The Factors Associated with the Decision of r-tPA Use in Acute Ischemic Stroke Patients Aged 80 Years or Older

Background Small proportions of all the elderly stroke patients receive recombinant tissue plasminogen activator (r-tPA) therapy, although old age is not a proven contraindication to intravenous thrombolytic therapy for acute ischemic stroke. The purpose of this study was to identify reasons for exclusion from r-tPA therapy and factors associated with the decision of r-tPA use in elderly patients with acute ischemic stroke. Methods From the acute stroke registries of 22 domestic university hospitals taking the r-tPA therapy from January 2007 to May 2010, we extracted data of all acute ischemic stroke patients who were aged 80 or over and arrived within onset 3 hours. For all patients, we assessed the eligibility of r-tPA therapy using National Institute of Neurological Disorders and Stroke (NINDS) r-tPA trial criteria. For eligible patients, we compared all clinical variables between patients who were treated with r-tPA and those who were not, and analyzed potential factors related to the decision of r-tPA use. Results A total of 494 patients were included in this study. 255 patients (51.6%) were excluded by NINDS r-tPA trial criteria and the major reasons for exclusion were minor neurological deficit (53.7%) and clinical improvement (17.3%). Among 239 patients who were eligible for r-tPA, 162 (32.8%) patients received r-tPA and 77 (15.6%) did not. Multivariable analysis showed that younger age, shorter time-delay from onset to admission, non-smoker, no history of prior stroke, good pre-stroke functional status and severe initial neurological deficit were independently associated with the decision of r-tPA use in the elderly stroke patients predictors for r-tPA treatment. Conclusion In very elderly patients, mild neurological deficit on arrival and rapid clinical improvement in neurological symptoms were the main reasons for exclusion from thrombolytic therapy.ope

Int J Stroke

BackgroundLimited studies exist on the outcome of thrombolytic therapy of acute ischemic stroke patients outside of clinical trials.AimTo assess the possible risk factors associated with in-hospital death and symptomatic intracerebral hemorrhage among patients who received intravenous tissue plasminogen activator.MethodsA total of 7193 patients with a clinical diagnosis of acute ischemic stroke and a documented National Institutes of Health Stroke Scale score were treated with intravenous tissue plasminogen activator within 4\uc2\ub75 hours of time last known to be well. Generalized estimating equations modeling was used to assess the associations of in-hospital death and symptomatic intracerebral hemorrhage with clinical characteristics.ResultsAmong 7193 patients treated with intravenous tissue plasminogen activator, 516 (7\uc2\ub72%) died during hospitalization. Factors associated with in-hospital death were older age, male gender, National Institutes of Health Stroke Scale score, history of myocardial infarction or coronary artery disease, and history of nonvalvular atrial fibrillation. Increasing age, higher National Institutes of Health Stroke Scale score, and history of dyslipidemia were associated with symptomatic intracerebral hemorrhage. There was no difference in the rates of in-hospital death or symptomatic intracerebral hemorrhage among patients treated with intravenous tissue plasminogen activator within three-hours of time last known to be well and those treated between three and 4\uc2\ub75 hours after this time.ConclusionsIn this study of acute ischemic stroke patients, older age, male gender, National Institutes of Health Stroke Scale score, history of myocardial infarction or coronary artery disease, and history of atrial fibrillation were associated with increased in-hospital death among patients receiving intravenous tissue plasminogen activator. Among patients treated with intravenous tissue plasminogen activator, in-hospital mortality and symptomatic intracerebral hemorrhage rates were similar between those treated within three-hours of time last known to be well and those treated between three and 4\uc2\ub75 hours after this time.CC999999/Intramural CDC HHS/United States2015-06-02T00:00:00Z24024962PMC445111

