMS; 62.6% versus 89.6%, P<0.01) and to receive EMS prenotification (43.9% versus 72.4%; P<0.01). Causal analyses estimated MS increased average DTN by 6 minutes, partly through mode of arrival. EMS prenotification decreased average DTN by 10 minutes in MS patients. CONCLUSIONS MS had longer DTN times, an effect partly explained by patterns of EMS prenotification. Interventions to improve EMS recognition of MS may accelerate care.
Collapse
Affiliation(s)
- Sara K. Rostanski
- Department of Neurology, New York University School of Medicine, New York, NY
| | - Zachary Shahn
- Department of Epidemiology, Harvard University School of Public Health, Boston, MA
| | - Mitchell S.V. Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Ava L. Liberman
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY
| | - Randolph S. Marshall
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Joshua I. Stillman
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Olajide Williams
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Joshua Z. Willey
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| |
Collapse
|
29
|
Tan Y, Pan Y, Liu L, Wang Y, Zhao X, Wang Y. One-year outcomes and secondary prevention in patients after acute minor stroke: results from the China National Stroke Registry. Neurol Res 2017; 39:484-491. [PMID: 28476094 DOI: 10.1080/01616412.2017.1322804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ying Tan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | | |
Collapse
|
30
|
Abstract
Although stroke declined from the third to fifth most common cause of death in the United States, the annual incidence and overall prevalence continue to increase. Since the available US Food and Drug Administration-approved treatment options are time dependent, improving early stroke care may have more of a public health impact than any other phase of care. Timely and efficient stroke treatment should be a priority for emergency department and prehospital providers. This article discusses currently available and emerging treatment options in acute ischemic stroke focusing on the preservation of salvageable brain tissue, minimizing complications, and secondary prevention.
Collapse
Affiliation(s)
- Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903, USA.
| |
Collapse
|
31
|
Ali SF, Siddiqui K, Ay H, Silverman S, Singhal A, Viswanathan A, Rost N, Lev M, Schwamm LH. Baseline Predictors of Poor Outcome in Patients Too Good to Treat With Intravenous Thrombolysis. Stroke 2016; 47:2986-2992. [PMID: 27834750 DOI: 10.1161/strokeaha.116.014871] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have reported poor outcomes in patients too good to treat with intravenous thrombolysis because of mild or rapidly improving symptoms. We sought to determine baseline clinical and imaging predictors of poor outcome in these patients. METHODS Among 3950 consecutive stroke admissions (2009-2015) in our local Get With the Guidelines-Stroke database, 632 patients presented ≤4.5 hours and did not receive tissue-type plasminogen activator, with 380 of 632 (60.1%) being too good to treat. Univariate and multivariable analyses explored the clinical and imaging features associated with poor outcome (defined as not being discharged to home) in these 380 cases. RESULTS Among these 380 cases, only 68% were discharged home; the other 25% to inpatient rehabilitation, 4% to a skilled nursing facility, and 3% expired or were discharged to hospice. Patients with poor outcome were older, were more often Hispanic, had more vascular risk factors, and had higher median National Institutes of Health Stroke Scale. Imaging characteristics associated with poor outcomes included large or multifocal infarction and poor collaterals. In multivariable analysis, only age, initial National Institutes of Health Stroke Scale, and infarct location were independently associated with poor outcome. CONCLUSIONS Approximately one third of patients deemed too good for intravenous tissue-type plasminogen activator are unable to be discharged directly to home. Given the current safety profile of intravenous tissue-type plasminogen activator, our results suggest that the concept of being too good to treat should be re-examined with an emphasis on the features associated with poor outcome identified in our study. If replicated, these findings could be incorporated into tissue-type plasminogen activator decision-making algorithms.
Collapse
Affiliation(s)
- Syed F Ali
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Khawja Siddiqui
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Hakan Ay
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Scott Silverman
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Aneesh Singhal
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Natalia Rost
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Michael Lev
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Lee H Schwamm
- From the Department of Neurology, Massachusetts General Hospital, Boston.
