Intravenous Thrombolysis 4.5-9 Hours After Stroke Onset: A Cohort Study from the TRISP Collaboration.

OBJECTIVE: To investigate the safety and effectiveness of intravenous thrombolysis (IVT) >4.5-9 hours after stroke onset, and the relevance of advanced neuroimaging for patient selection. METHODS: Prospective multicenter cohort study from the ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration. Outcomes were symptomatic intracranial hemorrhage, poor 3-month functional outcome (modified Rankin scale 3-6) and mortality. We compared: (i) IVT >4.5-9 hours versus 0-4.5 hours after stroke onset and (ii) within the >4.5-9 hours group baseline advanced neuroimaging (computed tomography perfusion, magnetic resonance perfusion or magnetic resonance diffusion-weighted imaging fluid-attenuated inversion recovery) versus non-advanced neuroimaging. RESULTS: Of 15,827 patients, 663 (4.2%) received IVT >4.5-9 hours and 15,164 (95.8%) within 4.5 hours after stroke onset. The main baseline characteristics were evenly distributed between both groups. Time of stroke onset was known in 74.9% of patients treated between >4.5 and 9 hours. Using propensity score weighted binary logistic regression analysis (onset-to-treatment time >4.5-9 hours vs onset-to-treatment time 0-4.5 hours), the probability of symptomatic intracranial hemorrhage (ORadjusted 0.80, 95% CI 0.53-1.17), poor functional outcome (ORadjusted 1.01, 95% CI 0.83-1.22), and mortality (ORadjusted 0.80, 95% CI 0.61-1.04) did not differ significantly between both groups. In patients treated between >4.5 and 9 hours, the use of advanced neuroimaging was associated with a 50% lower mortality compared with non-advanced imaging only (9.9% vs 19.7%; ORadjusted 0.51, 95% CI 0.33-0.79). INTERPRETATION: This study showed no evidence in difference of symptomatic intracranial hemorrhage, poor outcome, and mortality in selected stroke patients treated with IVT between >4.5 and 9 hours after stroke onset compared with those treated within 4.5 hours. Advanced neuroimaging for patient selection was associated with lower mortality. ANN NEUROL 2023;94:309-320.

Intravenous Thrombolysis in Patients With Ischemic Stroke Aged ≥90 Years: A Cohort Study From the TRISP Collaboration.

BACKGROUND: The probability to receive intravenous thrombolysis (IVT) for treatment of acute ischemic stroke declines with increasing age and is consequently the lowest in very elderly patients. Safety concerns likely influence individual IVT treatment decisions. Using data from a large IVT registry, we aimed to provide more evidence on safety of IVT in the very elderly. METHODS: In this prospective multicenter study from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry, we compared patients ≥90 years with those <90 years using symptomatic intracranial hemorrhage (ECASS [European Cooperative Acute Stroke Study]-II criteria), death, and poor functional outcome in survivors (modified Rankin Scale score 3-5 for patients with prestroke modified Rankin Scale score ≤2 and modified Rankin Scale score 4-5 for patients prestroke modified Rankin Scale ≥3) at 3 months as outcomes. We calculated adjusted odds ratio with 95% CI using logistic regression models. RESULTS: Of 16 974 eligible patients, 976 (5.7%) were ≥90 years. Patients ≥90 years had higher median National Institutes of Health Stroke Scale on admission (12 versus 8) and were more often dependent prior to the index stroke (prestroke modified Rankin Scale score of ≥3; 45.2% versus 7.4%). Occurrence of symptomatic intracranial hemorrhage (5.7% versus 4.4%, odds ratioadjusted 1.14 [0.83-1.57]) did not differ significantly between both groups. However, the probability of death (odds ratioadjusted 3.77 [3.14-4.53]) and poor functional outcome (odds ratioadjusted 2.63 [2.13-3.25]) was higher in patients aged ≥90 years. Results for the sample of centenarians (n=21) were similar. CONCLUSIONS: The probability of symptomatic intracranial hemorrhage after IVT in very elderly patients with stroke did not exceed that of their younger counterparts. The higher probability of death and poor functional outcome during follow-up in the very elderly seems not to be related to IVT treatment. Very high age itself should not be a reason to withhold IVT.

