Is off-label thrombolysis safe and effective in a real-life primary stroke center? A retrospective analysis of data from a 5-year prospective database.

BACKGROUND: Intravenous thrombolysis (IVT) use for acute ischemic stroke (AIS) varies among countries, partly due to guidelines and product labeling changes. The study aim was to identify the characteristics of patients with AIS treated with off-label IVT and to determine its safety when performed in a primary stroke center (PSC). METHODS: This observational, single-center study included all consecutive patients admitted to Perpignan PSC for AIS and treated with IVT and patients transferred for EVT, between January 1, 2015 and December 31, 2019. Data of patients treated with IVT according to ("in-label group") or outside ("off-label") the initial guidelines and manufacturer's product specification were compared. Safety was assessed using symptomatic intracerebral hemorrhage (SIH) as the main adverse event. RESULTS: Among the 892 patients in the database (834 screened by MRI, 93.5%), 746 were treated by IVT: 185 (24.8%) "in-label" and 561 (75.2%) "off-label". In the "off-label" group, 316 (42.4% of the cohort) had a single criterion for "off-label" use, 197 (26.4%) had two, and 48 (6.4%) had three or more criteria, without any difference in IVT safety pattern among them. SIH rates were comparable between the "off-label" and "in-label" groups (2.7% vs. 1.1%, P=0.21); early neurological deterioration and systematic adverse event due to IVT treatment were similar in the 2 groups. "Off-label" patients had higher in-hospital (8.7% vs. 3.8%, P=0.05) and 3-month mortality rates (12.1% vs 5.4%, P<0.01), but this is explained by confounding factors as they were older (76 vs 67 years, P<0.0001) and more dependent (median modified Rankin scale score 0.4 vs 0.1, P<0.0001) at admission. CONCLUSIONS: "Off-label" thrombolysis for AIS seems to be safe and effective in the routine setting of a primary stroke center.

Endovascular treatment for acute ischemic stroke at a primary stroke center: First results of the Perpignan center.

INTRODUCTION: Converting a high-volume primary stroke center (PSC) into a stroke center that can perform emergency endovascular treatment (EVT) could reduce the time to thrombectomy. We report the first results of a newly established EVT facility at the Perpignan PSC and their comparison with the targets defined by the established guidelines. PATIENTS AND METHOD: For this comprehensive observational study, data of patients with acute ischemic stroke (AIS) due to proximal large vessel occlusion (LVO) and treated by EVT at the Perpignan PSC from December 5, 2019 to September 15, 2020 were extracted from an ongoing prospective database. RESULTS: During the study period, 37 patients underwent EVT at the Perpignan PSC. The median (range) symptom-onset to recanalization time was 262min (100-485min). The median (range) intra-hospital times were: 20min (2-58min) for door-to-imaging, 57min (30-155min) for imaging-to-puncture, 55min (15-180min) for puncture-to-recanalization, and 137min (59-319min) for door-to-recanalization. At 3 months post-AIS, the favorable outcome (modified Ranking Score: 0-2) rate was 50% and the mortality rate was 19.4%. These results are comparable to those of previous clinical trials, and meet the targets defined by the current consensus statements for EVT. DISCUSSION AND CONCLUSION: Our results show the feasibility and safety of EVT in a PSC for patients with AIS due to LVO. The implementation of this strategy may be important for shortening the time to thrombectomy.

Results of a 1-year quality-improvement process to reduce door-to-needle time in acute ischemic stroke with MRI screening.