| |
Collapse
|
32
|
Romano JG, Smith EE, Liang L, Gardener H, Campo-Bustillo I, Khatri P, Bhatt DL, Fonarow GC, Sacco RL, Schwamm LH. Distinct Short-Term Outcomes in Patients With Mild Versus Rapidly Improving Stroke Not Treated With Thrombolytics. Stroke 2016; 47:1278-85. [PMID: 26987870 DOI: 10.1161/strokeaha.115.011528] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/24/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Mild stroke (MS) and rapidly improving stroke (RIS) symptoms are common stroke presentations. Our objective is to describe the short-term outcomes in this population. METHODS A retrospective analysis of patients with ischemic stroke in the Get With The Guidelines-Stroke registry who arrived ≤4.5 hours from symptom onset not treated with thrombolytics because of MS and RIS. Outcomes included in-hospital death, home discharge, independent ambulation at discharge, and length of stay; these were analyzed for the categories of MS, RIS, and MS+RIS. Multivariable models evaluated the associations of individual and hospital covariates with outcomes. RESULTS Among 42 394 patients with MS and RIS not treated with thrombolytics, 27% were not discharged directly home, 27.2% did not ambulate independently, and 61.1% had length of stay ≥3 days, despite a low in-hospital mortality of 0.8%. Adjusted outcomes were better for MS+RIS compared with MS; RIS also had better independent ambulation and home discharge compared with MS. Among those with a documented National Institutes of Health Stroke Scale, 25% of those with National Institutes of Health Stroke Scale 0 to 5 and half of those with National Institutes of Health Stroke Scale >5 could not be discharged directly to home or ambulate independently. Older individuals, women, blacks, transport by ambulance, delayed arrival, greater severity and greater burden of vascular risk factors, except for dyslipidemia, had worse adjusted outcomes for home discharge and independent ambulation. CONCLUSIONS A significant proportion of patients with MS and RIS not treated with thrombolytics have suboptimal discharge outcomes. We found significant differences between MS, RIS, and MS+RIS and identified factors associated with worse outcomes.
Collapse
Affiliation(s)
- Jose G Romano
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.).
| | - Eric E Smith
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Li Liang
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Hannah Gardener
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Iszet Campo-Bustillo
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Pooja Khatri
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Deepak L Bhatt
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Gregg C Fonarow
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Ralph L Sacco
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| | - Lee H Schwamm
- From the Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.); Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (E.E.S.); Duke Clinical Research Institute, Durham, NC (L.L.); Neuroscience Institute, University of Cincinnati, Cincinnati, OH (P.K.); Division of Cardiology, Department of Internal Medicine, Brigham and Women's Hospital Heart & Vascular Center/Harvard Medical School, Boston, MA (D.L.B.); Division of Cardiology, Department of Internal Medicine, University of California Los Angeles (G.C.F.); and Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
| |
Collapse
|
33
|
Lundström E, Zini A, Wahlgren N, Ahmed N. How common is isolated dysphasia among patients with stroke treated with intravenous thrombolysis, and what is their outcome? Results from the SITS-ISTR. BMJ Open 2015; 5:e009109. [PMID: 26608637 PMCID: PMC4663413 DOI: 10.1136/bmjopen-2015-009109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To describe the frequency and outcome of isolated dysphasia among patients treated with intravenous thrombolysis (IVT). DESIGN Patients registered in the SITS International Stroke Thrombolysis Register (SITS-ISTR). PARTICIPANTS Patients with stroke (N=58,293) treated with IVT between December 2002 and December 2012. SETTING A multinational, prospective, observational monitoring register. MAIN OUTCOME MEASURES Isolated dysphasia and modified Rankin Scale (mRS). METHODS We identified patients presenting with isolated dysphasia by reviewing items within the baseline National Institutes of Health Stroke Scale (NIHSS). We performed descriptive statistics for baseline and demographic data, and reported patients' characteristics, radiological data and changes in their NIHSS score within 7 days and mRS score at 3 months. We also reported corresponding data from the general SITS-ISTR cohort. RESULTS We found isolated dysphasia at baseline in 1.14% (663/58,293) of all patients treated with IVT patients. Patients with isolated dysphasia had a longer onset to treatment time, lower proportion of visible infarctions on admission imaging scan and atrial fibrillation, and were less often classified as having large vessels causing strokes, in comparison with the rest of the SITS-ISTR. Symptomatic intracerebral haemorrhage occurred in 2.3% of patients per SITS-MOST definition and fatal outcome in 5.5%. At 7 days, 50% of patients with isolated dysphasia recovered completely and at 3 months, 86.3% patients were functionally independent (mRS score 0-2), 71.7% had an excellent outcome (mRS score 0-1) and 45.5% had an mRS score of 0. CONCLUSIONS A low proportion of patients with isolated dysphasia are treated with IVT. Half of these patients were fully recovered at 7 days.