Intravenous thrombolytic treatment in the oldest old

Background and Purpose. Intravenous thrombolysis using tissue plasminogen activator is safe and probably effective in patients >80 years old. Nevertheless, its safety has not been specifically addressed for the oldest old patients (≥85 years old, OO). We assessed the safety and effectiveness of thrombolysis in this group of age. Methods. A prospective registry of patients treated with intravenous thrombolysis. Patients were divided in two groups (<85 years and the OO). Demographic data, stroke aetiology and baseline National Institute Health Stroke Scale (NIHSS) score were recorded. The primary outcome measures were the percentage of symptomatic intracranial haemorrhage (SICH) and functional outcome at 3 months (modified Rankin Scale, mRS). Results. A total of 1,505 patients were registered. 106 patients were OO [median 88, range 85–101]. Female sex, hypertension, elevated blood pressure at admission, cardioembolic strokes and higher basal NIHSS score were more frequent in the OO. SICH transformation rates were similar (3.1% versus 3.7%, P = 1.00). The probability of independence at 3 months (mRS 0–2) was lower in the OO (40.2% versus 58.7%, P = 0.001) but not after adjustment for confounding factors (adjusted OR, 0.82; 95% CI, 0.50 to 1.37; P = 0.455). Three-month mortality was higher in the OO (28.0% versus 11.5%,P < 0.001). Conclusion. Intravenous thrombolysis for stroke in OO patients did not increase the risk of SICH although mortality was higher in this groupThis work is part of the Spanish collaborative research network RENEVAS (Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, RD06/0026/008, RD07/0026/2003

Acute Stroke Intervention In Young Patients

Purpose: Stroke is a disease of the elderly, however it can affect the younger patients. We present a retrospective review of our series of young patients (55 years old and younger), treated at our institution from 2007 to 2012, to assess the safety, efficacy and patient outcome of multimodal endovascular treatment in this patient population. Methods: A total of 42 patients underwent multimodal endovascular revascularization for acute ischemic events. Recanalization rates were assessed using the Thrombolysis in Myocardial Infarction (TIMI)and clinical outcomes were assessed using the Modified Rankin Scale (mRS) obtained at discharge and follow-up visits. Patient demographics, medical co-morbidities, treatment complications and mortality data were collected and analyzed. Results: Of 42 patients, an improvement in Thrombolysis in Myocardial Infarction score (TIMI score) was noted in 38 patients (90.47%). The average modified Rankin Scale score on discharge was 3.2 with 25 patients (60%) having a favorable score of 0-3. All 21 patients (100%) with available clinical follow-up had a favorable mRS score (mean follow-up of 10.4 months). Symptomatic intracranial hemorrhage occurred in four patients (9.5%); none required surgery. Three fatalities resulted from intraoperative vessel rupture (7.14%). Conclusion: We observed good recanalization rates and favorable clinical outcomes after endovascular stroke intervention in young patients. Also, there was a low morbidity and mortality rate overall. Therefore multimodal endovascular recanalization of acute ischemic stroke is an effective treatment in younger patients, which justifies aggressive management of those patients

Does Preexisting Antiplatelet Treatment Influence Postthrombolysis Intracranial Hemorrhage in Community‐treated Ischemic Stroke Patients? An Observational Study