Myasthenia gravis treated in the neurology intensive care unit: a 14-year single-centre experience.

INTRODUCTION: Severe myasthenia gravis (MG) exacerbation with respiratory failure and/or dysphagia usually requires monitoring and treatment in the neurology intensive care unit (NICU). The aim of our study was to identify all patients with severe MG exacerbation treated in the NICU in order to assessed potential factors affecting patients' need for mechanical ventilation, occurrence of complications and the final outcome. METHODS: We retrospectively included all patients with severe exacerbation of MG who required management in the NICU during a 14-year period. Baseline sociodemographic and clinical features, data on medication, comorbidities and outcome were obtained by reviewing medical records and institutional databases. RESULTS: Our study comprised 130 severe MG exacerbations detected in 118 patients. Median age of patients was 61.5 years, and women accounted for 58.5% of the patients. Half of the patients required mechanical ventilation during hospitalization. Lethal outcome was observed in 12.3% of severe MG exacerbations. Only elder age was an independent negative predictor of survival (OR 0.89, 95% CI 0.82-0.97, p < 0.01). Complications during hospitalization were detected in 50% of patients. A higher number of comorbidities (OR 1.09, 95% CI 1.60-2.35, p = 0.01) and mechanical ventilation (OR 28.48, 95% CI 8.56-94.81, p < 0.01) were independent predictors of complications during hospitalization. CONCLUSION: Patients with a severe MG exacerbation who do not require mechanical ventilation have a good outcome after treatment in the NICU. Elder age is an independent predictor of lethal outcome in patients with severe MG exacerbation. Mechanical ventilation and a higher number of comorbidities lead to more frequent complications.

Atrial fibrillation is associated with poor long-term outcome after mechanical thrombectomy for anterior large vessel occlusion stroke.

OBJECTIVES: Atrial fibrillation (AF) is one of the leading causes of acute ischemic stroke (AIS). The aim of our study was to determine the influence of AF on the long-term outcome of patients with AIS due to anterior circulation large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). METHODS: Our study included 127 consecutive patients with AIS due to anterior LVO who underwent MT between January 2018 and March 2020. Demographics, clinical, radiological and treatment characteristics were prospectively collected. Modified Rankin scale (mRS) score ≤2 was defined as a good functional outcome. RESULTS: AF was detected in 62 (48.8%) patients. Patients with AF were elder (73.1 ± 8.7 vs. 58.5 ± 14.2 years, p<0.01) and usually female (56.5% vs. 36.9%, p=0.03). They had a lower percentage of good functional outcome (31.6% vs. 62.3%, p<0.01) and a higher mortality rate (47.5% vs. 18.5%, p<0.01) after one year of follow-up. In the multivariate logistic regression the variables that showed significance with p <0.05 in previous univariate analyses were included. The presence of AF (aOR 0.29, 95% CI 0.11-0.78, p=0.01) and initial NIHSS score >15 (aOR 0.25, 95% CI 0.11-0.56, p<0.01) were independent negative predictors of good functional outcome after one year of follow-up. However, the presence of AF did not affect all-cause mortality within one year (p=0.18). CONCLUSION: AF and initial NIHSS score >15 are independent negative predictors of good long-term functional outcome in patients with AIS due to anterior circulation LVO treated with MT.

Influence of Thrombocytopenia on the Outcome of Mechanical Thrombectomy in Patients with Acute Ischemic Stroke.