Collapse
Affiliation(s)
- Erik Lundström
- Department of Neurology, Karolinska University Hospital & Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Andrea Zini
- Stroke Unit, Department of Neuroscience, Nuovo Ospedale Civile “S Agostino-Estense,” AUSL Modena, Modena, Italy
| | - Nils Wahlgren
- Department of Neurology, Karolinska University Hospital & Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital & Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
34
|
Vagal AS, Sucharew H, Prabhakaran S, Khatri P, Jovin T, Michel P, Wintermark M. Final infarct volume discriminates outcome in mild strokes. Neuroradiol J 2015; 28:404-8. [PMID: 26427891 DOI: 10.1177/1971400915609347] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Knowledge of whether final infarct volume (FIV) predicts disability after mild stroke is limited. We sought to determine if FIV could differentiate good versus poor outcome after mild stroke. METHODS We retrospectively identified 65 patients with mild stroke (National Institutes of Health Stroke Scale≤5) in a multicenter registry of 2453 patients. We evaluated associations between FIV and clinical outcome and evaluated the optimal FIV threshold that discriminated favorable (modified Rankin scale (mRS) 0-1) versus poor (mRS 2-6) outcome. RESULTS The FIV cut-point of 20 mL differentiated favorable and poor outcomes (area under curve (AUC) 0.73, 95% confidence interval: 0.58-0.88). Favorable outcome was observed in 37/45 (82%) with FIV<20 mL, compared to 5/14 (36%) with FIV≥20 mL (p<0.01). FIV≥20 mL remained strongly associated with poor outcome independent of age, gender, stroke severity, Alberta Stroke Program Early CT Score (ASPECTS), and proximal arterial occlusion. CONCLUSION In our small sample size, an FIV of 20 mL best differentiated between the likelihood of good versus poor outcome in patients with mild stroke. Further validation of infarct volume as a surrogate marker in mild stroke is warranted.
Collapse
Affiliation(s)
- Achala S Vagal
- Department of Radiology, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, OH, USA
| | - Heidi Sucharew
- Department of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Pooja Khatri
- Department of Neurology, University of Cincinnati (UC) College of Medicine and Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, OH, USA
| | - Tudor Jovin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrik Michel
- Neurology Centre Hospitalier Universitaire, Lausanne, Switzerland; Department of Radiology, Stanford University, Palo Alto, CA, USA
| | - Max Wintermark
- Neurology Centre Hospitalier Universitaire, Lausanne, Switzerland; Department of Radiology, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
35
|
Yaghi S, Herber C, Willey JZ, Andrews HF, Boehme AK, Marshall RS, Lazar RM, Boden-Albala B. Itemized NIHSS subsets predict positive MRI strokes in patients with mild deficits. J Neurol Sci 2015; 358:221-5. [PMID: 26375623 DOI: 10.1016/j.jns.2015.08.1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 08/11/2015] [Accepted: 08/31/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND While imaging is useful in confirming the diagnosis of ischemic stroke, negative diffusion weighted imaging (DWI) is reported in up to 25% of patients. Our aim was to identify predictors of MRI-positive stroke from the itemized NIHSS. METHODS Data were derived from the Stroke Warning Information and Faster Treatment study from February 2006 to February 2010 among patients with mild deficits (NIHSS 0-5) and a final diagnosis of stroke by a vascular neurologist. All MRI sequences were reviewed for the presence or absence of an acute infarct on DWI. Multivariate logistic regression assessed factors predicting DWI-positive strokes; p<0.05 was considered significant. RESULTS 894 patients had a discharge diagnosis of stroke; 709 underwent MRI and 28.0% were DWI negative. All patients with visual field deficits or neglect were DWI positive. On multivariate analysis including total NIHSS (0-2 vs. 3-5) and itemized NIHSS score subsets, predictors of a positive DWI were NIHSS score of 3-5 (OR=3.3, 95% CI: 1.8-6.1), motor deficits (OR=1.7, 95% CI: 1.1-2.8), ataxia (OR=1.9, 95% CI: 1.0-3.5), and absence of sensory deficits (OR=1.7, 95% CI: 1.0-2.7). We developed the NIHSS-m score that predicts DWI positivity in patients with mild deficits in the absence of neglect or visual field deficits. CONCLUSION NIHSS score subsets predict DWI positivity in mild strokes. The presence of neglect or visual field deficits on the NIHSS subsets is most likely to have an MRI correlate even in patients with low NIHSS.
Collapse
Affiliation(s)
- Shadi Yaghi
- Columbia University Medical Center, United States.
