Sex differences in stroke reperfusion therapy in Aotearoa (New Zealand).

BACKGROUND AND AIMS: Stroke is a leading cause of death in Aotearoa (New Zealand), and stroke reperfusion therapy is a key intervention. Sex differences in stroke care have previously been asserted internationally. This study assessed potential differences in stroke reperfusion rates and quality metrics by sex in Aotearoa (New Zealand). METHODS: This study used data from three overlapping sources. The National Stroke Reperfusion Register provided 4-year reperfusion data from 2018 to 2021 on all patients treated with reperfusion therapy (intravenous thrombolysis and thrombectomy), including time delays, treatment rates, mortality and complications. Linkage to Ministry of Health administrative and REGIONS Care study data provided an opportunity to control for confounders and explore potential mechanisms. T-test and Wilcoxon rank-sum analyses were used for continuous variables, while the chi-squared test and logistic regression were used for comparing dichotomous variables. RESULTS: Fewer women presented with ischaemic stroke (12 186 vs 13 120) and were 4.2 years older than men (median (interquartile range (IQR)) 79 (68-86) vs 73 (63-82) years). Women were overall less likely to receive reperfusion therapy (13.9% (1704) vs 15.8% (2084), P < 0.001) with an adjusted odds ratio of 0.83 (0.77-0.90), P < 0.001. The adjusted odds ratio for thrombolysis was lower for women (0.82 (0.76-0.89), P < 0.001), but lower rates of thrombectomy fell just short of statistical significance ((0.89 (0.79-1.00), P = 0.05). There were no significant differences in complications, delays or documented reasons for non-thrombolysis. CONCLUSIONS: Women were less likely to receive thrombolysis, even after adjusting for age and stroke severity. We found no definitive explanation for this disparity.

Regional Disparity of Reperfusion Therapy for Acute Ischemic Stroke in Japan: A Retrospective Analysis of Nationwide Claims Data from 2010 to 2015.

Background We aimed to determine whether a regional disparity exists in usage of reperfusion therapy (intravenous recombinant tissue plasminogen activator [IV rt-PA] and endovascular thrombectomy [EVT]) and post-reperfusion 30-day mortality in patients with acute ischemic stroke, and which regional factors are associated with their usage. Methods and Results We retrospectively investigated 69 948 patients (mean age±SD, 74.9±12.0 years; women, 41.4%) with acute ischemic stroke treated with reperfusion therapy between April 2010 and March 2016 in Japan using nationwide claims data. Regional disparity was evaluated using Gini coefficients for age- and sex-adjusted usage of reperfusion therapy and 30-day post-reperfusion in-hospital death ratio in 47 administrative regions. The association between regional factors and reperfusion therapy usage was evaluated with fixed-effects regression models. During the study period, Gini coefficients showed low inequality (0.11-0.15) for use of IV rt-PA monotherapy and IV rt-PA and/or EVT and extreme inequality (0.49) for EVT usage in 2010, which became moderate inequality (0.25) by 2015. The densities of stroke centers and endovascular specialists, as well as market concentration, were associated with increased usage of reperfusion therapy whereas the proportion of rural residents and delayed ambulance transport were negatively associated with usage. Inequality in the standardized death ratio after EVT was extreme (0.86) in 2010 but became moderate (0.29) by 2015; inequality was low to moderate (0.17-0.23) for IV rt-PA monotherapy and IV rt-PA and/or EVT. Conclusions Scrutinizing existing data sources revealed regional disparity in reperfusion therapy for acute ischemic stroke and its associated regional factors in Japan.

Characterisation of an ischemia reperfusion model for the formation of a stage I pressure ulcer in mouse skin.

Pairs of magnets were applied to the loose skin on the backs of mice in order to cause ischemia for periods of 1.5, 2, 2.5 and 3 h followed by reperfusion. We found 1.5 h of ischemia resulted in the most reliable outcome of blanched skin but no redness or skin breakdown. Histological analysis at 4 h of reperfusion showed, in the centre of the insult, condensed nuclei in the epidermis and sebaceous glands with a build up of neutrophils in the blood vessels, and a reduction in the number of fibroblasts. At 24 h, spongiosis was seen in the epidermis and pockets of neutrophils began to accumulate under it, as well as being scatted through the dermis. In the centre of the insult there was a loss of sebaceous gland nuclei and fibroblasts. Four days after the insult, spongiosis was reduced in the epidermis at the edge of the insult but enhanced in the centre and in hair follicles. Leukocytes were seen throughout the central dermis. At 8 days, spongiosis and epidermal thickness had reduced and fibroblasts were reappearing. However, blood vessels still had leukocytes lining the lumen. The gap junction protein connexin 43 was significantly elevated in the epidermis at 4 h and 24 h reperfusion. Ischemia of 1.5 h generates a sterile inflammatory reaction causing the loss of some cell types but leaving the epidermis intact reminiscent of a stage I pressure ulcer.

