The treatment effect across ASPECTS in acute ischemic stroke: Analysis from the AcT Trial.

BACKGROUND: Early ischemic changes on baseline imaging are commonly evaluated for acute stroke decision-making and prognostication. AIMS: We assess the association of early ischemic changes on clinical outcomes and whether it differs between intravenous tenecteplase versus Alteplase. METHODS: Data are from the phase 3, Alteplase compared to Tenecteplase (AcT) trial. Subjects with anterior circulation stroke were included. Early ischemic changes were assessed using the Alberta Stroke Program Early CT score (ASPECTS). Efficacy outcomes included modified Rankin scale (mRS) 0-1, mRS 0-2, and ordinal mRS at 90 days. Safety outcomes included 24-hour symptomatic intracerebral hemorrhage (sICH), any hemorrhage on follow-up scan, and 90-day mortality rate. Mixed effects logistic regression was used to assess the association of ASPECTS [continuous and categorical (0-4 vs. 5-7 vs. 8-10)] with outcomes and if these associations were modified by thrombolytic type after adjusting for age, sex, and baseline stroke severity. RESULTS: Of the 1577 patients in the trial, 901 patients (56.3%) (median age 75 years [IQR 65-84], 50.8% females, median NIHSS 14 [IQR 17-19]) with anterior circulation stroke were included. mRS 0-1 at 90d was achieved in 1/14 (0.3%), 43/160 (14.7%) and 252/726 (85.1%) in the ASPECTS 0-4, 5-7 and 8-10 groups respectively. Every 1-point decrease in ASPECTS was associated with 2.7% and 1.9% decrease in chances of mRS 0-1 and mRS 0-2 at 90 days, respectively, and 1.9% chances of increase in mortality at 90 days. Subgroup analysis in EVT treated population showed similar results. Thrombolytic type did not modify this association between ASPECTS and 90-day mRS 0-1 (P interaction 0.75). There was no significant interaction by thrombolytic type with any other outcome. CONCLUSIONS: Similar to prior studies, we found that every one-point decrease in ASPECTS was associated with poorer clinical and safety outcomes. This effect did not differ between alteplase and tenecteplase.

Trends in Sex Differences of Functional Outcome after Intravenous Thrombolysis in Patients with Acute Ischemic Stroke.

BACKGROUND: Intravenous thrombolysis (IVT) is an approved treatment for patients with acute ischemic stroke irrespective of sex. However, the current literature on sex differences in functional outcomes following IVT is inconsistent. So far, a number of studies - including a previous analysis based on data from the Austrian Stroke Unit Registry (ASUR) - detected significant sex-related differences in functional outcome, while others did not report any differences between women and men. In addition, currently there is a lack of data on how sex-related differences evolve over time. AIMS: To assess time trends of sex-related differences in functional outcome of ischemic stroke in a large nationwide cohort and to investigate associations of patient characteristics with functional outcome post thrombolysis in women and men. These data will offer crucial insights into whether sex differences in functional outcome persist despite the large advances in acute stroke treatment. METHODS: We analyzed retrospective data of consecutive patients with acute ischemic stroke treated with IVT in 39 stroke centers contributing to the ASUR between 2006 and 2021. We included patients over 18 years of age diagnosed with an acute ischemic stroke who received IVT and with available data on functional outcome at 3 months after treatment. The primary outcome parameter was favorable functional outcome (modified Rankin Scale (mRS) of 0-2) at 3 months. Multivariable logistic regression analysis was performed in the overall population and stratified by sex to assess associations of baseline characteristics with functional outcome. RESULTS: Among 11840 patients receiving IVT, 2489/5503 (45.4%) women achieved favorable functional outcome compared to 3787/6337 (59.8%) men. Overall, female sex was a statistically significant predictor of functional outcome after thrombolysis, but additional predictors of outcome differed between women and men. Female sex was independently associated with decreased chances of achieving functional independency (adjOR 0.87, 95%CI 0.79-0.96, p=0.005) and we detected a statistically significant improvement in functional outcome over time only in men (year of treatment, adjOR (per year) 1.04, 95%CI 1.02-1.06, p<0.001) but not in women (adjOR (per year) 1.01, 95%CI 0.99-1.03, p=0.280). Hypertension, smoking, and longer or unknown onset-to-door times were statistically significant predictors of outcome only in male patients, whereas atrial fibrillation, prior myocardial infarction and longer door-to-needle times were significantly associated with outcome only in women. CONCLUSIONS: Sex differences in functional outcome after IVT for acute ischemic stroke are persisting over the past years. Results of our analysis can increase awareness and a resulting focus on sex differences in predictors of outcome could be helpful in mitigating these differences in the future by supporting a more individualized patient care in clinical routine. Follow-up analyses are needed to assess this potential impact and its effect in the future.Data access statement: Data from the Austrian Stroke Unit Registry can only be accessed by the employed statistician (DM), access inquiries have to be addressed to the registry's academic review board.