| | | | | | | | | | | | | | - Bernadette Boden-Albala
- Division of Social Epidemiology, Global Institute of Public Health, Department of Neurology, NYU Langone Medical Center, New York University, New York, NY 10003, United States; Department of Epidemiology, College of Dentistry, New York University, New York, NY 10003, United States
| |
Collapse
|
36
|
Khatri P, Tayama D, Cohen G, Lindley RI, Wardlaw JM, Yeatts SD, Broderick JP, Sandercock P. Effect of Intravenous Recombinant Tissue-Type Plasminogen Activator in Patients With Mild Stroke in the Third International Stroke Trial-3. Stroke 2015; 46:2325-7. [DOI: 10.1161/strokeaha.115.009951] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/08/2015] [Indexed: 01/12/2023]
Affiliation(s)
- Pooja Khatri
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Darren Tayama
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Geoff Cohen
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Richard I. Lindley
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Joanna M. Wardlaw
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Sharon D. Yeatts
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Joseph P. Broderick
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| | - Peter Sandercock
- From the Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K., J.P.B.); Genentech, Inc, South San Francisco, CA (D.T.); Division of Clinical Neurosciences (G.C., P.S.), and Division of Neuroimaging Sciences (J.M.W.), University of Edinburgh, Edinburgh, Scotland; Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, Australia (R.I.L.); and Department of Public Health Sciences, Medical University of South
| |
Collapse
|
37
|
Batchelor FA, Williams SB, Wijeratne T, Said CM, Petty S. Balance and Gait Impairment in Transient Ischemic Attack and Minor Stroke. J Stroke Cerebrovasc Dis 2015; 24:2291-7. [PMID: 26227322 DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/29/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND There has been little research into gait and balance impairment in transient ischemic attack (TIA) and minor stroke, despite these conditions affecting large numbers of people and the potential impact on function. The aim of this study was to determine the impact of TIA and minor stroke on gait and balance. METHODS Twelve people with TIA or minor stroke without previous gait/balance problems and 12 age- and sex-matched controls were recruited. Participants (mean age 67 years) underwent a comprehensive assessment including physiological, balance, and gait measures (clinical and computerized [NeuroCom/GAITRite]). Matched-pairs analysis was undertaken. RESULTS Groups were similar in body mass index, vision, leg proprioception/strength, and reaction time. Cognition was worse in the TIA/minor stroke group: mean Montreal Cognitive Assessment score 22.2 versus 26.6, P = .001. People with TIA/minor stroke were significantly worse on all but one clinical test. Median scores for TIA/minor stroke versus control were as follows: Timed Up and Go (TUG), 9.4 versus 7.6 seconds, P = .019; TUG dual task, 12.3 versus 8.5 seconds, P = .012; Four Square Step Test, 10.9 versus 7.2 seconds, P = .006. Mean Step Test score for TIA/minor stroke versus control was 14.1 versus 17.7, P = .021. The TIA/minor stroke group also had significantly worse performance on computerized tests: increased turn time/sway, increased step length, slower comfortable/fast gait speeds, and greater proportion of gait cycle spent in double support. CONCLUSIONS This study found that people with TIA/minor stroke have gait and balance dysfunction despite having no obvious physiological impairments. Intervention studies aimed at improving balance and gait in this population are needed.
Collapse
Affiliation(s)
- Frances A Batchelor
- Health Promotion Division, National Ageing Research Institute, Parkville, Victoria, Australia.
| | - Susan B Williams
- Health Promotion Division, National Ageing Research Institute, Parkville, Victoria, Australia
| | - Tissa Wijeratne
- University of Melbourne, Parkville, Victoria, Australia; Department of Neurology, Western Health, Footscray, Victoria, Australia
| | - Catherine M Said
- University of Melbourne, Parkville, Victoria, Australia; Physiotherapy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Sandra Petty
- University of Melbourne, Parkville, Victoria, Australia; Department of Neurology, Western Health, Footscray, Victoria, Australia
| |
Collapse
|
38
|
Kenmuir CL, Hammer M, Jovin T, Reddy V, Wechsler L, Jadhav A. Predictors of Outcome in Patients Presenting with Acute Ischemic Stroke and Mild Stroke Scale Scores. J Stroke Cerebrovasc Dis 2015; 24:1685-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/18/2015] [Accepted: 03/29/2015] [Indexed: 11/26/2022] Open
|
39
|
Ji HC, Yang LT, Yan FL. Thrombolysis for mild stroke. World J Neurol 2015; 5:57-63. [DOI: 10.5316/wjn.v5.i2.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/03/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023] Open
Abstract
The term “mild stroke”, or “minor stroke” refers to the acute ischemic stroke patients with mild and nondisabling symptoms. Currently there is still no unanimous consensus on the exact definition of mild stroke. Patients with mild stroke are assumed to have a good prognosis in natural course, so they are routinely not given thrombolysis despite early emergency department arrival. Recent studies have revealed that, however, approximately one third of so-called mild stroke patients who are not treated with thrombolysis have significant disability whereas those treated are more likely to achieve a good recovery. Thus excluding all mild strokes from thrombolysis is probably not justified. Those mild stroke patients who are likely to experience early deterioration or end with disability are mostly characterized by imaging findings. Therefore, selected patients with these characteristics based on neuroimaging to be given thrombolysis might be more justified. Meanwhile, new definition should be developed to exclude those who are at a higher risk of poor outcome. Applying information from imaging may make it come true. Using neuroimaging information to define mild stroke and select patients with mild symptoms to thrombolysis may be a future direction.