Radial first or patient first: a case series and meta-analysis of transradial versus transfemoral access for acute ischemic stroke intervention.

BACKGROUND: Few studies have compared technical success and effectiveness of transradial access (TRA) versus transfemoral access (TFA) for mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We compared the two approaches for technical success, effectiveness, and outcomes. METHODS: We retrospectively compared TRA with TFA for AIS MT at our institute. We additionally performed a systematic review and meta-analysis of studies describing the use of TRA alone or in comparison with TFA for MT. Primary outcomes included rate of successful reperfusion (thrombolysis in cerebral infarction (TICI) >2b), number of passes, access-site complications, and 3- month mortality and favorable functional outcomes (modified Rankin Scale (mRS) score 0-2). RESULTS: A total of 222 consecutive patients (TRA=93, TFA=129) were included in our case series. The rate of successful reperfusion was significantly higher for the TFA cohort (91.4% vs 79.6%, P=0.01) with lower mean number of passes (1.8±1.2 vs 2.4±1.6, P=0.014). Three-month mortality in the TFA group was lower (22.1% vs 40.9% for the TRA cohort (P=0.004), with a higher rate of favorable functional outcomes (51.3% vs 34.1%, P=0.015). A meta-analysis of 10 studies showed significant heterogeneity in rates of successful reperfusion (57.1% to 95.6%, heterogeneity=67.55%, P=0.001). None of the previous comparative studies reported 3-month mortality and functional outcomes. CONCLUSIONS: This case series demonstrate a higher successful reperfusion rate, fewer passes, lower 3-month mortality, and improved 3-month functional outcomes with TFA. The systematic review highlights the inadequacy of existing evidence. Prospective comparative studies are needed before a 'radial-first' approach can be adopted for stroke intervention.

Effects of the COVID-19 pandemic on reperfusion therapy for acute ischemic stroke patients in Huizhou City, China.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has impacted the reperfusion therapy for acute ischemic stroke (AIS) patients. Huizhou City utilized its experience with the SARS and MERS breakouts to establish a reperfusion treatment program for AIS patients. METHOD: This is a retrospective study on 8 certified stroke hospitals in Huizhou City from January 2020 to May 2020. We analyzed the number of AIS patients with reperfusion therapy, stroke type (anterior/posterior circulation stroke), modes of transport to hospital, NIHSS score, onset to door time (ODT), door to needle time (DNT), and door to puncture time (DPT). The analysis was compared with baseline data from the same time period in 2019. RESULT: In 2020, the number of AIS patients receiving reperfusion therapy decreased (315 vs. 377), NIHSS score increased [8 (4, 15) vs. 7 [ (1, 2)], P = 0.024], ODT increased [126 (67.5, 210.0) vs. 120.0 (64.0, 179.0), P = 0.032], and DNT decreased [40 (32.5, 55) vs. 48 (36, 59), P = 0.003]. DPT did not change. Seventy percent of AIS patients indicated self-visit as their main mode of transport to the hospital. In both periods, mild stroke patients were more likely to self-visit than utilize emergency systems [2019: 152 (57.6%) vs. 20 (45.6%), P = 0.034; 2020: 123 (56.9%) vs. 5 (14.7%), P < 0.001]. The NIHSS score for self-visiting patients was lower for patients who utilized the ambulance system in both years [self-visit: 6.00 (3.00, 12.00), ambulance: 14.00 (9.00, 19.00), P < 0.001]. The volume of reperfusion patients was lower in 2020; however, the decrease was only significant (P = 0.028) in February 2020. CONCLUSION: During the COVID-19 pandemic in 2020, the number of AIS patients receiving reperfusion therapy significantly decreased when compared to the same period in 2019. The patients' condition increased severity, ODT increased, and the DNT decreased. DPT was not significant for self-visiting and ambulance patients. Moderate to severe stroke patients were more likely to utilize ambulance services.