Veno-venous or veno-arterial extracorporeal membrane oxygenation support for massive pulmonary embolism: a case report.

Background: With regard to the treatment of massive pulmonary embolism (MPE) with circulatory and respiratory collapse and thrombolytic contraindications, current guidelines and researches usually give the priority to veno-arterial extracorporeal membrane oxygenation (V-A ECMO). However, the objective of this clinical case report is to highlight the effective use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) in a 35-year-old pregnant woman with MPE complicated by hemorrhage, persistent hypoxia and multiple cardiac arrests. Case Description: A 35-year-old pregnant woman with gestational mellitus suddenly presented with complaints of nausea, vomiting and dyspnea after going to the toilet, combined with increasing heart rate (HR) of 150 bpm, decreasing pulse oxygen saturation (SpO2) of 94%, larger right heart and the growing D-dimer at 11.2 µg/mL, who was considered as the pulmonary embolism. Unpredictable cardiac arrest occurred repeatedly before and after the cesarean section. Although cardiopulmonary resuscitation (CPR) was started timely and successfully, the maintenance of blood pressure still depended on high-dose pressor drugs, even terribly, the oxygenation was unstable under the assistance of mechanical ventilation with pure oxygen. Thus, V-V ECMO supporting was commenced following by gradual recovering in haemodynamics and respiratory function. And the diagnosis of MPE was ascertained again through computed tomographic pulmonary angiography (CTPA) and pulmonary angiography. Directing at the pathogeny, thrombolysis infusion catheters and anticoagulant therapy were initiated after bilateral uterine artery embolism for postpartum haemorrhage, later the patient discharged from hospital after recovery and had a good prognosis. Conclusions: V-V ECMO could be effective for some patients with MPE who suffer from successful CPR after cardiac arrest while still combined with severe hypotension and refractory hypoxemia.

Wake-Up Thrombolysis With Negative Diffusion-Weighted Magnetic Resonance Imaging.

This case underscores the importance of treating neurological deficits of an acute stroke presentation despite initial negative diffusion-weighted imaging (DWI), especially in the acute phase when there is high clinical suspicion of stroke. Additionally, it highlights the appropriate use of a WAKE-UP protocol for patients that present with stroke symptoms without a well-defined inception time. A 71-year-old female presented to the emergency department with symptoms of dizziness and double vision upon wake-up. While clinical exam findings revealed left intranuclear ophthalmoplegia (INO) and inability to ambulate due to gait ataxia, magnetic resonance imaging (MRI) was negative for acute stroke. Despite negative DWI MRI, this patient's clinical exam findings of a left INO and gait ataxia were indicative of an ischemic stroke localizing to the medial longitudinal fasciculus (MLF), and the patient received thrombolytics. Repeat MRI about 48 h later revealed an acute infarct in the left midbrain with a DWI lesion in the MLF.

Should patients with minor strokes be given thrombolytics?

