Thrombolysis in elderly stroke patients in Italy (TESPI) trial and updated meta-analysis of randomized controlled trials.

BACKGROUND: Since its approval, the use of alteplase had been limited to patients aged ≤80 years. AIMS: TESPI trial had been designed to evaluate whether alteplase treatment within 3 h in patients with acute ischemic stroke aged >80 years resulted in favorable benefit/risk ratio compared with standard care. The meta-analysis of randomized controlled trials was updated to put findings in the context of all available evidence. METHODS: TESPI was a multicenter, open-label with blinded outcome evaluation, randomized, controlled trial. Main clinical endpoints were 90-day favorable functional outcome (mRS score 0-2) and mortality and symptomatic intracerebral hemorrhage. The trial was prematurely terminated for ethical reasons after publication of IST-3 trial which provided evidence of treatment benefit in elderly. RESULTS: Of the planned 600 patients, 191 (88 assigned to alteplase) were enrolled. Overall, 24/83 (28.9%) alteplase patients had a favorable outcome compared to 22/95 (23.2%) controls (non-significant absolute difference of 5.7% for alteplase; OR 1.35, 95% CI 0.69-2.64, P = 0.381). Rates of death were non-significantly lower in the alteplase patients (18.1% vs. 26.5%); rates of symptomatic intracerebral hemorrhage were similar between the two groups (5.9% vs. 5.1%). The updated meta-analysis showed consistent results with prior estimates and add weights. CONCLUSIONS: The effects of alteplase observed in this interrupted trial did not reach statistical significance, probably for the small numbers, but are consistent with and add weight to the sum total of the randomized evidence demonstrating that alteplase is beneficial in patients with acute ischemic stroke aged over 80 years, particularly if given within 3 h.

Effect of Cardioembolic Etiology on Intravenous Thrombolysis Efficacy for Acute Ischemic Stroke.

Previous clinical studies suggest that intravenous (IV) recombinant tissue plasminogen activator (rt-PA) benefits stroke patients regardless of the underlying etiology. In this study, we assessed the possible differences in response to IV rt-PA between cardioembolic stroke and other stroke subtypes. A total of 303 consecutive stroke ischemic patients (from January 2005 to April 2014) admitted to our Stroke Unit and treated with IV rt-PA were retrospectively reviewed. All patients were classified in two groups: Cardioembolic (CE) and Non-Cardioembolic (NCE). We analyzed a total of 303 patients. Thirty patients died in the first hours after fibrinolysis and no statistically significant differences were found in two groups (14 CE vs 18 N-CE). We observed a significant differences in clinical outcome in terms of symptoms "improvement" (p< 0.01 .2) and symptoms" regression" (p<0.057 .2) even if this last result did not reach statistical significance in CE patients respect to N-CE patients. In conclusion, the intravenous fibrinolysis is more effective in CE group than in N-CE regarding symptoms "improvement" and the PFO-Stroke patients treated with fibrinolysis have better outcome than other patients and they have high rate of symptoms" regression". Moreover the main predictor of good outcomes were younger age and milder stroke severity on hospital admission.

Transient Ischemic Attack Fast-track and Long-Term Stroke Risk: Role of Diffusion-Weighted Magnetic Resonance Imaging.