OBJECTIVES: Mechanical thrombectomy (MT) has become leading treatment option for acute ischemic stroke (AIS) due to large vessels occlusion (LVO). Platelet counts may affect outcome in patients with AIS or transient ischemic attack. The aim of our study was to determine the influence of thrombocytopenia on the safety and efficacy of MT in patients with AIS due to anterior circulation LVO. MATERIALS AND METHODS: This study included 127 consecutive adult patients with AIS due to anterior circulation LVO who underwent MT. The patients were divided into 2 groups based on initial platelet count: with thrombocytopenia (<150 × 109/L) and without thrombocytopenia (≥150 × 109/L). Primary safety outcome was symptomatic intracerebral haemorrhage (SICH), while secondary safety outcome was stroke-related mortality. Efficacy outcome was functional independence, defined as modified Rankin Scale (mRS) score 0-2. Follow- up time was 90 days. RESULTS: Initial thrombocytopenia (<150 × 109/L) was detected in 19 (15%) patients. Multivariable analysis showed that initial thrombocytopenia did not increase the risk of SICH and did not affect the short-term functional outcome (p = 0.587). However, initial thrombocytopenia increased the risk for stroke-related mortality (aOR 3.639, 95% CI 1.079-12.641, p = 0.037). The main cause of mortality in the group with thrombocytopenia was malignant cerebral infarction (44.4%). CONCLUSIONS: Thrombocytopenia does not affect the efficacy and the risk of SICH in patients with AIS caused by anterior circulation LVO treated with MT. However, the risk of mortality is higher in patients with thrombocytopenia, mainly due to malignant cerebral infarction.

Long-Term Prognosis in Ischemic Stroke Patients Treated with Intravenous Thrombolytic Therapy.

BACKGROUND AND PURPOSE: It remains unclear if intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator has an impact on the survival and maintenance of a favorable effect on functional recovery over a long follow-up period. The aim of this study was to assess whether or not IVT treatment has a favorable effect on functional recovery and survival less than 1 year after a stroke. METHODS: This matched cohort study included 259 patients with acute ischemic stroke (IS) who were treated with IVT and standard care and 259 patients treated with standard care alone in the stroke unit between February 2006 and January 2013. RESULTS: After a median follow-up period of 3 years (range, 1-7 years), survival did not differ significantly between the groups; specifically, 56 patients (21.6%) in the thrombolysed group died versus 62 patients (23.94%) in the nonthrombolysed group (log-rank, .240, P = .624). Based on a multivariate Cox proportional hazards regression model, older age (>70 years), stroke severity (National Institutes of Health Stroke Scale score ≥ 15), diabetes mellitus, and a history of atrial fibrillation were independent predictors of long-term mortality after stroke. After the follow-up period, 144 patients (55.6%) in the IVT-treated group versus 112 patients (43.2%) in the control group had an excellent outcome, with a modified Rankin Scale score of 0-1 (hazard ratio [HR] = 1.64, 95% confidence interval [CI] = 1.16-2.32). Based on a multivariate Cox proportional hazards regression model, an excellent 3-month functional recovery was a strong predictor of favorable outcome (HR = 11.27, 95% CI = 6.45-19.63). CONCLUSION: The results suggest that IVT for acute IS has a favorable effect on functional recovery more than 1 year after stroke.

How to recognize and treat metabolic encephalopathy in Neurology intensive care unit.

Metabolic encephalopathy (ME) represents a syndrome of temporary or permanent disturbance of brain functions that occurs in different diseases and varies in clinical presentation. It can be manifested in a range from very mild mental disorders to deep coma and death. Clinically, it is characterized by a variety of psychiatric and neurological symptoms and signs. The most common causes of ME are: hypoxia, ischemia, systemic diseases and toxic agents. ME is the most frequent in elderly people who have previously been exhausted by chronic illnesses and prolonged stay in bed. ME is a very common complication in patients treated in intensive care units. Treatment and prognosis of the disease are varied and depend on aetiology, as well as on the type and severity of clinical presentation. Mortality of patients with septic encephalopathy ranges from 16-65%, while the one-year survival of patients with encephalopathy and liver cirrhosis is less than 50%.

Return to Paid Work after Ischemic Stroke in Patients Treated with Intravenous Thrombolysis.

