Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency

Nolte, Christian H.; Ebinger, Martin; Scheitz, Jan F.; Kunz, Alexander; Erdur, Hebun; Geisler, Frederik; Braemswig, Tim Bastian; Różański, Michał; Weber, Joachim E.; Wendt, Matthias; Zieschang, Katja; Fiebach, Jochen B.; Villringer, Kersten; Grittner, Ulrike; Kaczmarek, Sabina; Endres, Matthias; Audebert, Heinrich J.

doi:10.1161/strokeaha.117.019060

Cited by 21 publications

(34 citation statements)

References 25 publications

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“…Previously disabled patients do not seem to be different from the others regarding the better outcome related to onset-to-treatment interval. In fact, a recent study by Nolte et al showed that prehospital start of IVT treatment on mobile stroke units, as compared with in-hospital care, may translate into better clinical outcomes in patients with pre-stroke dependency [23].…”

Section: Discussionmentioning

confidence: 99%

Efficacy and Safety of Intravenous Thrombolysis in Patients with Acute Ischemic Stroke and Pre–Existing Disability

Merlino

Corazza

Lorenzut

et al. 2019

JCM

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Little is known about intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with pre-existing disability. Disabled patients are often excluded from IVT treatment. Previous studies investigated the role of pre-existing disability on outcomes in AIS patients after IVT. However, no studies have been conducted to date to determine whether IVT may improve clinical outcomes in AIS patients with pre-existing disability. The aim of our study was to evaluate efficacy and safety of IVT in patients with pre-existing moderate and moderately severe disability (pre-stroke modified Rankin Scale score = 3 or 4) affected by AIS. This study was based on a retrospective analysis of a prospectively collected database of consecutive patients admitted to the Udine University Hospital with AIS from January 2015 to May 2018. The efficacy endpoints were the rate of favorable outcome and rate of major neurological improvement. The safety endpoints were the rate of mortality at three months, presence of intracranial hemorrhage (ICH), and presence of symptomatic intracranial hemorrhage (sICH). The study population included 110 AIS patients with pre-existing moderate and moderately severe disability, 36 of which received (IVT+) and 74 did not receive IVT (IVT−). AIS disabled patients treated with IVT had higher rates of favorable outcome (66.7% vs. 36.5%, p = 0.003) and major neurological improvement (39.4% vs. 17.4%, p = 0.01) compared to non-treated ones. Two in three disabled patients returned to their pre-stroke functional status when treated with IVT. Prevalence of three-month mortality, ICH, and sICH did not differ in the two groups. Disabled patients affected by AIS significantly improved after IVT. Moderate and moderately severe disability alone should not be considered, per se, as a contraindication to IVT treatment.

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Section: Discussionmentioning

confidence: 99%

Efficacy and Safety of Intravenous Thrombolysis in Patients with Acute Ischemic Stroke and Pre–Existing Disability

Merlino

Corazza

Lorenzut

et al. 2019

JCM

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“…106 Despite high mortality rates, observational studies of patients with pre-existing disability have indicated that IVT may prevent further functional deterioration and that treatment is more beneficial the earlier it is given. 107,108 Observational studies have not found evidence that pre-stroke disability is associated with an increased risk of ICH after thrombolytic treatment. 107,109,110 The recommendations for patients with multimorbidity, frailty or pre-stroke disability is based on small observational studies, corresponding to a very low quality of evidence.…”

Section: Expert Consensus Statementmentioning

confidence: 99%

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Berge

Whiteley

Audebert

et al. 2021

European Stroke Journal

681

607

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Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.

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“…With MSUs, earlier thrombolytic therapy—within the first, or golden, hour—after acute ischaemic stroke has been shown to be beneficial for patients with improved functional outcomes—for both patients who were independent and those who needed assistance in activities of daily living before their stroke (28, 37–40). When compared to hospital-based thrombolysis in the first hour after acute stroke, MSUs have been shown to have comparable functional outcomes and mortality at 3 months (41).…”

Section: Introductionmentioning

confidence: 99%

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

et al. 2019

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In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs—especially in rural and remote settings—with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.

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Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency

Abstract: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02358772.

Cited by 21 publications

References 25 publications

Efficacy and Safety of Intravenous Thrombolysis in Patients with Acute Ischemic Stroke and Pre–Existing Disability

Efficacy and Safety of Intravenous Thrombolysis in Patients with Acute Ischemic Stroke and Pre–Existing Disability

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

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