Mild stroke symptoms are cited as the reason for not using tissue-type plasminogen activator in 29-43% of time-eligible patients. Previous studies suggested that not all of these patients had a good recovery or even survival to hospital discharge. Since then, stroke guidelines worldwide recommended thrombolysis in minor but disabling strokes.Dual antiplatelet treatment with aspirin and clopidogrel was more effective than aspirin alone for reducing subsequent events in patients with minor stroke if started within 24 hours of onset in both CHANCE (Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events) and POINT (Platelet-Oriented Inhibition in New TIA and Minor Ischaemic Stroke) trials. Recently, both PRISMS (The Potential of rtPA for Ischemic Strokes With Mild Symptoms) trial and TEMPO-2(The Potential of rtPA for Ischemic Strokes With Mild Symptoms) trial showed that treatment with thrombolysis versus antiplatelet did not increase the likelihood of favourable functional outcome at 90 days among patients with minor non-disabling acute ischaemic strokes. Therefore, a narrative review on thrombolysis for patients with minor strokes from published studies may help practicing clinicians.

Safety and efficacy of tirofiban combined with intravenous thrombolysis and endovascular treatment in acute large vessel occlusion stroke.

OBJECTIVE: This study assesses the safety and efficacy of tirofiban for patients with large vessel occlusion stroke after intravenous thrombolysis. METHODS: This study data was from SUSTAIN, DEVT, and RESCUE BT trials. According to whether the use of tirofiban who underwent endovascular treatment and preceding intravenous thrombolysis was divided into the tirofiban group and the no-tirofiban group. The safety outcomes were symptomatic intracranial hemorrhage, any intracranial hemorrhage within 48 h, and 3-month mortality. The efficacy outcome was defined as a score of 0-2 on the modified Rankin Scale scores at 3 months. RESULTS: A total of 372 patients with intravenous thrombolysis were included in these SUSTAIN, DEVT, and RESCUE BT trials. Adjusted multivariate analysis showed that tirofiban with intravenous thrombolysis was not associated with symptomatic intracranial hemorrhage (aOR, 0.87; 95 % CI, 0.49-1.57; P=0.65), any intracranial hemorrhage within 48 h (aOR, 1.00; 95 % CI, 0.60-1.66; P=1.00), 3-month mortality (aOR, 1.10; 95 % CI, 0.56-2.19; P=0.78) and 3-month modified Rankin Scale scores 0-2 (aOR, 0.72; 95 % CI, 0.42-1.25; P=0.25) in patients with acute large vessel occlusion. In the subgroup analysis, we found that tirofiban was not recommended for females (aOR, 0.34; 95 % CI, 0.12-0.93), baseline Alberta Stroke Program Early CT Score≤9 (aOR, 0.37; 95 % CI, 0.18-0.76), and cardiogenic embolism (aOR, 0.36; 95 % CI, 0.14-0.97). CONCLUSION: Tirofiban combined with intravenous thrombolysis in patients with acute large vessel occlusion may be safe. Further studies need to confirm the effectiveness of tirofiban after intravenous thrombolysis in different stroke etiology.

Management of Ischemic Stroke in a Tertiary Care Hospital in Khyber Pakhtunkhwa: Existing Status and Prospective Opportunities.

Background and objective Khyber Pakhtunkhwa is the third largest province of Pakistan by population and has a high incidence of ischemic stroke. We evaluated all patients who presented to the largest tertiary care facility in the province to learn about the current trends in the management of ischemic stroke and explore future opportunities in this regard.  Materials and methods This prospective observational research was carried out at the Lady Reading Hospital-Medical Teaching Institute (LRH-MTI), Peshawar, in the province of Khyber Pakhtunkhwa (KP). The hospital's ethics committee granted the required permissions for the research. Any patient with an ischemic stroke diagnosis, regardless of age, met the inclusion criteria if their diagnosis was confirmed by clinical assessment, imaging (such as CT or MRI), or both. The clinical parameters that were evaluated included the duration since the patient's reported onset of symptoms, the patient's first mode of transfer to the hospital (such as ambulance, private vehicle, or other means), and the date and time of admission to the hospital. A structured database containing the data was utilized, and IBM SPSS Statistics for Windows, Version 25 (released 2017; IBM Corp., Armonk, New York, United States) was used for statistical analysis. Results One hundred fifty-six stroke patients were diagnosed throughout the study period, with 76 of them having an ischemic stroke, accounting for 49% of all stroke cases. Approximately 43% (n = 33) of the patients were from Peshawar, with the remaining patients coming from adjacent districts. There was only a small percentage (19%, n = 15) of patients who were eligible for any thrombolytic therapy, and the majority (93%) were brought by private vehicles. There was a significant association between age and arrival in the emergency room (p = 0.003). Conclusion The study reveals subpar ischemic stroke management in Khyber Pakhtunkhwa, requiring coordinated efforts, modernization of treatment methods, and increased public awareness to improve patient outcomes.