BACKGROUND: There are no available data confirming the efficacy of intravenous thrombolytic (IVT) treatment on the return to work as one of important outcome measure after acute ischemic stroke (IS). The aim of this study was to analyze the influence of IVT treatment on the return to work after stroke. METHODS: This matched cohort study included 279 patients with acute IS (146 treated with IVT and 133 matched patients without IVT) admitted to the Stroke Unit between 2007 and 2013. All patients were working in paid employment immediately before stroke onset. The main outcome measure was return to full-time paid work during follow-up period. RESULTS: After a median follow-up period of 3 years (range 1-7 years), the prevalence of stroke survivors returning to paid work was 42.1% in the IVT group and 33.3% in the non-IVT group (hazard ratio 1.28, 95% CI 0.86-1.91), and IVT treatment was associated with a higher chance of returning to full-time jobs (OR 2.07, 95% CI 1.21-3.51). After adjustment for possible variables, IVT was an independent predictor of returning to full-time jobs. CONCLUSION: IVT treatment was a positive predictor of returning to full-time work after stroke.

Predicting the outcomes of acute ischaemic stroke in atrial fibrillation: the role of baseline CHADS2, CHA2DS2-VASC and HAS-BLED score values.

OBJECTIVE: Atrial fibrillation (AF)-related risk of stroke is commonly assessed using the CHADS2 or CHA2DS2-VASc score, whilst the oral anticoagulation-related bleeding risk can be estimated by the HAS-BLED score. We investigated the association of these scores with outcomes of AF-associated strokes, defined as symptomatic intracranial haemorrhage (sICH), favourable outcome (modified Rankin Scale [mRS] 0-2) or death. METHODS: Analyses of prospective data on stroke patients with non-valvular AF treated in the Stroke Unit from January 2009 to June 2012 were performed. RESULTS: Of 787 patients with an acute ischaemic stroke, 131 had AF (16.6%, median age 70, range 62-76 years). Of those, 6 patients (4.6%) had sICH, 49 (37.4%) died and 55 (42.0%) had a favourable 90-day outcome. HAS-BLED score of > or = 3 was associated with sICH both in the univariate analysis (OR 15.13; 95% CI 2.11-108.25, P = 0.007) and in the multivariable model (OR 19.96; 95% CI 2.23-178.81, P = 0.007), which also included the baseline neurological deficit score (NIHSS), intravenous thrombolysis or the use of antiplatelet/anticoagulant therapy. The CHADS2 and CHA2DS2-VASc scores were associated with 90-day mortality in the univariate analyses (OR 1.47; 95% CI 1.11-1.95 and OR 1.36; 95% CI 1.08-1.69, respectively, both P = 0.008). The CHA2DS2-VASc score was inversely related to the favourable outcome in the univariate analysis (OR 0.80; 95% CI 0.65-0.99, P = 0.042). CONCLUSION: HAS-BLED was found to have an independent predictive value on the occurrence of sICH regardless of the treatment (thrombolysis or conservative therapy). A trend toward statistical relation to the influence of the CHA2DS2-VASc values on the favourable outcome was registered.

Influence of differences in case mix on the better outcome of smokers after intravenous thrombolysis for acute cerebral ischemia.