Impact of off-hour endovascular therapy on outcomes for acute ischemic stroke: insights from STAR.

BACKGROUND: The off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large vessel occlusion (ELVO). We aimed to investigate the clinical outcomes of EVT between on-hour and off-hour admissions. METHODS: Patients who underwent EVT for ELVO from January 2013 to June 2019 from the STAR Registry were included. Patients were grouped based on time of groin puncture: on-hour period (Monday through Friday, 7:00 am-4:59 pm) and off-hour period (overnight 5:00pm-6:59am and the weekends). Primary outcome was final modified Rankin Scale (mRS) at 90 days on mRS-shift analysis. RESULTS: A total of 1919 patients were included in the study from six centers. The majority of patients (1169, 60.9%) of patients presented during the off-hour period. The mean age was 68.1 years and 50.5% were women. Successful reperfusion, as defined by a Thrombolysis In Cerebral Infarction (TICI) score of ≥2B, was achieved in 88.8% in the on-hour group and 88.0% in the off-hour group. Good clinical outcome (mRS 0-2) was obtained in 34.4% of off-hour patients and 37.7% of on-hour patients. On multivariable ordinal logistic regression analysis, time of presentation was not associated with worsened outcome (OR 1.150; 95% CI 0.96 to 1.37; P=0.122). Age, admission National Institutes of Health Stroke Scale (NIHSS), baseline mRS, and final TICI score were significantly associated with worse outcomes. CONCLUSION: There is no statistical difference in functional outcome in acute ischemic stroke patients who underwent EVT during on-hours versus off-hours.

Impact of COVID-19 pandemic on acute stroke care: facing an epidemiological paradox with a paradigm shift.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) outbreak, a decrease of stroke's hospital admissions and reperfusion therapy has been reported worldwide. This retrospective observational study assessed the volume of stroke cases managed in the Emergency Department (ED) and reperfusion therapies in an Italian stroke network with a high incidence of COVID-19, particularly to evaluate if the in-hospital rerouting and the switch from a drip-and-ship to a mothership model could assure an adequate volume of acute treatments. METHODS: We compared data from March 2020 with those from previous years and formulated five PICO questions regarding (1) incidence of stroke cases in the ED; (2) relation between stroke cases and COVID-19; (3) differences in the number of reperfusion therapies, (4) in the call-to-needle and door-to-needle times for intravenous thrombolysis, and (5) in the call-to-groin and door-to-groin times for thrombectomy. RESULTS: We found (1) a 28% decreased of confirmed stroke cases managed in the ED, (2) a negative correlation between stroke cases in ED and COVID-19 progression (rs = - .390, p = .030), and (3) a similar number of treatments in March 2020 and March 2019. The adoption of the mothership model (4) did not delay alteplase infusion (median call-to-needle p = .126, median door-to-needle p = .142) but led to (5) a significant reduction in median call-to-groin (p = .018) and door-to-groin times (p = .010). CONCLUSION: The "hospital avoidance" of stroke patients during the "stay-at-home" appeals needs to be considered for future public health campaigns. A prompt reorganization of the stroke network can guarantee optimal performances at times of crisis.

Percutaneous angioplasty in the treatment of thrombosed hemodialysis fistulas: A single-center experience with 1 year of follow-up.

OBJECTIVE: Thrombosis of a hemodialysis arteriovenous fistula (AVF) is a serious complication that needs urgent treatment. Most cases are treated surgically, but recently, endovascular strategies have become a viable alternative. This study is an evaluation of the success and patency rate of percutaneous balloon angioplasty of thrombosed hemodialysis fistulas using a drug-coated balloon (DCB) contrasted with a standard balloon (SB). METHODS: The data of 33 patients with a thrombosed native hemodialysis AVF treated percutaneously in a tertiary care center were analyzed retrospectively. Success of the procedure was defined as restoration of flow with less than 30% residual stenosis and resumption of dialysis through the hemodialysis AVF. The success rate of the procedure and the patency rate at 1, 6, and 12 months were evaluated. The effect on patency of a DCB was compared to that of a SB. RESULTS: Twenty-five radiocephalic and 8 brachiocephalic thrombosed hemodialysis AVFs were treated during the study period. Flow was restored in 23 thrombosed fistulas, a success rate of 69.7%. The patency rate of successfully treated fistulas was 95.6% at 1 month, 76.1% at 6 months, and 57.9% at 12 months. Ten of the 23 re-established AVFs were treated with a DCB and the remainder were treated with a SB. The patency of the fistulas treated with a DCB was similar to that of a SB at 1 month (100% vs 92.3%, respectively; p=0.393). The patency rate of a DCB was greater than that of a SB at 6 months (88.9% vs 66.7%, respectively; p=0.258) and 12 months (75% vs 45.4%, respectively; p=0.219). CONCLUSION: Percutaneous intervention for thrombosed hemodialysis AVFs is a safe, minimally invasive, and effective procedure. There was a positive trend in the patency rate of patients treated with a DCB at 6 and 12 months compared with a SB.