Vascular Surgeon Involvement in Pulmonary Embolism Response Teams: Barriers, Challenges, Concerns and the Imperative for Integration.

OBJECTIVES: The effective management of pulmonary embolism (PE) necessitates coordinated care among physicians from diverse specialties within a time-sensitive framework. Pulmonary Embolism Response Teams (PERTs) have been developed as a strategic approach to optimize and expedite treatment by integrating and coordinating different specialties. This multidisciplinary paradigm facilitates prompt risk assessment, formulation of treatment strategy, and resource mobilization, enhancing PE outcomes. METHODS: A de-identified REDCap survey was disseminated to vascular surgeons, with collected data submitted to the Vascular Surgery Collaborative (VASC) database. RESULTS: A total of 139 vascular surgeons with an average of 10.6 years of practice experience responded to the VASC PERT audit. The majority (70.5%) practice in academic settings and only 24.5% currently perform PE interventions in their practice. While nearly half of respondents (52.5%) reported the existence of PERT in their institutions, only a fraction (23.3%) was actively involved in the PERT. Notably, a significant proportion in our cohort (38.1%) expressed dissatisfaction with the representation of vascular surgeons in multidisciplinary teams managing venous thromboembolism (VTE), including deep vein thrombosis (DVT) and PE. Vascular surgery representation in PERT was only 34.2%, with pulmonology (60.3%), interventional radiology (57.5%), interventional cardiology (57.5%), and critical care (50.7%) being the most represented specialties. The primary barriers to vascular surgery participation in PERT were competing interests from other specialties and logistical scheduling challenges. Figure 1 visually summarizes the study's key findings in a visual abstract. CONCLUSIONS: The audit shows a global deficit in the integration of vascular surgery expertise within PERT frameworks. Primary barriers include exclusion due to competing interests from other specialties and challenges in the logistical coordination of PERT calls.

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion.

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

The Management of Intracardiac Thrombus in a COVID-19 Patient Using IV Thrombolytics: A Case Report.

The coronavirus disease 2019 (COVID-19) pandemic has unveiled numerous clinical challenges, particularly its association with thrombotic events, which significantly contribute to morbidity and mortality. While thrombotic complications such as arterial and venous thromboembolism (VTE) are well-documented, instances of intracardiac thrombus are notably rare. This case report discusses a 60-year-old male with COVID-19 who came to the hospital due to respiratory distress. Despite treatment with remdesivir, the patient's condition worsened prompting further workup. His nuclear medicine (NM) ventilation-perfusion scan was inconclusive, but a 2D echocardiogram showed an intracardiac thrombus in the right atrium (RA) and right ventricle (RV). As the patient's condition worsened, necessitating a transition from nasal cannula to high-flow nasal cannula, a decision was made to treat him with intravenous (IV) thrombolytic therapy. The patient received 100 mg IV alteplase and IV heparin, resulting in significant respiratory improvement and symptomatic relief. A repeat echocardiogram after 48 hours showed normal ejection fraction and complete thrombus resolution. In conclusion, this case highlights the complex link between COVID-19 infection and prothrombotic states, leading to severe complications such as intracardiac thrombus in transit. The successful treatment of this patient through a multidisciplinary approach and thrombolytic therapy underscores the importance of prompt recognition and intervention in high-risk cases.

Mobile stroke units: Beyond thrombolysis.

