Protocol adherence and safety of intravenous thrombolysis after telephone consultation with a stroke center.

Intravenous tissue plasminogen activator (tPA) for acute ischemic stroke must be provided in an appropriate setting. The best way to provide thrombolysis in small community hospitals remains uncertain. Medical records were reviewed of tPA treatments at a stroke center between January 2002 and October 2005. The stroke center provides phone consultation for acute stroke to smaller hospitals in the region. Subjects were classified into 3 groups: tPA started at referring hospitals before transfer (treat and transfer group), tPA started at the stroke center after transfer (transfer and treat group), and the control group of patients who presented directly to the stroke center and received tPA (stroke center group). We recorded the patient and treatment characteristics, protocol deviations, symptomatic intracranial hemorrhage (ICH), and in-hospital deaths. There were 133 patients in the treat and transfer group, 35 patients in the transfer and treat group, and 86 patients in the stroke center group. Time from onset to treatment was similar in the treat and transfer and the stroke center groups, but the door-to-needle time was shorter by 12 minutes in the latter (P=.02). Fifty-five protocol deviations occurred in 38% patients in the treat and transfer group, compared with 6% in the stroke center group (P<.001). The most common deviations were related to time window violations and incorrect tPA dosing. Symptomatic ICH occurred in 8.2%, with no significant difference between the groups. Neither community hospital treatment nor protocol deviation was a predictor of symptomatic ICH or in-hospital mortality. Our findings indicate the need for improved protocol adherence for stroke thrombolysis in patients presenting to small community hospitals.

Uchino K ，Massaro L ，Jovin TG ，Hammer MD ，Wechsler LR ... -  《-》

Risk of thrombolytic therapy for acute ischemic stroke in patients with current malignancy.

Little is known about the risk of thrombolysis in patients with malignancy, because these patients have been excluded from most clinical trials. We reviewed our acute ischemic stroke (AIS) database for clinical outcomes and complications in patients with current malignancy (CM) who received thrombolytic therapy. Consecutive AIS patients receiving thrombolysis between January 2003 and December 2006 were retrospectively abstracted in accordance with the American Stroke Association's Get With the Guidelines-Stroke definitions and charts were reviewed for history of malignancy. Patients with brain metastases did not receive tissue plasminogen activator (tPA). Stepwise logistic regression was used to identify independent predictors of in-hospital mortality. Of 308 AIS patients treated with thrombolytic therapy, 210 (68%) received intravenous (IV) tPA only, 41 (13%) received IV tPA plus intra-arterial therapy (IAT), and 57 (18%) received IAT only. Eighteen patients (5.8%) had a CM, and 26 patients (8.4%) had a remote history of malignancy. Patients with CM had a higher in-hospital mortality (38.9% vs 19.7 %; P=.05) and were more likely to have died due to worsening medical comorbidity (71.4% vs 9.6%; P < .001). The rate of symptomatic intracranial hemorrhage (ICH) was similar in the 2 groups (5.6% vs 2.7%; P=.47). In multivariate analysis, the only independent predictors of mortality were National Institutes of Health Stroke Scale score, history of hypertension, and smoking. CM was not independently associated with increased in-hospital mortality following thrombolysis. Mortality was attributable largely to medical comorbidities, not to symptomatic ICH. Our data suggest that thrombolysis may be a reasonable option for patients with malignancy who have acceptable medical comorbidities and performance status. Further research is warranted.

Masrur S ，Abdullah AR ，Smith EE ，Hidalgo R ，El-Ghandour A ，Rordorf G ，Schwamm LH ... -  《-》

Older age does not increase risk of hemorrhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke.

Pundik S ，McWilliams-Dunnigan L ，Blackham KL ，Kirchner HL ，Sundararajan S ，Sunshine JL ，Tarr RW ，Selman WR ，Landis DM ，Suarez JI ... -  《-》

Tissue plasminogen activator thrombolytic therapy for acute ischemic stroke in 4 hospital groups in Japan.

In October 2005 in Japan, the recombinant tissue plasminogen activator (tPA) alteplase was approved for patients with acute ischemic stroke within 3 hours of onset at a dose of 0.6 mg/kg. The present study was undertaken to assess the safety and efficacy of alteplase in Japan. Between October 2005 and December 2009, a total of 114 consecutive patients admitted to 4 hospitals received intravenous tPA within 3 hours of stroke onset. Clinical backgrounds and outcomes were investigated. The patients were divided into 2 chronological groups: an early group, comprising 45 patients treated between October 2005 and December 2007, and a later group, comprising 69 patients treated between January 2008 and December 2009. The mean time from arrival at the hospital to the initiation of treatment was significantly reduced in the later group, from 82.6 minutes to 70.9 minutes. Intracerebral hemorrhage (ICH) occurred in 26 patients (22.8%); compared with patients without ICH, these patients had a significantly higher prevalence of cardiogenic embolism (88.5% vs 58.0%); greater warfarin use (26.8% vs 6.8%); higher mean National Institutes of Health Stroke Scale (NIHSS) scores on admission (16 vs 10), at 3 days after admission (14 vs 5), and at 7 days after admission (13.5 vs 3); and a lower Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score (7.8 vs 9.1). Patients who received edaravone had a higher prevalence of cardiogenic embolism (70.9% vs 36.4%), a higher recanalization rate (77.7% vs 36.4%), and lower NIHSS scores on admission and at 3 and 7 days after admission compared with those who did not receive edaravone. Our data suggest that administration of intravenous alteplase 0.6 mg/kg within 3 hours of stroke onset is safe and effective, that the NIHSS and Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score are useful predictors of ICH after tPA administration, and that warfarin-treated patients are more likely to develop symptomatic ICH despite an International Normalized Ratio <1.7.

Kono S ，Deguchi K ，Morimoto N ，Kurata T ，Deguchi S ，Yamashita T ，Ikeda Y ，Matsuura T ，Narai H ，Omori N ，Manabe Y ，Yunoki T ，Takao Y ，Kawata S ，Kashihara K ，Abe K ... -  《-》

The Cologne stroke experience: safety and outcome in 450 patients treated with intravenous thrombolysis.

Sobesky J ，Frackowiak M ，Zaro Weber O ，Hahn M ，Möller-Hartmann W ，Rudolf J ，Neveling M ，Grond M ，Schmulling S ，Jacobs A ，Heiss WD ... -  《CEREBROVASCULAR DISEASES》