Pre-hospital stroke screening and notification of patients with reperfusion-eligible acute ischaemic stroke using modified Face Arm Speech Time test.

OBJECTIVES: To investigate the effects of pre-hospital stroke screening and notification on reperfusion therapy for patients with acute ischaemic stroke. METHODS: Pre-hospital stroke screening criteria were established based on a modified version of the Face Arm Speech Time (FAST) test. Screening was performed during ambulance transport by emergency medical service (EMS) personnel who completed a 2-hour training session on stroke screening. Temporal trends affecting acute ischaemic stroke investigation and intervention were compared before and after implementation of the pre-hospital screening. RESULTS: From July 2018 to October 2019, 298 patients with suspected stroke were screened by EMS personnel during ambulance transport prior to hospital arrival. Of these 298 patients, 213 fulfilled the screening criteria, 166 were diagnosed with acute stroke, and 32 received reperfusion therapy. The onset-to-door time was shortened by more than 1.5 hours (100.6 min vs 197.6 min, P<0.001). The door-to-computed tomography time (25.6 min vs 32.0 min, P=0.021), door-to-needle time (49.2 min vs 70.1 min, P=0.003), and door-to-groin puncture time for intra-arterial mechanical thrombectomy (126.7 min vs 168.6 min, P=0.04) were significantly shortened after implementation of the pre-hospital screening and notification, compared with historical control data of patients admitted from January 2018 to June 2018, before implementation of the screening system. CONCLUSION: Implementation of pre-hospital stroke screening using criteria based on a modified version of the FAST test, together with pre-arrival notification, significantly shortened the door-to-reperfusion therapy time for patients with ischaemic stroke. Pre-hospital stroke screening during ambulance transport by EMS personnel who complete a 2-hour focused training session is effective for identifying reperfusion-eligible patients with stroke.

Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States.

BACKGROUND AND PURPOSE: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. METHODS: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. RESULTS: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). CONCLUSIONS: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

Canadian survey on the rates of use of intraoperative diuretics and justification for their use during renal allograft reperfusion.

BACKGROUND: Mannitol and furosemide have been used as diuretics intraoperatively to facilitate early renal allograft function and reduce delayed graft function. As the evidence of any efficacy of these agents is limited, we sought to characterize the use of diuretics among transplant surgeons. METHODS: An anonymous online survey was sent to all Canadian transplant programs where kidney transplants are routinely performed. Questions were related to the use and indications for mannitol and furosemide. Responses were collected and analyzed as counts and percentages of respondents. We used χ2 analysis to assess the relationship between demographic factors and survey responses. RESULTS: Thirty-five surgeons completed the survey (response rate 50%). Seventy per cent of respondents reported performing 26 or more transplants per year, 88% had formal transplant fellowship training and 67% indicated that they currently train fellows. Only 24% and 12% reported believing that delayed graft function is reduced by mannitol and furosemide use, respectively. However, 73% routinely gave mannitol to patients and 53% routinely gave furosemide. The most common justification given for mannitol use was to induce diuresis (54%); 37% of respondents reported using mannitol because of training dogma. Likewise, 57% used furosemide for diuresis, with 23% reporting that their use of this agent was based on dogma. No relationship emerged between fellowship training, case volume or training program status and the use of any agent. Interestingly, 71% of respondents indicated that a randomized controlled trial evaluating the utility of intraoperative diuretics is needed and that they were interested in participating in such a trial. CONCLUSION: Use of intraoperative diuretics and the rationale for their use vary among surgeons. A substantial proportion of surgeons use these medications on the basis of dogma alone. A randomized controlled trial is needed to clarify the role of intraoperative diuretics in kidney transplant surgery.

