Association of Time to Thrombolysis With Early Reperfusion After Alteplase and Tenecteplase in Patients With Large Vessel Occlusion

BACKGROUND AND OBJECTIVES

Early treatment with intravenous alteplase increases the probability of lytic-induced reperfusion in large vessel occlusion (LVO) patients. The relationship of tenecteplase-induced reperfusion and the timing of thrombolytic administration has not been explored. In this study, we performed a comparative analysis of tenecteplase and alteplase reperfusion rates and assessed their relationship to the time of thrombolytic administration.

METHODS

Patients who were initially treated with a thrombolytic within 4.5 hours of symptom onset were pooled from the Royal Melbourne Stroke Registry, EXTEND-IA, EXTEND-IA TNK, and EXTEND-IA TNK part 2 trials. The primary outcome, thrombolytic-induced reperfusion, was defined as the absence of retrievable thrombus or >50% reperfusion at initial angiographic assessment (or repeat CT perfusion/angiography). We compared the treatment effect of tenecteplase and alteplase through fixed-effects Poisson regression modelling.

RESULTS

Among 846 patients included in the primary analysis, early reperfusion was observed in 173 (20%) patients (tenecteplase: 98/470 [21%], onset-to-thrombolytic time: 132 minutes [interquartile range (IQR): 99-170], and thrombolytic-to-assessment time: 61 minutes [IQR: 39-96]; alteplase: 75/376 [19%], onset-to-thrombolytic time: 143 minutes [IQR: 105-180], thrombolytic-to-assessment time: 92 minutes [IQR: 63-144]). Earlier onset-to-thrombolytic administration times were associated with an increased probability of thrombolytic-induced reperfusion in patients treated with either tenecteplase (adjusted risk ratio [aRR] 1.05 per 15 minutes [95% confidence interval (CI) 1.00-1.12] or alteplase (aRR 1.06 per 15 minutes [95% CI 1.00-1.13]). Tenecteplase remained associated with higher rates of reperfusion vs alteplase after adjustment for onset-to-thrombolytic time, occlusion site, thrombolytic-to-assessment time, and study as a fixed effect, (adjusted incidence rate ratio: 1.41 [95% CI 1.02-1.93]). No significant treatment-by-time interaction was observed (p = 0.87).

DISCUSSION

In patients with LVO presenting within 4.5 hours of symptom onset, earlier thrombolytic administration increased successful reperfusion rates. Compared with alteplase, tenecteplase was associated with a higher probability of lytic-induced reperfusion, independent of onset-to-lytic administration times.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifiers: NCT02388061, NCT03340493.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that among patients with LVO receiving a thrombolytic, reperfusion was more likely with tenecteplase than alteplase.

Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well: The SELECT Late Study

Importance

The role of endovascular thrombectomy is uncertain for patients presenting beyond 24 hours of the time they were last known well.

Objective

To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) vs medical management in patients with large-vessel occlusion beyond 24 hours of last known well.

Design, Setting, and Participants

This retrospective observational cohort study enrolled patients between July 2012 and December 2021 at 17 centers across the United States, Spain, Australia, and New Zealand. Eligible patients had occlusions in the internal carotid artery or middle cerebral artery (M1 or M2 segment) and were treated with EVT or medical management beyond 24 hours of last known well.

Interventions

Endovascular thrombectomy or medical management (control).

Main Outcomes and Measures

Primary outcome was functional independence (modified Rankin Scale score 0-2). Mortality and symptomatic intracranial hemorrhage (sICH) were safety outcomes. Propensity score (PS)-weighted multivariable logistic regression analyses were adjusted for prespecified clinical characteristics, perfusion parameters, and/or Alberta Stroke Program Early CT Score (ASPECTS) and were repeated in subsequent 1:1 PS-matched cohorts.

Results

Of 301 patients (median [IQR] age, 69 years [59-81]; 149 female), 185 patients (61%) received EVT and 116 (39%) received medical management. In adjusted analyses, EVT was associated with better functional independence (38% vs control, 10%; inverse probability treatment weighting adjusted odds ratio [IPTW aOR], 4.56; 95% CI, 2.28-9.09; P < .001) despite increased odds of sICH (10.1% for EVT vs 1.7% for control; IPTW aOR, 10.65; 95% CI, 2.19-51.69; P = .003). This association persisted after PS-based matching on (1) clinical characteristics and ASPECTS (EVT, 35%, vs control, 19%; aOR, 3.14; 95% CI, 1.02-9.72; P = .047); (2) clinical characteristics and perfusion parameters (EVT, 35%, vs control, 17%; aOR, 4.17; 95% CI, 1.15-15.17; P = .03); and (3) clinical characteristics, ASPECTS, and perfusion parameters (EVT, 45%, vs control, 21%; aOR, 4.39; 95% CI, 1.04-18.53; P = .04). Patients receiving EVT had lower odds of mortality (26%) compared with those in the control group (41%; IPTW aOR, 0.49; 95% CI, 0.27-0.89; P = .02).