BACKGROUND/AIMS: Thrombolysis for myocardial infarction is more effective in smokers. Our aim was to determine whether smokers treated by intravenous (i.v.) rt-PA for acute cerebral ischemia have better outcomes. METHOD: Comparison of smokers and non-smokers for baseline characteristics and month-3 outcome in patients treated by i.v. rt-PA for cerebral ischemia in Lille, France, and Belgrade, Serbia. The primary outcome was a modified Rankin scale (mRS) 0-1 or similar to the pre-stroke mRS. Secondary outcomes were an mRS 0-2 and death. RESULTS: We included 459 patients (255 men; median age 65 years, interquartile range 52-76; 135 smokers). Smokers were younger (median 53 vs. 70 years, p < 0.0001) and had less severe strokes (median NIHSS 10 vs. 14, p < 0.0001). At month 3, they were more likely to have an mRS 0-1 [odds ratio (OR) 1.75; 95% confidence interval (CI) 1.17-2.62], or an mRS 0-2 (OR 2.90; 95% CI 1.86-4.52) and less likely to be dead (OR 0.28; 95% CI 0.13-0.61). Smoking was not independently associated with outcome after adjustment for case mix [adjusted OR ((adj)OR) 0.86; 95% CI 0.52-1.43]. CONCLUSION: Smoking does not independently influence the outcome in patients treated by rt-PA for cerebral ischemia. The better outcome in smokers is the consequence of differences in case mix.

Is there a difference between GBS triggered by COVID-19 and those of other origins?

Background: Since the outbreak of the coronavirus disease 2019 (COVID-19), an increasing number of Guillain-Barré syndrome (GBS) cases following the infection has been reported. The aim of our study was to detect patients with GBS treated in our hospital over a 1-year period and to compare the characteristics and outcomes of those triggered by COVID-19 with the rest of GBS patients. Our prospective study included 29 patients who were diagnosed with GBS from March 2020 to March 2021. Based on the preceding event, patients were stratified as post-COVID-19 and non-COVID-19. The GBS disability scale (GDS) was used to assess functional disability. Results: We identified 10 (34.5%) patients with post-COVID-19 GBS and 19 (65.5%) patients with non-COVID-19 GBS. The median time from the preceding event to the symptoms onset was longer in post-COVID-19 than in non-COVID-19 GBS patients (p = 0.04). However, the time from the symptom onset to the nadir did not differ (p = 0.12). GDS at admission, as well as at nadir, did not differ between these two groups. The level of proteinorrachia was higher in post-COVID-19 GBS patients (p = 0.035). The most frequent subtype of GBS in both groups was acute inflammatory demyelinating polyneuropathy (AIDP). GDS score at discharge (p = 0.56) did not differ between two study groups. Conclusions: There was no difference in clinical and electrophysiological features, disease course, and outcome in post-COVID-19 compared with non-COVID-19 GBS patients.

Thrombolysis in stroke patients with elevated inflammatory markers.

OBJECTIVE: To investigate the prognostic value of white blood cell count (WBC) on functional outcome, mortality and bleeding risk in stroke patients treated with intravenous thrombolysis (IVT). METHODS: In this prospective multicenter study from the TRISP registry, we assessed the association between WBC on admission and 3-month poor outcome (modified Rankin Scale 3-6), mortality and occurrence of symptomatic intracranial hemorrhage (sICH; ECASS-II-criteria) in IVT-treated stroke patients. WBC was used as continuous and categorical variable distinguishing leukocytosis (WBC > 10 × 109/l) and leukopenia (WBC < 4 × 109/l). We calculated unadjusted/ adjusted odds ratios with 95% confidence intervals (OR [95% CI]) with logistic regression models. In a subgroup, we analyzed the association of combined leukocytosis and elevated C-reactive protein (CRP > 10 mg/l) on outcomes. RESULTS: Of 10,813 IVT-treated patients, 2527 had leukocytosis, 112 leukopenia and 8174 normal WBC. Increasing WBC (by 1 × 109/l) predicted poor outcome (ORadjusted 1.04[1.02-1.06]) but not mortality and sICH. Leukocytosis was independently associated with poor outcome (ORadjusted 1.48[1.29-1.69]) and mortality (ORadjusted 1.60[1.35-1.89]) but not with sICH (ORadjusted 1.17[0.94-1.45]). Leukopenia did not predict any outcome. In a subgroup, combined leukocytosis and elevated CRP had the strongest association with poor outcome (ORadjusted 2.26[1.76-2.91]) and mortality (ORadjusted 2.43[1.86-3.16]) when compared to combined normal WBC and CRP. CONCLUSION: In IVT-treated patients, leukocytosis independently predicted poor functional outcome and death. Bleeding complications after IVT were not independently associated with leukocytosis.