In the last decade, mobile stroke units (MSUs) have shown the potential to transform prehospital stroke care, marking a paradigm shift in delivering ultra-rapid thrombolysis and streamlining triage processes. These units bring acute stroke care directly to patients, significantly shortening treatment times. This review outlines the rationale for MSU care and discusses the potential applications beyond the original purpose of delivering thrombolysis, including large vessel occlusion detection, intracerebral hemorrhage management, and innovative forms of prehospital research.

Unlocking the potential of HB/RDW ratio as a simple marker for predicting mortality in acute ischemic stroke patients after thrombolysis.

BACKGROUND: Systemic inflammation impairs outcomes in acute ischemic stroke (AIS). There is limited knowledge regarding the prognostic value of inflammatory biomarkers derived from complete blood count in predicting in-hospital mortality (IHM) in AIS patients treated with recombinant tissue plasminogen activator (rt-PA). Our study aims to compare the predictive performance of various inflammatory biomarkers for predicting IHM in AIS patients. METHODS: This retrospective study included AIS patients treated with rt-PA between January 2015 and July 2022. We identified the following inflammatory biomarkers: white blood cell counts (WBCs), absolute neutrophil count, absolute lymphocyte count, neutrophil to lymphocyte count ratio, platelet to neutrophil ratio, platelet to lymphocyte ratio, red cell distribution width (RDW), RDW to platelet ratio (RPR), and hemoglobin to RDW (HB/RDW) at admission before rt-PA administration. We assessed the predictive value of these biomarkers for IHM by plotting receiver operating characteristic (ROC) curves. The associations between inflammatory biomarkers and IHM were analyzed using multivariable logistic regression (MVLR) analyses. RESULTS: Of 345 AIS patients, IHM occurred in 65 patients (18.84%). HB/RDW and RDW showed better predictive performance compared to other inflammatory biomarkers. In ROC curve analysis, HB/RDW and RDW had an area under ROC of 0.668. HB/RDW outperformed RDW in terms of the positive likelihood ratio (2.733 vs 1.575), accuracy (0.757 vs 0.585), specificity (0.814 vs 0.560), and positive predictive values (0.388 vs 0.267). In MVLR analysis, RDW, RPR, and HB/RDW remained significantly associated with IHM (per 1-unit increases: odds ratios (ORs) = 1.450, 95% CI: [1.178-1.784]; per 1-unit increases: ORs = 1.329, 95% CI [1.103-1.602]; and per 0.1-unit decreases: ORs = 1.412, 95% CI [1.089-1.831], respectively). CONCLUSIONS: The association between HB/RDW and IHM in AIS patients treated with rt-PA was significant. HB/RDW exhibited superior predictive performance compared to other inflammatory biomarkers in predicting IHM.

Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis.

BACKGROUND: Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS. METHODS: A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated. RESULTS: Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity. CONCLUSION: 3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.

Ultrasound-assisted catheter-directed thrombolysis versus surgical pulmonary embolectomy for intermediate-high or high-risk pulmonary embolism: a randomized phase II non-inferiority trial.

OBJECTIVES: We hypothesized that ultrasound-assisted thrombolysis (USAT) is non-inferior to surgical pulmonary embolectomy (SPE) to improve right ventricular (RV) function in patients with acute pulmonary embolism (PE). METHODS: In a single-centre, non-inferiority trial, we randomly assigned 27 patients with intermediate-high or high-risk acute PE to undergo either USAT or SPE stratified by PE risk. Primary and secondary outcomes were the baseline-to-72-h difference in right-to-left ventricular (RV/LV) ratio and the Qanadli pulmonary occlusion score, respectively, by contrast-enhanced chest-computed tomography assessed by a blinded CoreLab. RESULTS: The trial was prematurely terminated due to slow enrolment. Mean age was 62.6 (SD 12.4) years, 26% were women, and 15% had high-risk PE. Mean change in RV/LV ratio was -0.34 (95% CI -0.50 to -0.18) in the USAT and -0.53 (95% CI -0.68 to -0.38) in the SPE group (mean difference: 0.152; 95% CI 0.032-0.271; Pnon-inferiority = 0.80; Psuperiority = 0.013). Mean change in Qanadli pulmonary occlusion score was -7.23 (95% CI -9.58 to -4.88) in the USAT and -11.36 (95% CI -15.27 to -7.44) in the SPE group (mean difference: 5.00; 95% CI 0.44-9.56, P = 0.032). Clinical and functional outcomes were similar between the 2 groups up to 12 months. CONCLUSIONS: In patients with intermediate-high and high-risk acute PE, USAT was not non-inferior when compared with SPE in reducing RV/LV ratio within the first 72 h. In a post hoc superiority analysis, SPE resulted in greater improvement of RV overload and reduction of thrombus burden.