Objectives Intracranial hemorrhage ( ICH ) after acute stroke thrombolysis is associated with poor outcomes. Previous investigations of the relationship between preexisting antiplatelet use and the safety of intravenous ( IV ) thrombolysis have been limited by low event rates. The objective of this study was to determine whether preexisting antiplatelet therapy increased the risk of ICH following acute stroke thrombolysis. The primary hypothesis was that antiplatelet use would not be associated with radiographic evidence of ICH after controlling for relevant confounders. Methods Consecutive cases of thrombolysis patients treated in the emergency department (ED) were identified using multiple methods. Retrospective data were collected from four hospitals from 1996 to 2004 and 24 other hospitals from 2007 to 2010 as part of a cluster‐randomized trial. The same chart abstraction tool was used during both time periods, and data were subjected to numerous quality control checks. Hemorrhages were classified using a prespecified methodology: ICH was defined as presence of hemorrhage in radiographic interpretations of follow‐up imaging (primary outcome). Symptomatic ICH ( sICH ) was defined as radiographic ICH with associated clinical worsening. A multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to postthrombolysis ICH. Sensitivity analyses were conducted where the unadjusted and adjusted results from this study were combined with those of previously published external studies on this topic via meta‐analytic techniques. Results There were 830 patients included, with 47% having documented preexisting antiplatelet treatment. The mean (± standard deviation [SD]) age was 69 (±15) years, and the cohort was 53% male. The unadjusted proportion of patients with any ICH was 15.1% without antiplatelet use and 19.3% with antiplatelet use (absolute risk difference = 4.2%, 95% confidence interval [CI] = −1.2% to 9.6%); for sICH this was 6.1% without antiplatelet use and 9% with antiplatelet use (absolute risk difference = 3.1%, 95% CI = −1% to 6.7%). After adjusting for confounders, antiplatelet use was not significantly associated with radiographic ICH (odds ratio [OR] = 1.1, 95% CI = 0.8 to 1.7) or sICH (OR = 1.3, 95% CI = 0.7 to 2.2). In patients 81 years and older, there was a higher risk of radiographic ICH (absolute risk difference = 11.9%, 95% CI = 0.1% to 23.6%). The meta‐analyses combined the findings of this investigation with previous similar work and found increased unadjusted risks of radiographic ICH (absolute risk difference = 4.9%, 95% CI = 0.7% to 9%) and sICH (absolute risk difference = 4%, 95% CI = 2.3% to 5.6%). The meta‐analytic adjusted OR of sICH for antiplatelet use was 1.6 (95% CI = 1.1 to 2.4). Conclusions The authors did not find that preexisting antiplatelet use was associated with postthrombolysis ICH or sICH in this cohort of community treated patients. Preexisting tobacco use, younger age, and lower severity were associated with lower odds of sICH . The meta‐analyses demonstrated small, but statistically significant increases in the absolute risk of radiographic ICH and sICH , along with increased odds of sICH in patients with preexisting antiplatelet use. Resumen ¿Influye el Tratamiento Antiagregante Previo en la Hemorragia Intracraneal tras la Trombolisis en los Pacientes con Ictus Isquémicos Tratados en la Comunidad? Un Estudio Observacional Objetivos La hemorragia intracraneal ( HIC ) tras la trombolisis de un ictus agudo se asocia con malos resultados. Los estudios previos de la relación entre el uso de antiagregantes y la seguridad de la trombolisis intravenosa ( IV ) han estado limitados por los porcentajes bajos de sucesos. El objetivo de este estudio fue determinar si el tratamiento antiagregante previo está asociado con la evidencia radiológica de HIC tras el control por los factores de confusión relevantes. Metodología Se identificaron los casos consecutivos de pacientes tratados con trombolisis en el SU de múltiples formas. Se recogieron los datos de forma retrospectiva de cuatro hospitales de 1996 a 2004 y de 24 hospitales distintos de 2007 a 2010 como parte de un ensayo clínico aleatorizado en racimos. Se utilizó la misma tabla resumen de historia clínica durante ambos periodos de tiempo y los datos fueron sometidos a numerosos controles de calidad. Las hemorragias se clasificaron siguiendo una metodología preestablecida: la HIC se definió como la presencia de hemorragia en las interpretaciones radiológicas de las imágenes de seguimiento (resultado primario); y la HIC sintomática ( HIC s) se definió como la HIC radiológica asociada con un empeoramiento clínico. Se construyó un modelo multivariable de regresión logística para ajustar los factores clínicos previamente identificados como relacionados con un la HIC tras la trombolisis. Los análisis de sensibilidad se realizaron mediante técnicas de metanálisis y se combinaron los resultados ajustados y no ajustados de esta investigación con los estudios externos previamente publicados en este tema. Resultados Se incluyeron 830 pacientes, de los cuales el 47% tenía documentado tratamiento antiagregante previo. La media de edad fue de 69 años, y el 53% eran varones. La proporción no ajustada de pacientes con cualquier tipo de HIC fue del 15,1% sin toma de antiagregante y del 19,3% con la toma de antiagregante (diferencia del riesgo absoluto 4,2%, IC 95% = −1,2% a 9,6%); y para las HIC s fue del 6,1% sin toma de antiagregantes y del 9% con la toma de antiagregantes (diferencia absoluta del riesgo 3,1%, IC 95% = −1% a 6,7%). Tras ajustar por los factores de confusión, la toma de antiagregantes no se asoció de forma significativa con la HIC radiológica ( OR 1,1, IC 95% = 0,8 a 1,7]) o HIC s ( OR 1,3, IC 95% = 0,7 a 2,2). En los pacientes de 81 años o más, hubo mayor riesgo de HIC radiológica (diferencia de riesgo absoluta 11,9%, IC 95% = 0,1% a 23,6%). El metanálisis que combinó los hallazgos de esta investigación con los trabajos similares previos encontró un riesgo no ajustado incrementado para la HIC radiológica (diferencia absoluta del riesgo 4,9%, IC 95% = 0,7% a 9%) y de HIC s (diferencia absoluta del riesgo 4%, IC 95% = 2,3% a 5,6%). La odds ratio ajustada del metanálisis de HIC s para los pacientes con tratamiento de antigregantes fue de 1,6 ( IC 95% = 1,1 a 2,4). Conclusiones Los autores no encontraron que la toma previa de antigregantes se asocie con la HIC o la HIC s tras la trombolisis en esta cohorte de pacientes tratados en la comunidad. El consumo previo de tabaco, la edad más joven y la menor gravedad se asociaron con odds ratio menores de HIC s. El metanálisis demostró un incremento bajo, aunque estadísticamente significativo, de riesgo absoluto de HIC radiológica o de HIC s, con una odds ratio aumentada de HIC s en los pacientes con toma previa de antiagregantes.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96759/1/acem12077.pd