Intravenous thrombolysis for acute cerebral ischemia in Belgrade, Serbia: comparison with Lille, France.

BACKGROUND: Worse socioeconomic situation is associated with worse outcomes in stroke cases. Whether it also influences outcomes in patients treated with intravenous thrombolysis remains unknown. The aim of this study was to test the hypothesis that outcomes are less favorable in patients treated with intravenous thrombolysis in Belgrade, Serbia, than in Lille, France. METHODS: We compared outcomes at day 7 and month 3, between 123 consecutive stroke patients treated with intravenous thrombolysis in Belgrade and 273 in Lille. RESULTS: At month 3, there was no significant difference between Belgrade and Lille in patients' excellent outcomes [modified Rankin Scale 0-1; 49.6 vs. 45.4%, odds ratio (OR): 1.21, 95% confidence interval (CI): 0.79-1.86] or in death (11.4 vs. 16.1%, OR 0.67, 95% CI: 0.35-1.27). However, compared with a subgroup of age-matched patients from Lille, Belgrade patients tended to have worse outcomes. Patients from Belgrade were 16 years younger (p < 0.0001), more likely to be men (OR 2.40, 95% CI: 1.52-3.78), and more likely to be smokers (OR 2.24, 95% CI: 1.43-3.51). Also, a trend for a slightly higher rate of symptomatic hemorrhagic transformation was registered in this group (7.3 vs. 3.3%, OR 2.32, 95% CI: 0.90-5.99). In Belgrade, patients arrived 27 min earlier to the hospital (p < 0.0001), but their door-to-needle time was 37 min longer (p < 0.0001). Compared with a subgroup of age-matched patients from Lille, they tended to have worse outcomes. CONCLUSION: Intravenous thrombolysis-treated stroke patients in Belgrade have similar outcomes and rates of complications as those from Lille.

EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry.

PURPOSE: The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry. PARTICIPANTS: All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS). FINDINGS TO DATE: Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups. FUTURE PLANS: This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women.

RATIONALE: Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn. AIMS: To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome. METHODS AND DESIGN: This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant. SUMMARY: To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table.

Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke.

Association of prestroke metformin use, stroke severity, and thrombolysis outcome.

OBJECTIVE: To evaluate whether pretreatment with metformin (MET) is associated with less stroke severity and better outcome after IV thrombolysis (IVT), we analyzed a cohort of 1,919 patients with stroke with type 2 diabetes mellitus in a multicenter exploratory analysis. METHODS: Data from patients with diabetes and ischemic stroke treated with IVT were collected within the European Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration. We applied propensity score matching (PSM) to obtain balanced baseline characteristics of patients treated with and without MET. RESULTS: Of 1,919 patients with stroke with type 2 diabetes who underwent IVT, 757 (39%) had received MET before stroke (MET+), whereas 1,162 (61%) had not (MET-). MET+ patients were younger with a male preponderance. Hypercholesterolemia and pretreatment with statins, antiplatelets, or antihypertensives were more common in the MET+ group. After PSM, the 2 groups were well balanced with respect to demographic and clinical aspects. Stroke severity on admission (NIH Stroke Scale 10.0 ± 6.7 vs 11.3 ± 6.5), 3-month degree of independence on modified Rankin Scale (2 [interquartile range (IQR) 1.0-4.0] vs 3 [IQR 1.0-4.0]), as well as mortality (12.5% vs 18%) were significantly lower in the MET+ group. The frequency of symptomatic intracerebral hemorrhages did not differ between groups. HbA1c levels were well-balanced between the groups. CONCLUSIONS: Patients with stroke and diabetes on treatment with MET receiving IVT had less severe strokes on admission and a better functional outcome at 3 months. This suggests a protective effect of MET resulting in less severe strokes as well as beneficial thrombolysis outcome.

Intravenous thrombolysis and platelet count.