Spontaneous spinal epidural hematoma following IV heparin and catheter-directed thrombolysis for deep vein thrombosis.

Spontaneous spinal epidural hematoma (SSEH) is a rare condition, and it usually presents with acute onset neck or back pain, progressive weakness, and other symptoms of spinal cord compression. Catheter-directed thrombolysis is one option for limbs threatened by iliofemoral venous thrombosis; other options, such as venous thrombectomy (either open or percutaneous), are also available. There are few reported cases of SSEH owing to catheter-directed thrombolysis for deep venous thrombosis (DVT). We present a case of a 65-year-old man who presented with left lower limb extensive iliofemoral DVT and received catheter-directed thrombolysis. The patient initially had rapid improvement in his symptoms with restoration of limb perfusion. However, within 6 hours of starting catheter-directed thrombolysis, the patient developed extensive SSEH and underwent emergent spinal decompression surgery with laminectomy of T11 to T12 with complete resolution of the neurological deficit. Clinicians should consider SSEH in differential diagnosis if the patient develops acute onset neck or back pain after catheter-guided thrombolysis for DVT.

Successful use of intra venous tenecteplase for acute ischemic stroke in pregnancy.

Intravenous thrombolysis (IVT) with tenecteplase or alteplase is the standard of care in, patients with Acute Ischemic Stroke (AIS) presenting within 3-4.5 h. However here, are no established guidelines for such treatment during pregnancy. We report a case, of AIS in third trimester of pregnancy successfully treated with Tenecteplase. To the, best of our knowledge, this is the first and only case of acute ischemic stroke in, pregnancy treated with Tenecteplase.

Evolution of Pulmonary Embolism Response Teams in the United States: A Review of the Literature.

Pulmonary embolism (PE) is a significant cause of cardiovascular mortality, with varying presentations and management challenges. Traditional treatment approaches often differ, particularly for submassive/intermediate-risk PEs, because of the lack of clear guidelines and comparative data on treatment efficacy. The introduction of pulmonary embolism response teams (PERTs) aims to standardize and improve outcomes in acute PE management through multidisciplinary collaboration. This review examines the conception, evolution, and operational mechanisms of PERTs while providing a critical analysis of their implementation and efficacy using retrospective trials and recent randomized trials. The study also explores the integration of advanced therapeutic devices and treatment protocols facilitated by PERTs. PERT programs have significantly influenced the management of both massive and submassive PEs, with notable improvements in clinical outcomes such as decreased mortality and reduced length of hospital stay. The utilization of advanced therapies, including catheter-directed thrombolysis and mechanical thrombectomy, has increased under PERT guidance. Evidence from various studies, including those from the National PERT Consortium, underscores the benefits of these multidisciplinary teams in managing complex PE cases, despite some studies showing no significant difference in mortality. PERT programs have demonstrated potentials to reduce morbidity and mortality, streamlining the use of healthcare resources and fostering a model of sustainable practice across medical centers. PERT program implementation appears to have improved PE treatment protocols and innovated advanced therapy options, which will be further refined as they are employed in clinical practice. The continued expansion of the capabilities of PERTs and the forthcoming results from ongoing randomized trials are expected to further define and optimize management protocols for acute PEs.

"One-Stone-Three-Birds" H2S-Photothermal Therapy for Enhanced Thrombolysis and Vascular Healing.