Conclusions and Relevance

In this study of treatment beyond 24 hours of last known well, EVT was associated with higher odds of functional independence compared with medical management, with consistent results obtained in PS-matched subpopulations and patients with presence of mismatch, despite increased odds of sICH. Our findings support EVT feasibility in selected patients beyond 24 hours. Prospective studies are warranted for confirmation.

Abstract 36: Endovascular Thrombectomy Beyond 24 Hours From Last Known Well: A Pooled Multicenter International Cohort

Background: Limited data are available on endovascular thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) patients presenting >24hr from last known well (LKW). We compared outcomes between patients receiving EVT and best medical management (MM) in a multicenter international cohort.

Methods: Consecutive patients with anterior circulation LVO presenting >24h after LKW from 13 centers from 7/2012-4/2021 were analyzed. Multivariable models for 90d mRS distribution and symptomatic ICH were adjusted for age, NIHSS, glucose, IV tPA, transfer status, clot location, time from LKW, CT ASPECTS and ischemic core (rCBF<30%) and Tmax >6s volumes.

Results: Of 240 patients with a median (IQR) LKW to presentation 28.3h (24.9-38.2), 153 (64%) received EVT. Baseline characteristics were similar except for NIHSS (EVT: 13 (8-20) vs MM: 17 (10-22), p=0.005), CT ASPECTS (EVT: 8(6-9) vs MM: 4(3-6), p<0.001) and ischemic core 2.5(0-13) vs 15(0-71) mL, p<0.001. EVT was associated with a better shift in 90d mRS (acOR: 2.45, 95% CI=1.42-4.22, p=0.001), higher functional independence (42% vs 10%, aOR: 4.84, 95% CI=2.02-11.64, p<0.001) and numerically lower mortality (22% vs 42%, aOR: 0.50, 95% CI=0.23-1.06, p=0.071), Fig 1A. However, EVT was associated with numerically higher sICH (5.5% vs 0%, p=0.10). Following EVT, 82% achieved successful reperfusion (mTICI 2b-3), which was associated with better shift in 90d mRS (acOR: 5.82, 95% CI: 1.77-19.10, p=0.004), higher functional independence (44% vs 22%, aOR: 5.03, 95% CI: 0.87-29.12, p=0.07) and lower mortality (20% vs 52%, aOR: 0.08, 95% CI: 0.01-0.57, p=0.01), Fig 1B.

Conclusions: EVT may be associated with better functional outcomes, despite numerically increased risk of sICH in patients presenting with anterior circulation LVO beyond 24 hours. Further prospective studies are warranted.

Warfarin-associated intracerebral hemorrhage: volume, anticoagulation intensity and location

BACKGROUND

Warfarin use increases mortality in patients with intracerebral hemorrhage (ICH). Larger hematoma volume and infratentorial location are both major determinants of poor outcome in ICH. Although warfarin-associated intracerebral hemorrhages have greater volumes, there is uncertainty about the effects of location. We aimed to investigate the influence of warfarin on hematoma volume and location.

METHODS

We conducted a retrospective study of all patients hospitalized for ICH at a large stroke center from October 2007 to January 2012. Initial CT scans were used to quantify hematoma volumes using the computer-assisted planimetric analysis. Univariate and multivariable analyses determined the influence of warfarin on hemorrhage location. Median regression analysis was performed to estimate the effects of INR on hematoma volumes.

RESULTS

We included 404 consecutive patients with ICH of whom 69 were on warfarin. Patients on warfarin had larger hematoma volumes (median 23.9mL vs. 14.2mL; P=0.046). In patients excessively anticoagulated with warfarin (defined as INR>3.0), compared with those in the therapeutic range, brainstem ICH was more frequent (24.0% vs. 6.1%; P=0.005). Patients with INR>3.0 had increased odds of infratentorial hemorrhage (OR 3.63; 95% CI 1.52-8.64; P=0.004) when compared to non-warfarin ICH patients. After adjustment for hematoma location, there was no significant association between INR and hematoma volume.

