Tissue plasminogen activator; identifying major barriers related to intravenous injection in ischemic acute cerebral infraction

Intra-arterial combination therapy for experimental acute ischemic stroke

Acute ischemic stroke continues to devastate millions of individuals worldwide. Current treatments work to restore blood flow but not rescue affected tissue. Our goal was to develop a combination of neuroprotective agents administered intra-arterially following recanalization to target ischemic tissue. Using C57Bl/6J male mice, we performed tandem transient ipsilateral middle cerebral/common carotid artery occlusion, followed by immediate intra-arterial pharmacotherapy administration through a standardized protocol. Two pharmacotherapy agents, verapamil and lubeluzole, were selected based on their potential to modulate different aspects of the ischemic cascade; verapamil, a calcium channel blocker, works in an acute fashion blocking L-type calcium channels, whereas lubeluzole, an N-methyl-D-aspartate modulator, works in a delayed fashion blocking intracellular glutamate trafficking. We hypothesized that combination therapy would provide complimentary and potentially synergistic benefit treating brain tissue undergoing various stages of injury. Physiological measurements for heart rate and pulse distention (blood pressure) demonstrated no detrimental effects between groups, suggesting that the combination drug administration is safe. Tissue analysis demonstrated a significant difference between combination and control (saline) groups in infarct volume, neuronal health, and astrogliosis. Although a significant difference in functional outcome was not observed, we did note that the combination treatment group had a greater percent change from baseline in forced motor movement as compared with controls. This study demonstrates the safety and feasibility of intra-arterial combination therapy following successful recanalization and warrants further study.

Factors affecting time between symptom onset and emergency department arrival in stroke patients

Background and purpose

Delays in seeking care compromise diagnosis, treatment options, and outcomes in ischemic strokes. This study identified factors associated with time between stroke symptom onset and emergency department (ED) arrival at a private nonprofit medical center serving a large rural catchment area in central Texas, with the goal of identifying symptomatic, demographic, and historical factors that might influence seeking care.

Methods

Demographic and clinical data from a large tertiary care center's Get With The Guidelines (GWTG) database were evaluated in 1874 patients presenting to the ED with a diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, subarachnoid hemorrhage, or ischemic stroke. The dependent variable was time between discovery of stroke symptoms and presentation at the hospital (time-to-ED). Factors entered into regression models predicting time-to-ED within 4 h or categorical time-to-ED.

Results

The average time from symptom onset to presentation was 15.0 h (sd = 23.2), with 43.6% of the sample presenting within 4 h of symptom onset. Results suggested that female gender (Odds Ratio [OR] = 0.70; 95% Confidence Interval [CI] 0.23–0.74), drug abuse (OR = 0.41; CI 0.23–0.74), and diabetes were significantly associated with longer time to presentation.

Conclusions

A combination of demographics, stroke severity, timing, and health history contributes to delays in presenting for treatment for ischemic stroke. Stroke education concentrating on symptom recognition may benefit from a special focus on high-risk individuals as highlighted in this study.

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Patients that had stroke symptoms occurring during the daytime were more likely to present within 4h of symptom onset.

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Females and younger patients were more likely to arrive after 4h of symptom onset.

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Comorbid conditions such as diabetes and substance abuse were associated with delayed presentation times.

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Other comorbid conditions such as hypertension or dyslipidemia were not associated with decreased time of presentation.