Delayed Intravenous Thrombolysis in Patients with Minor Stroke

Yoo, Joonsang; Sohn, Sung Il; Kim, Jinkwon; Ahn, Seong Hwan; Lee, Kijeong; Baek, Jang Hyun; Kim, Kyoungsub; Hong, Jeong Ho; Koo, Jaseong; Kwak, Jin Ho; Nam, Hyo Suk; Heo, Ji Hoe

doi:10.1159/000492123

Cited by 10 publications

(9 citation statements)

References 19 publications

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“…Our findings are clinically relevant due to the substantial number of tPA‐eligible AIS patients precluded from IVT only because of mild symptoms at hospital admission [28,29] and the possibility of neurological deterioration during the first hours of hospitalization in patients with AIS due to large vessel occlusions [30,31]. Also taking into account the increased delays in IVT administration for AIS patients with mild neurological deficits on admission [32‐34] and the inverse relationship between onset to bolus time and functional improvement in AIS patients with large vessel occlusions [35], prompt tPA delivery for these patients appears to be crucial for their outcome independent of their eligibility for MT. The lack of difference in 3‐month functional outcomes according to MT treatment highlighted in our report (Fig.…”

Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

Tsivgoulis

Goyal

Katsanos

et al. 2020

Euro J of Neurology

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Background and purpose: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. Methods: The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. Results: We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 AE 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. Conclusions: Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.

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Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

Tsivgoulis

Goyal

Katsanos

et al. 2020

Euro J of Neurology

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“…Although age, vascular risk factors other than dyslipidemia, and occlusion site did not change over time, stroke severity slightly decreased. This may be ascribed to the increase in reperfusion therapy for minor stroke and decrease in the prevalence of atrial fibrillation-or atrial flutter-related stroke [20,21]. Furthermore, time from stroke onset to ED was longer than those in previous studies because patient eligibility for EVT might be based more on imaging parameters recently, instead of the time window paradigm [22].…”

Section: Discussionmentioning

confidence: 99%

Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic or Endovascular Treatment in Korea: from the SECRET Study

Heo

Yoo

Park

et al. 2020

JCM

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We investigated whether there was an annual change in outcomes in patients who received the thrombolytic therapy or endovascular treatment (EVT) in Korea. This analysis was performed using data from a nationwide multicenter registry for exploring the selection criteria of patients who would benefit from reperfusion therapies in Korea. We compared the annual changes in the modified Rankin scale (mRS) at discharge and after 90 days and the achievement of successful recanalization from 2012 to 2017. We also investigated the determinants of favorable functional outcomes. Among 1230 included patients, the improvement of functional outcome at discharge after reperfusion therapy was noted as the calendar year increased (p < 0.001). The proportion of patients who were discharged to home significantly increased (from 45.6% in 2012 to 58.5% in 2017) (p < 0.001). The successful recanalization rate increased over time from 78.6% in 2012 to 85.1% in 2017 (p = 0.006). Time from door to initiation of reperfusion therapy decreased over the years (p < 0.05). These secular trends of improvements were also observed in 1203 patients with available mRS data at 90 days (p < 0.05). Functional outcome was associated with the calendar year, age, initial stroke severity, diabetes, preadmission disability, intervals from door to reperfusion therapy, and achievement of successful recanalization. This study demonstrated the secular trends of improvement in functional outcome and successful recanalization rate in patients who received reperfusion therapy in Korea.

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“…There were numerous possibilities to explain why more patients with non-disabling stroke (NIHSS ≤4) during the post-intervention group. Previous studies showed longer DNT in patients with minor stroke, possibly due to higher chance of atypical symptoms, delayed neurology notification and diagnosis [23,24]. The early diagnosis and decision making from better implementation of the Stroke: Target strategies in the postintervention group would naturally increase IVT for patients with minor strokes.…”

Section: Discussionmentioning

confidence: 99%

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

Tran

Zhu

Shafie

et al. 2019

Preprint

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Background: The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 min at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods: This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre-and post-intervention groups. Results: Ninety and 136 patients were treated with IVT in pre-and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p = 0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 min (63[53-81] vs. 40[29-53], p < 0.001) with more patients in the post-intervention group receiving IVT within 60 min (81.6% vs. 46.7%) and 45 min (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0-1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions: Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.

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Delayed Intravenous Thrombolysis in Patients with Minor Stroke

Cited by 10 publications

References 19 publications

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic or Endovascular Treatment in Korea: from the SECRET Study

Three Easily-Implementable Changes Reduce Median Door-To-Needle Time for Intravenous Thrombolysis by 23 Minutes

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