CONTEXTE: On a utilisé le mannitol et le furosémide comme diurétiques peropératoires pour stimuler le fonctionnement précoce de l'allogreffe rénale et réduire le retard de fonctionnement du greffon. Comme les données probantes quant à l'efficacité de ces agents sont limitées, nous avons voulu caractériser l'utilisation des diurétiques chez les chirurgiens qui effectuent ces transplantations. MÉTHODES: Un sondage anonyme en ligne a été envoyé à tous les programmes de greffe canadiens où des greffes rénales sont couramment effectuées. Les questions avaient trait à l'utilisation et aux indications du mannitol et du furosémide. Les réponses ont été recueillies et analysées sous forme de nombres et de pourcentages des répondants. Le test du χ2 a été utilisé pour évaluer le lien entre les facteurs démographiques et les réponses au sondage. RÉSULTATS: Trente-cinq chirurgiens ont répondu au sondage (taux de réponse 50 %). Soixante-dix pour cent des répondants ont indiqué effectuer annuellement 26 greffes ou plus, 88 % avaient suivi une spécialisation formelle pour l'exécution des greffes et 67 % ont dit être en cours de spécialisation. Seulement 24 % et 12 % respectivement ont dit croire que le mannitol et le furosémide permettent de réduire le retard de fonctionnement du greffon. Toutefois, 73 % et 53 % respectivement administraient de routine du mannitol et du furosémide aux patients. La justification la plus fréquente de l'utilisation du mannitol était d'induire la diurèse (54 %); 37 % des répondants ont dit utiliser le mannitol parce que c'est ce qu'on leur a enseigné durant leur formation. De même, 57 % utilisaient le furosémide pour la diurèse, dont 23 % disaient que c'est ce qu'on leur avait enseigné durant leur formation. Aucun lien n'est ressorti entre la spécialisation, le volume de cas ou le statut à l'égard du programme de formation et l'utilisation d'un agent quelconque. Fait à noter, 71 % des répondants ont indiqué qu'un essai randomisé et contrôlé sur l'utilité des diurétiques peropératoires serait nécessaire et qu'ils y participeraient volontiers. CONCLUSION: L'utilisation de diurétiques peropératoires et la justification de leur utilisation varient d'un chirurgien à l'autre. En majeure partie, les chirurgiens utilisent ces médicaments sur la base des notions théoriques seulement. Un essai randomisé et contrôlé s'impose pour clarifier le rôle des diurétiques peropératoires dans la greffe rénale.

The presence of leukoaraiosis enhances the association between sTWEAK and hemorrhagic transformation.

OBJECTIVE: To investigate whether elevated serum levels of sTWEAK (soluble tumor necrosis factor-like inducer of apoptosis) might be involved in a higher frequency of symptomatic hemorrhagic transformation (HT) through the presence of leukoaraiosis (LA) in patients with acute ischemic stroke (IS) undergoing reperfusion therapies. METHODS: This is a retrospective observational study. The primary endpoint was to study the sTWEAK-LA-HT relationship by comparing results with biomarkers associated to HT and evaluating functional outcome at 3-months. Clinical factors, neuroimaging variables and biomarkers associated to inflammation, endothelial/atrial dysfunction or blood-brain barrier damage were also investigated. RESULTS: We enrolled 875 patients (mean age 72.3 ± 12.2 years; 46.0% women); 710 individuals underwent intravenous thrombolysis, 87 endovascular therapy and 78 both. HT incidence was 32%; LA presence was 75.4%. Patients with poor functional outcome at 3-months showed higher sTWEAK levels at admission (9844.2 [7460.4-12,542.0] vs. 2717.3 [1489.7-5852.3] pg/mL, P < 0.0001). By means of logistic regression models, PDGF-CC and sTWEAK were associated with mechanisms linked simultaneously to HT and LA. Serum sTWEAK levels at admission ≥6700 pg/mL were associated with an odds ratio of 13 for poor outcome at 3-months (OR: 13.6; CI 95%: 8.2-22.6, P < 0.0001). CONCLUSIONS: Higher sTWEAK levels are independently associated with HT and poor functional outcome in patients with IS undergoing reperfusion therapies through the presence of LA. sTWEAK could become a therapeutic target to reduce HT incidence in patients with IS.