Thrombus causes a serious condition characterized by the formation of blood clots in blood vessels or heart, potentially leading to life-threatening emergencies. Photothermal therapy (PTT) serves as a treatment for thrombosis that provides noninvasive thrombus dissolution and fewer bleeding side effects. However, the high temperatures generated by PTT can exacerbate vascular inflammation and promote thrombus recurrence. In this study, a photothermal hydrogen sulfide (H2S) nanogenerator (PSA@ADT-OH) is constructed using a perylene-cored photothermal agent (PSA) coassembled with a H2S donor ADT-OH. The system PSA@ADT-OH demonstrates outstanding targeting and accumulation efficiency against blood flow shear forces. It also provides sustained H2S release at thrombus sites, contributing to antiplatelet aggregation, reactive oxygen species clearance, and vascular healing. This approach opens up new possibilities for advanced thrombus treatment.

Comparison of the Clinical Outcomes Between Reperfusion and Non-Reperfusion Therapy in Elderly Patients with Acute Ischemic Stroke.

Purpose: To investigate the benefit (90-day mRS score) and rate of major complications (early symptomatic intracranial hemorrhage-SICH) after reperfusion therapy (RT) (including intravenous thrombolysis -IVT and mechanical thrombectomy -MT) in patients over 80 years with acute ischemic stroke (AIS). Patients and Methods: AIS patients aged over 80 admitted to Huizhou Central People's Hospital from September 2018 to 2023 were included in this study. Data on SICH, NIHSS, and mRS were analyzed. A good prognosis was defined as a mRS ≤ 2 or recovery to pre-stroke status at 90 days. Results: Of 209 patients, 80 received non-RT, 100 received IVT and 29 underwent MT. The non-RT group had the lowest baseline NIHSS while the MT group had the highest (non-RT 6.0 vs IVT 12.0 vs MT 18.0, P <0.001). Higher NIHSS was associated with increased SICH risk (OR 1.083, P=0.032), while RT was not (OR 5.194, P=0.129). The overall SICH rate in the RT group was higher but not significantly different after stratification by stroke severity. Poor prognosis was associated with higher admission NIHSS, stroke due to large artery atherosclerosis (LAA) combined with cardioembolism (CE), and stroke-associated pneumonia (SAP) (OR 0.902, P<0.001; OR 0.297, P=0.029; OR 0.103, P<0.001, respectively). The RT group showed a greater reduction in NIHSS (delta NIHSS) than the non-RT group (non-RT 2.0 vs IVT 4.0 vs MT 6.0, P<0.005). For severe AIS, the IVT group had a better prognosis at 90 days (non-RT 0% vs IVT 38.2%, P=0.039). No 90-day mortality difference was found between groups after stratification. Conclusion: Stroke severity, rather than RT, is an independent risk factor for SICH in AIS patients over 80. RT in severe stroke patients improves NIHSS at 90 days, suggesting RT is safe and effective in this demographic. Further studies with larger samples are required to confirm these findings.

Paget-Schroetter Syndrome: A Case of a Young Weightlifter.

Venous thoracic outlet syndrome is a rare type of thoracic outlet disorder that is often overlooked. When an upper extremity deep vein thrombosis (UEDVT) occurs due to thoracic outlet compression, it is commonly referred to as Paget-Schroetter syndrome (PSS). The space between the first rib and the clavicle where the subclavian vein passes through is highly vulnerable to compression and injury. This space often undergoes repetitive trauma due to extrinsic compression which ultimately results in scarring and clot formation. This case report reviews the case of a 26-year-old white male who presented with the chief complaint of right arm swelling and soreness after strenuous bench pressing. He went to urgent care and the initial diagnosis was a strained muscle. An ultrasound was ordered, revealing multiple UEDVTs. At this time, the patient was referred to vascular surgery for further management. Recommended management for PSS is to initiate anticoagulation or thrombolytic therapy depending on the timing between the onset of symptoms and diagnosis. Although there is some disagreement on the next steps after thrombolysis, most physicians agree that decompression of the thoracic outlet with first rib resection is the logical next step to prevent clot recurrence. The patient received the above-mentioned therapy and is progressing well with recovery. Recognizing the thoracic outlet as a potential location for pathology and keeping in mind those who have a presentation similar to this case study is extremely important.