OBJECTIVE: To determine the effects of a 1-year quality-improvement (QI) process to reduce door-to-needle (DTN) time in a secondary general hospital in which multimodal MRI screening is used before tissue plasminogen activator (tPA) administration in patients with acute ischemic stroke (AIS). METHODS: The QI process was initiated in January 2015. Patients who received intravenous (iv) tPA<4.5h after AIS onset between 26 February 2015 to 25 February 2016 (during implementation of the QI process; the "2015 cohort") were identified (n=130), and their demographic and clinical characteristics and timing metrics compared with those of patients treated by iv tPA in 2014 (the "2014 cohort", n=135). RESULTS: Of the 130 patients in the 2015 cohort, 120 (92.3%) of them were screened by MRI. The median DTN time was significantly reduced by 30% (from 84min in 2014 to 59min; P<0.003), while the proportion of treated patients with a DTN time≤60min increased from 21% to 52% (P<0.0001). Demographic and baseline characteristics did not significantly differ between cohorts, and the improvement in DTN time was associated with better outcomes after discharge (patients with a 0-2 score on the modified rankin scale: 59% in the 2015 cohort vs 42.4% in the 2014 cohort; P<0.01). During the 1-year QI process, the median DTN time decreased by 15% (from 65min in the first trimester to 55min in the last trimester; P≤0.04) with a non-significant 1.5-fold increase in the proportion of treated patients with a DTN time≤60min (from 41% to 62%; P=0.09). CONCLUSION: It is feasible to deliver tPA to patients with AIS within 60min in a general hospital, using MRI as the routine screening modality, making this QI process to reduce DTN time widely applicable to other secondary general hospitals.

[Predictive value of postural and dynamic walking parameters after high-volume lumbar puncture in normal pressure hydrocephalus]. / Intérêt prédictif de l'évolution des facteurs posturaux et locomoteurs après ponction lombaire soustractive dans l'hydrocéphalie chronique de l'adulte.

INTRODUCTION: Normal pressure hydrocephalus (NPH) was described by Adams et al. (1965). The common clinical presentation is the triad: gait disturbance, cognitive decline and urinary incontinence. Although these symptoms are suggestive, they are not specific to diagnosis. The improvement of symptoms after high-volume lumbar puncture (hVLP) could be a strong criterion for diagnosis. We tried to determine a specific pattern of dynamic walking and posture parameters in NPH. Additionally, we tried to specify the evolution of these criteria after hVLP and to determine predictive values of ventriculoperitoneal shunting (VPS) efficiency. PATIENTS AND METHODS: Sixty-four patients were followed during seven years from January 2002 to June 2009. We identified three periods: before (S1), after hVLP (S2) and after VPS (S3). The following criteria concerned walking and posture parameters: walking parameters were speed, step length and step rhythm; posture parameters were statokinesigram total length and surface, length according to the surface (LFS), average value of equilibration for lateral movements (Xmoyen), anteroposterior movements (Ymoyen), total movement length in lateral axis (longX) and anteroposterior axis (longY). RESULTS: Among the 64 patients included, 22 had VPS and 16 were investigated in S3. All kinematic criteria are decreased in S1 compared with normal values. hVLP improved these criteria significantly (S2). Among posture parameters, only total length and surface of statokinesigram showed improvement in S1, but no improvement in S2. A gain in speed greater or equal to 0.15m/s between S1 and S2 predicted the efficacy of VPS with a positive predictive value (PPV) of 87.1% and a negative predictive value (NPV) of 69.7% (area under the ROC curve [AUC]: 0.86). CONCLUSION: Kinematic walking parameters are the most disruptive and are partially improved after hVLP. These parameters could be an interesting test for selecting candidates for VPS. These data have to be confirmed in a larger cohort.

An atypical ballistic traumatic cauda equina syndrome with a positive outcome. Focus on prognostic factors.

INTRODUCTION: Traumatic cauda equina syndromes due to projectile wounds often have a poor prognosis. We report on an unusual ballistic cauda equina traumatism with a good functional outcome. CLINICAL CASE: A 44-year-old man was admitted to emergency room for an incomplete cauda equina syndrome after trying to kill himself by means of a pneumatic nail gun. The nail had gone right through the third lumbar vertebra. Because of the stability of the fracture, orthopaedic surgery was not indicated. Neurological recovery was progressive. At 6 months, there was still a partial L5-S1 motor deficit on the left side but the patient could walk without crutches, and within an unlimited walking distance. DISCUSSION: Initial imaging displayed a projectile trajectory focused on the spinal canal on level L3, which could have been considered as bad prognosis. The positive analytic and functional outcome correlates with the limited neurological tissue damage, probably explained by the ballistic properties of the projectile. CONCLUSION: Apart from the influence of a possible surgical act, the neurological and functional prognosis of a traumatic cauda equina syndrome caused by a projectile also depends on its physical characteristics.