Collapse
|
40
|
Helenius J, Henninger N. Leukoaraiosis Burden Significantly Modulates the Association Between Infarct Volume and National Institutes of Health Stroke Scale in Ischemic Stroke. Stroke 2015; 46:1857-63. [PMID: 25999386 DOI: 10.1161/strokeaha.115.009258] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The National Institutes of Health Stroke Scale (NIHSS) provides a reliable, quantitative measure of ischemic stroke severity and is predicted by the infarct size. We sought to determine whether leukoaraiosis severity affects the association between infarct size and NIHSS. METHODS NIHSS and diffusion-weighted imaging-defined infarct volumes from 312 prospectively enrolled patients with supratentorial, ischemic strokes were analyzed. Leukoaraiosis severity was graded according to the Fazekas scale and conceptually defined as absent (0; n=44), mild (1-2; n=106), moderate (3-4; n=105), and severe (5-6; n=57). ANCOVA was used to describe the effect of leukoaraiosis on the association between infarct volume and NIHSS. Multivariable linear regression models were constructed to assess whether the association of leukoaraiosis and infarct volume on NIHSS was independent of other clinically relevant covariates. RESULTS Overall, there was a significant correlation between the infarct volume and NIHSS (r=0.591; P<0.001). This correlation significantly attenuated with increasing leukoaraiosis severity from r=0.786 (P<0.001; absent leukoaraiosis) to r=0.498 (P<0.001; severe leukoaraiosis) and as shown by ANCOVA (P<0.001). Leukoaraiosis (coefficient, 0.107; 95% confidence interval, 0.036-0.179; P=0.016) and infarct volume (coefficient, 0.360; 95% confidence interval, 0.305-0.416; P<0.001) were independently associated with a greater NIHSS deficit in the fully adjusted multivariable model. CONCLUSIONS Leukoaraiosis significantly modulates the association between infarct volume and NIHSS. The clinical implications of these findings need further exploration in prospective studies but may be relevant to mitigate outcome differences in patients with stroke by aiding treatment decisions that rely on the NIHSS.
Collapse
Affiliation(s)
- Johanna Helenius
- From the Departments of Neurology (J.H., N.H.) and Psychiatry (N.H.), University of Massachusetts Medical School, Worcester
| | - Nils Henninger
- From the Departments of Neurology (J.H., N.H.) and Psychiatry (N.H.), University of Massachusetts Medical School, Worcester.
| |
Collapse
|
41
|
Brown TA, Luby M, Shah J, Giannakidis D, Latour LL. Magnetic Resonance Imaging in Acute Ischemic Stroke Patients with Mild Symptoms: An Opportunity to Standardize Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2015; 24:1832-40. [PMID: 25997980 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Patients presenting with mild stroke symptoms are excluded inconsistently from intravenous (IV) thrombolysis. We aimed to compare acute magnetic resonance imaging findings in patients with mild symptoms to those with more severe deficits to identify clinically mild patients who might benefit from IV thrombolysis. METHODS We retrospectively studied consecutive stroke patients presenting with perfusion deficit who underwent time-of-flight magnetic resonance angiography within 24 hours of time last seen normal. Two raters measured the lesion volumes on diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) with mismatch (MM) calculated as PWI minus DWI. Occlusion site was categorized as "proximal," "distal," or "magnetic resonance angiography-negative" by consensus review. Stroke with mild symptoms was defined as admit National Institutes of Health Stroke Scale score of 4 or less. Values were reported as n (%). RESULTS Ninety-one patients were included; 56 (61.5%) with nonmild and 35 (38.5%) with mild symptoms. After stratifying for occlusion site, there were no differences in PWI and MM lesion volumes for the nonmild versus mild patients (P = .34-.98 and P = .54-1, respectively). Furthermore, there was a trend for thrombolyzed mild stroke patients (88%, n = 7 of 8) to more likely have a favorable clinical outcome (discharge modified Rankin score ≤ 2) versus untreated patients (70%, n = 16 of 23). CONCLUSIONS When present, conspicuous vessel occlusions in clinically mild stroke patients are concomitant with similar perfusion deficit and MM volumes in more clinically severe stroke patients. Coupled with a trend toward better outcomes in mild stroke patients who were treated with IV tissue plasminogen activator (t-PA), this could indicate that advanced imaging may be used in standardizing the way these patients are selected for IV t-PA therapy.
Collapse
Affiliation(s)
- Tyler A Brown
- Stroke Diagnostics and Therapeutics Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Marie Luby
- Stroke Diagnostics and Therapeutics Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Jignesh Shah
- Stroke Diagnostics and Therapeutics Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Dimitrios Giannakidis
- Stroke Diagnostics and Therapeutics Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Lawrence L Latour
- Stroke Diagnostics and Therapeutics Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland.