Acute Stroke in Times of the COVID-19 Pandemic: A Multicenter Study.

BACKGROUND AND PURPOSE: This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. RESULTS: Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (-85%, -46%, -42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, -60%; thrombectomy, -61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. CONCLUSIONS: These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.

Stroke reperfusion therapy following dabigatran reversal with idarucizumab in a national cohort.

OBJECTIVE: To assess the frequency and utilization trends of dabigatran reversal with idarucizumab and compare associated complications, outcomes, and door-to-needle times to those of patients not exposed to idarucizumab in a nationwide cohort of thrombolyzed patients over a 24-month period. METHODS: This is an observational cohort study of all New Zealand patients with stroke treated with stroke reperfusion entered into a mandatory online national registry. Each hospital records data including patient demographics, treatment delays, complications, 7-day outcomes, and idarucizumab use. RESULTS: Between 1 January 2017 and 31 December 2018, 1,336 patients received thrombolysis. Fifty-one patients received idarucizumab prior to thrombolysis (median [interquartile range] age 73 [57-83] years): 8 (1.3%) in 2017 and 43 (6%) in 2018 (p < 0.001). Over the same 24-month period, 386 patients had stroke clot retrieval, of whom 8 (2.1%) were first treated with idarucizumab. Idarucizumab-treated patients had slower door-to-needle times (83 [54-110] minutes vs 61 [43-85] minutes, p = 0.0006). Symptomatic intracerebral hemorrhage occurred in 2 (3.9%) of the idarucizumab-treated patients and 49 (3.8%) of the other thrombolyzed patients (p = 0.97). None of the idarucizumab-treated patients had significant thrombotic complications. At 7 days, 3 (5.9%) idarucizumab-treated and 101 (7.9%) of the other thrombolyzed patients had died (p = 0.61). CONCLUSION: Idarucizumab was used in 6% of all thrombolyzed patients in a national cohort during 2018, up from 1.3% in 2017. Idarucizumab appeared to be safe with similar clinical outcomes to routinely managed patients, despite a 22-minute door-to-needle time delay. Idarucizumab can facilitate thrombolysis in patients with stroke taking dabigatran. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that idarucizumab use is associated with similar early post-thrombolysis outcomes compared with patients not exposed to this drug.

MT in anticoagulated patients: Direct oral anticoagulants versus vitamin K antagonists.

Mechanical thrombectomy (MT) is one of the main treatments for acute ischemic stroke (AIS) in patients on effective anticoagulation. The use of direct oral anticoagulants (DOA) has increased, given their efficacy and safety profile compared to vitamin K antagonists (VKA). We compared procedural and clinical outcomes of MT in patients on DOA and VKA treatment before stroke onset. We analyzed 2 groups from the Endovascular Treatment in Ischemic Stroke prospective registry: patients on DOA and patients on VKA treated by MT without thrombolysis. Generalized linear mixed models including center as random effect were used to compare angiographic (rates of reperfusion at end of procedure, number of passes >2, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to anticoagulation subgroups. Comparisons were adjusted for prespecified confounders (age, admission NIH Stroke Scale score) as well as for meaningful baseline between-group differences. Among 221 patients included, more DOA-treated patients (n = 115, 52%) achieved successful (modified Thrombolysis in Cerebral Infarction score [mTICI] 2b/3) or near complete (mTICI 2c/3) reperfusion at the procedure end than did VKA-treated patients, with an adjusted odds ratio (OR) for DOA vs VKA of 3.27 (95% confidence interval [CI], 1.40-7.65) and 2.00 (95% CI, 1.08-3.73), respectively. DOA-treated patients had a lower 90-day mortality risk with an adjusted OR of 0.47 (95% CI, 0.24-0.89) and a better excellent outcome OR of 2.40 (1.10-5.27). There was no significant between-group difference in hemorrhagic or procedural complications. The study highlights the benefits of DOA compared to VKA. Regarding mortality, excellent outcomes, and recanalization rate, DOA appears to provide a favorable setting for MT treatment in AIS.

Implementation of a protocol for direct stroke patient transfer and mobilization of a stroke team to reduce times to reperfusion. / Implementación de un protocolo de transferencia directa y movilización del equipo de ictus para reducir los tiempos de reperfusión.