Endovascular Thrombectomy for Patients Over the Age of 75 with Acute Ischemic Stroke: A Systematic Review

Stroke is a leading cause of disability and death worldwide. According to Slawski et al. (2018), strokes will more than double in 2050, with the greatest percentage of affected patients being over the age of 75. Administering interventions to patients affected by acute ischemic stroke (AIS) has been a controversial topic when elderly patients were involved (Alawieh et al., 2018). Elderly patients have been known to be excluded from clinical trials solely due to their age and comorbidities (Karhi et al., 2018). The purpose of this project was to determine if the use of endovascular thrombectomy (EVT) is recommended for elderly patients over the age of 75 years of age who have suffered an acute ischemic stroke from a large vessel occlusion (LVO). Six studies met inclusion and were included in this systematic review. The overall findings of this systematic review suggest the use of EVT to be effective for elderly patients over the age of 75 years of age who have suffered an AIS from an LVO. Despite high mortality rates and less favorable outcomes in the elderly cohorts in the six studies, four of the six articles concluded that the alternative of not providing thrombectomy could have detrimental outcomes. Implications of this systematic review include the importance of the advanced practice nurse’s (APRN) role in advocating and educating patients and families about the benefits of receiving thrombectomy after suffering an AIS from an LVO. In addition, APRNs should educate their colleagues about the evidence regarding thrombectomy in order help bridge the gap in the lack of knowledge regarding EVT in the elderly population

Added value of acute multimodal CT-based imaging (MCTI) : a comprehensive analysis

Introduction: MCTI is used to assess acute ischemic stroke (AIS) patients.We postulated that use of MCTI improves patient outcome regardingindependence and mortality.Methods: From the ASTRAL registry, all patients with an AIS and a non-contrast-CT (NCCT), angio-CT (CTA) or perfusion-CT (CTP) within24 h from onset were included. Demographic, clinical, biological, radio-logical, and follow-up caracteristics were collected. Significant predictorsof MCTI use were fitted in a multivariate analysis. Patients undergoingCTA or CTA&amp;CTP were compared with NCCT patients with regards tofavourable outcome (mRS ≤ 2) at 3 months, 12 months mortality, strokemechanism, short-term renal function, use of ancillary diagnostic tests,duration of hospitalization and 12 months stroke recurrence