| |
Collapse
|
42
|
Spokoyny I, Raman R, Ernstrom K, Khatri P, Meyer DM, Hemmen TM, Meyer BC. Defining mild stroke: outcomes analysis of treated and untreated mild stroke patients. J Stroke Cerebrovasc Dis 2015; 24:1276-81. [PMID: 25906938 PMCID: PMC4457618 DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/21/2015] [Accepted: 01/30/2015] [Indexed: 11/26/2022] Open
Abstract
Introduction Mild deficit is a relative contraindication to administration of IV rtPA for acute ischemic stroke. However, what constitutes “mild” deficit is vague. Prior studies showed patients with mild strokes have substantial disability rates at hospital discharge and at 90 days. We investigated whether the application of a new definition altered the rates of disability overall, and assessed the effects of thrombolysis. Methods This analysis included all adult acute ischemic stroke patients from a prospective registry of consecutive patients (UCSD SPOTRIAS database, 2003-2014) with 90-day mRS score available who were defined as “mild” using either: NIHSS 0-5 or a TREAT Task Force definition (NIHSS 0-5 and non-disabling based on pre-specified syndromes). Dichotomized 90-day mRS were compared between treated and untreated patients using the two definitions. Results Of 802 ischemic stroke patients with mRS scores available, 184 had baseline mRS(0) and met TREAT criteria; 45(24.5%) were rtPA-treated. Among treated patients, 35.6% had 90-day mRS(2-6), versus 28.8% in the untreated group, a non-significant difference after adjusting for baseline NIHSS (p=0.47). None of the 45 treated patients had symptomatic hemorrhage. Outcomes were similar using the simpler NIHSS 0-5 definition. Conclusions About one-third of mild stroke patients were not functionally independent at 90 days, irrespective of treatment or mild definition applied, calling into question the treatment efficacy of IV rtPA for mild strokes as well as what constitutes an appropriate definition of “mild”. Randomized studies are necessary to determine rtPA treatment efficacy in mild stroke patients.
Collapse
Affiliation(s)
- Ilana Spokoyny
- Department of Neurology, University of California, San Diego, San Diego, California.
| | - Rema Raman
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Karin Ernstrom
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Dawn M Meyer
- Department of Neurology, University of California, San Diego, San Diego, California
| | - Thomas M Hemmen
- Department of Neurology, University of California, San Diego, San Diego, California
| | - Brett C Meyer
- Department of Neurology, University of California, San Diego, San Diego, California
| |
Collapse
|
43
|
Choi JC, Jang MU, Kang K, Park JM, Ko Y, Lee SJ, Cha JK, Kim DH, Park SS, Park TH, Lee KB, Lee J, Kim JT, Cho KH, Yu KH, Oh MS, Lee BC, Cho YJ, Kim DE, Lee JS, Lee J, Gorelick PB, Bae HJ. Comparative effectiveness of standard care with IV thrombolysis versus without IV thrombolysis for mild ischemic stroke. J Am Heart Assoc 2015; 4:e001306. [PMID: 25628404 PMCID: PMC4330045 DOI: 10.1161/jaha.114.000596] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
44
|
Choi JC, Jang MU, Kang K, Park J, Ko Y, Lee S, Cha J, Kim D, Park SS, Park TH, Lee KB, Lee J, Kim J, Cho K, Yu K, Oh M, Lee B, Cho Y, Kim D, Lee JS, Lee J, Gorelick PB, Bae H. Comparative effectiveness of standard care with IV thrombolysis versus without IV thrombolysis for mild ischemic stroke. J Am Heart Assoc 2015. [PMID: 25628404 PMCID: PMC4330057 DOI: 10.1161/jaha.114.001306] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, Korea (J.C.C.)
| | - Min Uk Jang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea (M.U.J., H.J.B.)
| | - Kyusik Kang
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea (K.K., J.M.P.)
| | - Jong‐Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea (K.K., J.M.P.)
| | - Youngchai Ko
- Department of Neurology, Eulji University Hospital, Daejeon, Korea (Y.K., S.J.L.)
| | - Soo‐Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea (Y.K., S.J.L.)
| | - Jae‐Kwan Cha
- Department of Neurology, Dong‐A University College of Medicine, Busan, Korea (J.K.C., D.H.K.)
| | - Dae‐Hyun Kim
- Department of Neurology, Dong‐A University College of Medicine, Busan, Korea (J.K.C., D.H.K.)
| | - Sang Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea (S.S.P., T.H.P.)
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea (S.S.P., T.H.P.)
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea (K.B.L.)
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea (J.L.)
| | - Joon‐Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.T.K., K.H.C.)
| | - Ki‐Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.T.K., K.H.C.)
| | - Kyung‐Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (K.H.Y., M.S.O., B.C.L.)
| | - Mi‐Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (K.H.Y., M.S.O., B.C.L.)
| | - Byung‐Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (K.H.Y., M.S.O., B.C.L.)
| | - Yong‐Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (Y.J.C.)
| | - Dong‐Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.E.K.)