OBJECTIVES: The timing of treatment is a key prognostic factor in stroke. Our hospital implemented a rapid-action time-to-intervention protocol to optimize reperfusion times. The protocol consisted of direct transfer of stroke-code patients to the scanner or angiosuite and mobilization of the stroke team. Our aim was to assess the impact of the protocol on times to reperfusion. We also sought to evaluate the feasibility and safety of including a stroke-team nurse and assess staff satisfaction with the protocol. MATERIAL AND METHODS: Descriptive study of patients attended by the hospital stroke team between March 2015 and March 2018. Outcomes were compared to those for the previous period (February 2014 to February 2015). RESULTS: Nine hundred three patients were attended under the rapid-action protocol; 502 of them (55.6%) underwent reperfusion. The median (interquartile range) door-to-needle or groin access times were 24 (18-33) minutes for fibrinolysis and 39 (20-75) minutes for thrombectomy. Both times were significantly shorter than in the earlier period (43 [31-66] and 93 [60-150] minutes, respectively; P<.001). Median duration of nurse attendance was 25 (20-32) minutes during the implementation period, and no problems of feasibility or safety appeared during nurse attendance. Twenty staff members (95%) reported that the rapid-action protocol increased their workload but they felt it warranted continued application. CONCLUSION: Direct transfer of stroke patients for scanning or to the angiography suite, with nurse attendance, safely reduced reperfusion times.

OBJETIVO: El tiempo es un factor clave en el tratamiento y pronóstico del ictus. Nuestro centro ha implementado un protocolo de Actuación Rápida Puerta Aguja (ARPA) para optimizar los tiempos de reperfusión. Este protocolo intrahospitalario consiste en tratar a los pacientes derivados por código ictus (CI) directamente en el escáner o en la sala de angiografía movilizando al equipo de ictus. Los objetivos son evaluar el impacto del protocolo ARPA en los tiempos de reperfusión, y valorar la viabilidad y seguridad de incorporar un enfermero de la unidad de ictus (UI) al equipo de ictus para la asistencia a pacientes CI, así como la satisfacción de los profesionales. METODO: Estudio descriptivo de pacientes atendidos en el circuito CI entre marzo 2015 y marzo 2018. Se compararon con el periodo previo entre febrero 2014 y febrero 2015. RESULTADOS: Se atendieron 903 pacientes con el protocolo ARPA y recibieron tratamiento de reperfusión 502 pacientes (55,6%). La mediana de tiempo puerta-aguja para fibrinolisis fue de 24 (18-33) minutos y puerta-punción para trombectomía 39 (20-75) minutos, ambos inferiores (p < 0,001) al periodo anterior, que tuvo unos tiempos de 43 (31-66) y 93 (60-150) minutos, respectivamente. El enfermero atendió los CI durante 25 (20-32) minutos, y no se encontraron problemas graves de seguridad o viabilidad. Veinte profesionales (95%) refirieron que el protocolo ARPA aumentaba su carga de trabajo pero consideraron que se debía seguir aplicando. CONCLUSIONES: El tratamiento de pacientes CI directamente en el escáner o en la sala de angiografía incorporando un enfermero de la UI reduce, de forma segura, los tiempos de reperfusión.

Mechanical Thrombectomy Using the new Solitaire™ Platinum Stent-retriever : Reperfusion Results, Complication Rates and Early Neurological Outcome.

