Prospective Observational Cohort Study of Tenecteplase Versus Alteplase in Routine Clinical Practice.

BACKGROUND: A 10-hospital regional network transitioned to tenecteplase as the standard of care stroke thrombolytic in September 2019 because of potential workflow advantages and reported noninferior clinical outcomes relative to alteplase in meta-analyses of randomized trials. We assessed whether tenecteplase use in routine clinical practice reduced thrombolytic workflow times with noninferior clinical outcomes. METHODS: We designed a prospective registry-based observational, sequential cohort comparison of tenecteplase- (n=234) to alteplase-treated (n=354) stroke patients. We hypothesized: (1) an increase in the proportion of patients meeting target times for target door-to-needle time and transfer door-in-door-out time, and (2) noninferior favorable (discharge to home with independent ambulation) and unfavorable (symptomatic intracranial hemorrhage, in-hospital mortality or discharge to hospice) in the tenecteplase group. Total hospital cost associated with each treatment was also compared. RESULTS: Target door-to-needle time within 45 minutes for all patients was superior for tenecteplase, 41% versus 29%; adjusted odds ratio, 1.85 (95% CI, 1.27-2.71); P=0.001; 58% versus 41% by Get With The Guidelines criteria. Target door-in-door-out time within 90 minutes was superior for tenecteplase 37% (15/43) versus 14% (9/65); adjusted odds ratio, 3.62 (95% CI, 1.30-10.74); P=0.02. Favorable outcome for tenecteplase fell within the 6.5% noninferiority margin; adjusted odds ratio, 1.26 (95% CI, 0.89-1.80). Unfavorable outcome was less for tenecteplase, 7.3% versus 11.9%, adjusted odds ratio, 0.77 (95% CI, 0.42-1.37) but did not fall within the prespecified 1% noninferior boundary. Net benefit (%favorable-%unfavorable) was greater for the tenecteplase sample: 37% versus 27%. P=0.02. Median cost per hospital encounter was less for tenecteplase cases ($13 382 versus $15 841; P<0.001). CONCLUSIONS: Switching to tenecteplase in routine clinical practice in a 10-hospital network was associated with shorter door-to-needle time and door-in-door-out times, noninferior favorable clinical outcomes at discharge, and reduced hospital costs. Evaluation in larger, multicenter cohorts is recommended to determine if these observations generalize.

Neuroimaging of Normal Pressure Hydrocephalus and Hydrocephalus.

Since the clinical syndrome of progressive gait disturbance, urinary incontinence, and dementia in the setting of occult hydrocephalus responsive to cerebrospinal fuid (CSF) shunting was first reported in 1965, the existence of a potentially reversible cause for a form of a dementia illness has generated extensive clinical research and numerous clinical trials. Idiopathic normal pressure hydrocephalus (iNPH) continues to be a heavily debated clinical syndrome. This paper reviews guidelines and imaging findings most often associated with iNPH and the relationship of the neuroimaging findings to some of the theories for this complex syndrome.

Imaging of Intracranial Cysts.

PURPOSE OF REVIEW: Intracranial cysts are common findings on both CT and MRI. The majority of intracranial cysts are benign and incidental and without clinical significance. However, a minority are due to infectious, neoplastic, or other pathologic processes. RECENT FINDINGS: Neuroimaging, in particular brain MRI, can readily identify intracranial cysts. It can often be difficult to characterize the likely histopathology of intracranial cysts based solely on their signal intensity, even when using contrast. However, with the knowledge that most intracranial cysts occur within a fairly narrow anatomic distribution, a concise and specific differential diagnosis can often be developed based primarily on location. The first location-based question to consider regarding intracranial cysts is whether the lesion is intraaxial or extraaxial. Intraaxial cysts should be further characterized as intraparenchymal or intraventricular, and extraaxial cysts should be identified as either midline or nonmidline. Signal characteristics using CT, MRI, or both can help further characterize the cystic process. SUMMARY: Neurologists should be familiar with the characteristic patterns of intracranial cysts to distinguish between benign and pathologic processes. A systematic approach to the assessment of intracranial cysts based on location and appearance should greatly narrow the differential diagnosis.

Neuroimaging of dementia.

Dementia, whether secondary to Alzheimer disease or another process, is a significant cause of morbidity and mortality worldwide. Although dementia remains a clinical diagnosis, for many years imaging has served as a key component in the assessment of patients with cognitive impairment. There have been tremendous advancements in the neuroimaging of dementia over the past decade, moving the field past the rule-out dogma toward ruling in specific pathophysiologic processes. This article is written for the practicing clinician, to provide a review of neuroimaging findings associated with selected degenerative and nondegenerative forms of dementia.