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea (J.L.)
| | - Philip B. Gorelick
- Department of Translational Science & Molecular Medicine, Michigan State University College of Human Medicine, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI (P.B.G.)
| | - Hee‐Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea (M.U.J., H.J.B.)
| |
Collapse
|
45
|
Balucani C, Bianchi R, Feldmann E, Weedon J, Kolychev D, Levine SR. To treat or not to treat? Pilot survey for minor and rapidly improving stroke. Stroke 2015; 46:874-6. [PMID: 25604250 DOI: 10.1161/strokeaha.114.008290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Minor strokes and rapidly improving stroke symptoms are frequent exclusions for intravenous tissue-type plasminogen activator. We explored factors influencing tissue-type plasminogen activator treatment decision for minor strokes/rapidly improving stroke symptoms. METHODS A pilot survey, including 110 case scenarios, was completed by 17 clinicians from 2 academic medical centers. Respondents were asked whether they would treat each case with tissue-type plasminogen activator at 60 minutes after emergency department admission. Cases varied by (1) National Institutes of Health Stroke Scale score at treatment decision time, (2) symptom pattern over time (improvement or worsening and then improving), (3) type of neurological deficit (3 main domains: motor, visual/sensory/ataxia, and language/neglect), and (4) age/occupation (4 profiles). Logistic regression was used to predict probability of omission (pO). A binomial regression model was used to predict probability of treatment decision. RESULTS Predicted probability of treatment decision was affected by National Institutes of Health Stroke Scale score (P<0.001) and age/occupation profiles (P<0.001) but not by symptom patterns (P=0.334). There were significant, albeit modest, main effects on probability of treatment decision for neurological domains. Responses were most likely omitted (P=0.027) for cases improvement pattern and language/neglect domain (pO=0.74; 95% confidence interval, 0.52-0.89) and with visual/sensory/ataxia domain (pO=0.74; confidence interval, 0.37-0.93) when compared with improvement pattern and motor domain (pO=0.17; confidence interval, 0.06-0.42) and to any worsening and then improving patterns (0.37<pO<0.56). CONCLUSIONS This pilot survey provides the first quantitative evidence that National Institutes of Health Stroke Scale score is not the only determinant of treatment decision. A National Institutes of Health Stroke Scale score of 2 is the potential equipoise point, with the least consensus on treatment decision. These preliminary findings require validation in larger population surveys.
Collapse
Affiliation(s)
- Clotilde Balucani
- From the Department of Neurology and Stroke Center (C.B., S.R.L.), Department of Physiology and Pharmacology (R.B.), Department of Scientific Computing (J.W.), and Department of Emergency Medicine (S.R.L.), The State University of New York (SUNY) Downstate Medical Center, Brooklyn; Department of Neurology, TUFTS Medical Center, Boston, MA (E.F., D.K.); and Department of Neurology, The Kings County Hospital Center, Brooklyn, NY (S.R.L.).
| | - Riccardo Bianchi
- From the Department of Neurology and Stroke Center (C.B., S.R.L.), Department of Physiology and Pharmacology (R.B.), Department of Scientific Computing (J.W.), and Department of Emergency Medicine (S.R.L.), The State University of New York (SUNY) Downstate Medical Center, Brooklyn; Department of Neurology, TUFTS Medical Center, Boston, MA (E.F., D.K.); and Department of Neurology, The Kings County Hospital Center, Brooklyn, NY (S.R.L.)
| | - Edward Feldmann
- From the Department of Neurology and Stroke Center (C.B., S.R.L.), Department of Physiology and Pharmacology (R.B.), Department of Scientific Computing (J.W.), and Department of Emergency Medicine (S.R.L.), The State University of New York (SUNY) Downstate Medical Center, Brooklyn; Department of Neurology, TUFTS Medical Center, Boston, MA (E.F., D.K.); and Department of Neurology, The Kings County Hospital Center, Brooklyn, NY (S.R.L.)
| | - Jeremy Weedon
- From the Department of Neurology and Stroke Center (C.B., S.R.L.), Department of Physiology and Pharmacology (R.B.), Department of Scientific Computing (J.W.), and Department of Emergency Medicine (S.R.L.), The State University of New York (SUNY) Downstate Medical Center, Brooklyn; Department of Neurology, TUFTS Medical Center, Boston, MA (E.F., D.K.); and Department of Neurology, The Kings County Hospital Center, Brooklyn, NY (S.R.L.)
| | - Dmitri Kolychev
- From the Department of Neurology and Stroke Center (C.B., S.R.L.), Department of Physiology and Pharmacology (R.B.), Department of Scientific Computing (J.W.), and Department of Emergency Medicine (S.R.L.), The State University of New York (SUNY) Downstate Medical Center, Brooklyn; Department of Neurology, TUFTS Medical Center, Boston, MA (E.F., D.K.); and Department of Neurology, The Kings County Hospital Center, Brooklyn, NY (S.R.L.)
| | - Steven R Levine
- From the Department of Neurology and Stroke Center (C.B., S.R.L.), Department of Physiology and Pharmacology (R.B.), Department of Scientific Computing (J.W.), and Department of Emergency Medicine (S.R.L.), The State University of New York (SUNY) Downstate Medical Center, Brooklyn; Department of Neurology, TUFTS Medical Center, Boston, MA (E.F., D.K.); and Department of Neurology, The Kings County Hospital Center, Brooklyn, NY (S.R.L.)