CONCLUSIONS

Patients with warfarin-associated ICH have a predilection for brainstem ICH. After adjustment for ICH location, no relationship between admission INR and hematoma volume was found.

Radioprotective effect of rhizome extract of Zingiber montanum in Rattus norvegicus

The present study aims at determining the ability of 60% ethanol extract of the rhizome of Zingiber montanum (J. König) A. Dietr. to protect bone marrow cells in vivo from radiation-induced chromosomal aberrations. Albino rats (Rattus norvegicus, 2n = 42) were used to carry out investigations on the radioprotective properties of Z. montanum. Acute toxicity of the extract was determined, and a suitable injectable dose was selected for intra-peritoneal administration. The LD(50) of the extract calculated for 72 h was 2.9 g/kg, and the calculated LD(10) dose was 1.7 g/kg. The calculated maximum tolerated dose of the rhizome extract was 1.3 g/kg. Rats were divided into 12 groups (with or without the administration of extract) and exposed to different radiation doses from 1 to 5 Gy. Whole-body irradiation of rats showed a significant dose-dependent increase in different types of chromosomal aberrations. The most common chromosomal aberrations were breaks, fragments, gaps, rings, endoreduplications and dicentric chromosomes. Ethanol extract of rhizome at a dose of 0.5 g/kg did not show any significant increase in chromosomal aberrations in unirradiated animals as compared to that of the control group. Intra-peritoneal administration of the extract at a dose of 0.5 g/kg considerably reduced the frequency of the aberrations stated above in irradiated animals with DMF value of 1.36 at 1 to 5 Gy dose range of gamma radiation. The incidence of micronucleated polychromatic erythrocytes and micronucleated normochromatic erythrocytes due to the radiation exposure was considerably reduced in extract-treated groups of animals with DMFs 1.34 and 1.17, respectively, as compared to that of the extract-untreated groups. Our results suggest that rhizome extract of Z. montanum may have a potential in protecting normal hematopoietic cells from radiation-induced damage.

In vitro propagation and rhizome formation in Curcuma longa Linn

Turmeric (Curcuma longa Linn.) which is cultivated by underground rhizomes is a slow propagating species. Multiplication and callus induction starting from the rhizome buds and shoot tips of C. longa in MS medium was carried out. A combination of naphthalene acetic acid (NAA; 1.0 mg/l) with kinetin (Kn; 1.0 mg/l) or NAA (1.0 mg/l) with 6-benzylaminopurine (BAP; 2.0 mg/l) was optimum for rapid clonal propagation of turmeric. A concentration of 2.5-3.0 mg/l of 2,4-dichlorophenoxy-acetic acid (2,4-D) was found to be optimum for callus induction. Regeneration of plantlets from a callus was successfully conducted in MS medium supplemented with standard growth hormones for multiplication at 25 +/- 2 degrees C under a 16 h photoperiod. These plantlets were successfully transferred to the field. Plantlets (4-month-old) were incubated in a medium containing different concentrations of sucrose supplemented with NAA (0.1 mg/l) and Kn (1.0 mg/l) at 27 +/- 2 degrees C under an 8 h photoperiod for induction of rhizomes. In vitro rhizome formation was observed in media containing 6 and 8% sucrose.

Effect of plant extracts and systemic fungicide on the pineapple fruit-rotting fungus, Ceratocystis paradoxa

Antifungal activities of extracts of sixteen plants were tested against Ceratocystis paradoxa which causes soft rot of pineapples. Xanthium strumarium was the most effective followed by Allium sativum. The effectiveness of various extracts against C. paradoxa was in the decreasing order of Meriandra bengalensis, Mentha piperita, Curcuma longa, Phlogacanthus thyrsiflorus, Toona ciliata, Vitex negundo, Azadirachta indica, Eupatorium birmanicum, Ocimum sanctum and Leucas aspera. Extracts of Cassia tora, Gynura cusimba, Calotropis gigantea and Ocimum canum showed poor fungitoxicity. Ethanol was suitable for extraction of the inhibitory substance from X. strumarium. Acetonitrile was highly toxic to this fungus. Millipore filter-sterilized extracts had a more inhibitory effect on the fungus than the autoclaved samples. Treatment of pineapple fruits infested with C. paradoxa by X. strumarium extract reduced the severity of the disease.