BACKGROUND AND PURPOSE: The application of radiopaque markers to the Solitaire™ stent-retriever for better visibility during mechanical thrombectomy (MT) has the potential to alter the well-known characteristics of the device; however, it is uncertain whether this adjustment influences efficacy or safety of the enhanced stent-retriever. METHODS: Retrospective analysis of stroke databases of three comprehensive stroke centers. Our investigation was focused on technical and angiographic parameters, including procedure times, reperfusion results (thrombolysis in cerebral infarction, TICI), periprocedural complications and favorable early neurological recovery at discharge (modified Rankin scale ≤2 or National Institutes of Health Stroke Scale, NIHSS = 0 or ∆NIHSS ≥ 10), from consecutive patients with acute anterior circulation ischemic stroke treated with a Solitaire™ Platinum stent-retriever between October 2016 and March 2017. RESULTS: A total of 75 patients (male: n = 27, 36%, age in years: mean (SD): 75 (±12), median baseline NIHSS: 17 (interquartile range IQR: 11-21), n = 41, 54.7% received additional i. v. thrombolytics) were treated with a median number of 2 device passes (range: 1-5). The median time from groin puncture to final TICI was 56 min (IQR: 41-79). In 69 patients (92%) TICI 2b-3 was achieved. Early neurological recovery was seen in 47 (62.7%) patients. The following periprocedural complications occurred: vasospasms (n = 7, 9.3%), emboli into a new territory (n = 4, 5.3%), symptomatic intracranial hemorrhage (n = 3, 4%), difficulties during device delivery/deployment (n = 1, 1.3%). CONCLUSION: The usage of the Solitaire™ Platinum stent-retriever for MT in acute ischemic stroke patients was highly effective and was not accompanied by an increased periprocedural complication rate.

Association of Computed Tomographic Leg Muscle Characteristics With Lower Limb and Cardiovascular Events in Patients With Peripheral Artery Disease.

Background Poor lower extremity physical performance is an independent predictor of unfavorable outcome in patients with peripheral artery disease ( PAD ); however, few studies have assessed muscle characteristics on imaging directly. Method and Results A novel 3-dimensional semi-automated protocol was developed to estimate leg muscle volume and density (mean attenuation) from computed tomography images. Patients with PAD who underwent a lower extremity computed tomography scan at a tertiary vascular surgery center were included, and were followed up using hospital records and linked data as part of a retrospective cohort study. The primary outcomes were lower limb events (major amputation or peripheral revascularization) and cardiovascular events (myocardial infarction, stroke, or cardiovascular death). Two hundred and twenty-three patients with PAD were included (median age 69.0 years; 73% men) and followed for a median of 4.9 [2.6-7.0] years. During this time there were 99 index lower limb events and 97 cardiovascular events. Low leg muscle density was associated with increased risk of lower limb (rate ratio 1.41 [1.11-1.80] per SD reduction) and cardiovascular events (rate ratio 1.60 [1.29-1.99] per SD reduction). Low muscle density remained an independent predictor of cardiovascular (but not lower limb) events, after adjusting for age, sex, traditional cardiovascular risk factors, and angiographic PAD severity (rate ratio 1.39 [1.09-1.77] per lower SD ). In contrast, leg muscle volume was not associated with outcomes after adjusting for risk factors and PAD severity. Conclusions Low leg muscle density, but not volume, is a strong, independent predictor of major cardiovascular events among people with PAD . Further research is needed to understand the mechanisms underlying these associations.

Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke.

BACKGROUND AND PURPOSE: This study aims to describe the relationship between computed tomographic (CT) perfusion (CTP)-to-reperfusion time and clinical and radiological outcomes, in a cohort of patients who achieve successful reperfusion for acute ischemic stroke. METHODS: We included data from the CRISP (Computed Tomographic Perfusion to Predict Response in Ischemic Stroke Project) in which all patients underwent a baseline CTP scan before endovascular therapy. Patients were included if they had a mismatch on their baseline CTP scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into target mismatch and malignant mismatch profiles, according to the volume of their Tmax >10s lesion volume (target mismatch, <100 mL; malignant mismatch, >100 mL). We investigated the impact of CTP-to-reperfusion times on probability of achieving functional independence (modified Rankin Scale, 0-2) at day 90 and radiographic outcomes at day 5. RESULTS: Of 156 included patients, 108 (59%) had the target mismatch profile, and 48 (26%) had the malignant mismatch profile. In patients with the target mismatch profile, CTP-to-reperfusion time showed no association with functional independence (P=0.84), whereas in patients with malignant mismatch profile, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (odds ratio, 0.08; P=0.003). Compared with patients with target mismatch, those with the malignant mismatch profile had significantly more infarct growth (90 [49-166] versus 43 [18-81] mL; P=0.006) and larger final infarct volumes (110 [61-155] versus 48 [21-99] mL; P=0.001). CONCLUSIONS: Compared with target mismatch patients, those with the malignant profile experience faster infarct growth and a steeper decline in the odds of functional independence, with longer delays between baseline imaging and reperfusion. However, this does not exclude the possibility of treatment benefit in patients with a malignant profile.

Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center.

The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.