| |
Collapse
|
46
|
Logallo N, Kvistad CE, Naess H, Waje-Andreassen U, Thomassen L. Mild stroke: safety and outcome in patients receiving thrombolysis. Acta Neurol Scand 2014:37-40. [PMID: 24588505 DOI: 10.1111/ane.12235] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to compare the short-term clinical outcome of patients with acute cerebral ischemia and mild symptoms receiving rt-PA with that of patients with acute cerebral ischemia and mild symptoms not treated with rt-PA, and to investigate the frequency of symptomatic intracranial hemorrhage (sICH) in these patients. MATERIALS AND METHODS All patients with confirmed ischemic stroke/TIA and mild symptoms were included. Mild symptoms were defined as NIHSS score≤5 on admission. Functional outcome was assessed with modified Rankin Scale (mRS) at day 7 or at earlier discharge. Excellent outcome was defined as mRS=0. sICH was defined according to both NINDS and ECASS III criteria. RESULTS Of 2753 patients with confirmed ischemic stroke/TIA admitted between February 2006 and February 2013, 966 (35.3%) were excluded because of having admission NIHSS>5. A total of 1791 patients presented with mild symptoms on admission (NIHSS≤5), of which 158 (8.8%) patients received rt-PA. Treatment with rt-PA and early admission were independently associated with excellent outcome. Higher NIHSS score on admission and prior ischemic stroke were independently associated with poor outcome. Three (1.9%) sICH were diagnosed in rt-PA-treated patients and one (0.1%) in patients not receiving rt-PA. CONCLUSIONS This study highlights the efficacy of rt-PA in patients with acute cerebral ischemia presenting with mild symptoms and confirms the low-risk profile of this treatment.
Collapse
Affiliation(s)
- N. Logallo
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - C. E. Kvistad
- Center for Neurovascular Diseases; Haukeland University Hospital; Bergen Norway
| | - H. Naess
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Center for Neurovascular Diseases; Haukeland University Hospital; Bergen Norway
- Centre for Age-related Medicine; Stavanger University Hospital; Stavanger Norway
| | - U. Waje-Andreassen
- Center for Neurovascular Diseases; Haukeland University Hospital; Bergen Norway
| | - L. Thomassen
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Center for Neurovascular Diseases; Haukeland University Hospital; Bergen Norway
| |
Collapse
|
47
|
Shi L, Zhang M, Liu H, Song B, Song C, Song D, Xu Y. Safety and outcome of thrombolysis in mild stroke: a meta-analysis. Med Sci Monit 2014; 20:2117-24. [PMID: 25362481 PMCID: PMC4228861 DOI: 10.12659/msm.892259] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Whether patients presenting with mild stroke should or should not be treated with intravenous rtPA is still controversial. This systematic review aims to assess the safety and outcome of thrombolysis in these patients. Material/Methods We systematically searched PubMed and Cochrane Central Register of Controlled Trials for studies evaluating intravenous rtPA in patients with mild or rapidly improving symptoms except case reports. Excellent outcome (author reported, mainly mRS 0-1), symptomatic intracranial hemorrhage (sICH) and mortality were analyzed. Results Fourteen studies were included (n=1906 patients). Of these, 4 studies were comparative (2 randomized and 2 non-randomized). The remaining were single-arm studies. On the basis of 4 comparative studies with a total of 1006 patients, the meta-analysis did not identify a significant difference in the odds of excellent outcome (OR=0.86; 95% CI: 0.64–1.15; I2=0) between IV rtPA-treated minor stroke and those without rtPA treatment. Eleven studies involving 1083 patients showed the pooled rate of excellent outcome was 76.1% (95% CI: 69.8–81.5%, I2=42.5). Seven studies involving 378 patients showed the mortality rate was 4.5% (95% CI: 2.6–7.5%, I2=1.4). Twelve studies involving 831 patients showed the pooled rate of sICH was 2.4% (95% CI: 1.5–3.8, I2=0). Conclusions Although efficacy is not clearly established, this study reveals the adverse event rates related to thrombolysis are low in mild stroke. Intravenous rtPA should be considered in these patients until more RCT evidence is available.
Collapse
Affiliation(s)
- Lei Shi
- Department of Neurology, Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| | - Min Zhang
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| | - Hengfang Liu
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| | - Bo Song
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| | - Changdong Song
- Department of Neurology, Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| | - Dandan Song
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| | - Yuming Xu
- Department of Neurology, Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland)
| |
Collapse
|
48
|
Intravenously Administered Tissue Plasminogen Activator Useful in Milder Strokes? A Meta-analysis. J Stroke Cerebrovasc Dis 2014; 23:2156-2162. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/02/2014] [Indexed: 01/03/2023] Open
|
49
|
Abstract
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.
Collapse
Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
| | | |
Collapse
|
50
|
Intravenous thrombolysis for minor stroke and rapidly improving symptoms: a quantitative overview. Neurol Sci 2014; 35:1321-8. [DOI: 10.1007/s10072-014-1859-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 06/17/2014] [Indexed: 10/25/2022]
|