OBJECTIVE: To study the effect of platelet count (PC) on bleeding risk and outcome in stroke patients treated with IV thrombolysis (IVT) and to explore whether withholding IVT in PC < 100 × 109/L is supported. METHODS: In this prospective multicenter, IVT register-based study, we compared PC with symptomatic intracranial hemorrhage (sICH; Second European-Australasian Acute Stroke Study [ECASS II] criteria), poor outcome (modified Rankin Scale score 3-6), and mortality at 3 months. PC was used as a continuous and categorical variable distinguishing thrombocytopenia (<150 × 109/L), thrombocytosis (>450 × 109/L), and normal PC (150-450 × 109/L [reference group]). Moreover, PC < 100 × 109/L was compared to PC ≥ 100 × 109/L. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from the logistic regression models were calculated. RESULTS: Among 7,533 IVT-treated stroke patients, 6,830 (90.7%) had normal PC, 595 (7.9%) had thrombocytopenia, and 108 (1.4%) had thrombocytosis. Decreasing PC (every 10 × 109/L) was associated with increasing risk of sICH (ORadjusted 1.03, 95% CI 1.02-1.05) but decreasing risk of poor outcome (ORadjusted 0.99, 95% CI 0.98-0.99) and mortality (ORadjusted 0.98, 95% CI 0.98-0.99). The risk of sICH was higher in patients with thrombocytopenic than in patients with normal PC (ORadjusted 1.73, 95% CI 1.24-2.43). However, the risk of poor outcome (ORadjusted 0.89, 95% CI 0.39-1.97) and mortality (ORadjusted 1.09, 95% CI 0.83-1.44) did not differ significantly. Thrombocytosis was associated with mortality (ORadjusted 2.02, 95% CI 1.21-3.37). Forty-four (0.3%) patients had PC < 100 × 109/L. Their risks of sICH (ORunadjusted 1.56, 95% CI 0.48-5.07), poor outcome (ORadjusted 1.63, 95% CI 0.82-3.24), and mortality (ORadjusted 1.38, 95% CI 0.64-2.98) did not differ significantly from those of patients with PC ≥ 100 × 109/L. CONCLUSION: Lower PC was associated with increased risk of sICH, while higher PC indicated increased mortality. Our data suggest that PC modifies outcome and complications in individual patients, while withholding IVT in all patients with PC < 100 × 109/L is challenged.

Long-term medication persistence in stroke patients treated with intravenous thrombolysis.

OBJECTIVE: There are no data regarding long-term medication persistence in stroke survivors treated with intravenous thrombolysis (IVT), which is one of the most important determinants of treatment success. Our objective was to determine long-term medication persistence in stroke patients treated with IVT. METHODS: This retrospective observational study included 203 IVT-treated and 197 non-IVT treated patients with acute ischemic strokes (IS) admitted to the Stroke Unit between January 2007 and January 2013. RESULTS: During a median follow-up period of 3 years (range 1-7 years), 56 (21.6%) patients in the IVT-group and 62 (23.9%) patients in the non-IVT-group died. There was a higher medication persistence for all secondary stroke prevention medications (anti-thrombotic agents, anti-hypertensive drugs, statins and hypoglycemic drugs) in the IVT-group compared to the non-IVT group (88.7% vs. 69.0%; OR=3.68, 95% CI=2.17-6.23). After adjusting for baseline characteristics and possible confounders IVT was the independent predictor of medication persistence (OR=2.93, 95% CI=1.48-5.81, p=0.002). Higher medication persistence was observed in patients with favorable long-term functional outcome, both in the IVT-group (OR=4.37, 95% CI=1.83-10.40, p<0.001) and the non-IVT-group (OR=3.46, 95% CI=1.84-6.52, p<0.001). CONCLUSION: Medication persistence was higher among IVT-treated patients compared to non-IVT-treated patients. The higher rate of non- medication persistence was recorded among patients with more pronounced disabilities after stroke.