BACKGROUND: Acute ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI-MRI) are reliable predictors of recurrent stroke at 90 days. However, to date, limited information on transient ischemic attack (TIA) patients with positive DWI lesions for stroke risk from 1 to 5 years is available. In this study, we evaluated the role of positive DWI lesions and vascular risk factors on stroke, cardiovascular death, and mortality at 90 days (T0), 1 year (T1), and 5 years (T2). Moreover, we also evaluated the association between stroke risk and the presence of DWI lesions. METHODS: We performed an observational study on consecutive patients admitted to the emergency department of San Camillo-Forlanini Hospital, Rome, Italy, from January 2007 to November 2012. Over the study period, 4300 patients with TIA or ischemic stroke were examined by stroke specialists in an emergency room setting within 1 hour from admittance. RESULTS: In 510 of 4300 patients (11.86%), a TIA was diagnosed, and 445 patients satisfy the study inclusion criteria. For all 445 patients, the mean ABCD2 score was 4.35 ± 1.30. Using DWI-MRI, we identified acute ischemic lesions in 185 patients (41.57%). We did not observe any correlation between duration of symptoms, ABCD2 score, and positive or negative DWI lesions. Positivity for DWI was not associated with the presence of diabetes mellitus, hypertension, smoking habit, or age; however, an association with weakness was observed. We documented a time-dependent increase in the absolute risk of stroke: T0: 1.35% (95% confidence interval [CI], .81-2.8); T1: 4.78% (95% CI, 2.88-7.47); T2: 9.02% (95% CI, 4.66-5.70). We did not record any difference in stroke risk in patients with positive DWI lesions: T0: hazard ratio [HR], 1.43; 95% CI, .35-5.88; log-rank P = .60; T1: HR, 1.04; 95%CI, .42-2.61; log-rank P = .91; T2: HR, .83; 95% CI, .25-2.67; log-rank P = .86. CONCLUSIONS: This long-term follow-up study in TIA patients documents that both positive and negative DWI patients treated with fast-track had similar long-term risks of stroke.

The cloud stroke unit: 24-hour acute stroke expertise-on-demand.

The use of telemedicine, especially as it is relates to telestroke, has significantly expanded over the past one or two decades. The fact that stroke therapy is a time-critical disease process, coupled with the relative paucity of stroke-trained practitioners, makes telestroke an attractive technique of care. The authors' objective was to summarize the evidence that support the reliability of telemedicine for diagnosis and efficacy in acute stroke treatment in collaboration between hospitals in two different countries.

Muscle, peripheral nerve and autonomic changes.

Muscle, peripheral nerve and autonomic disorders associated with acute cerebrovascular events are a large spectrum of conditions, their pathophysiology, clinical features, frequencies of occurrence, prognosis and treatment are diverse; the disturbances may be primary or secondary to acute cerebrovascular events. These disorders have been previously defined as multiple neurological complications as the underlying pathophysiological mechanism may largely differ; their characterization may need a full clinical, neuroradiological, neurophysiological, immunological, biochemical and genetic analyses assessment, and an autonomic function test may also be needed as well as nerve and muscle biopsy. In this chapter we present multiple neurological complications secondary to acute cerbrovascular events.

[First-aid treatment for acute myocardial infarction. Experience at the San Camillo Hospital of Rome]. / Trattamento in pronto soccorso dell'infarto acuto del miocardio. L'esperienza dell'Ospedale San Camillo di Roma.

STUDY OBJECTIVE: The aim of the study is to verify: 1) the trustworthiness level of the diagnosis of AMI defined in Emergency Department (ER); 2) the frequency and the effectiveness (length of staying in hospital, mortality rate) of the invasive or not invasive treatment which are implemented in the ER area. METHODS: We have studied the crowding of the patients suffering from chest pain (CP) who asked the ER for assistance during the year 2000 and that of the patients with AMI diagnosed in ER (diagnosis at the admittance and at the discharge from the hospital, therapeutic procedures, staying in hospital, mortality rate). RESULTS: The patients suffering from CP have been the 5.4% of all the patients who reached the ER and were admitted to the hospital more than the patients who reached the ER for all the other causes (41.5% versus 22.1%). In 61.7% of the patients affected by AMI the disease was identified by the physicians of the ER; the invasive treatment has been developed in 67.7% of those patients and the not invasive in 32.3% of the same patients. The mean length of the staying in hospital for the patients who have been treated with PTCA was 10.3 days; on the contrary, the same value for the patients treated with thrombolysis was 13.8 days and the difference was significant at the 0.001 level. The mortality rate during the staying in Hospital was 5.9% in the patients treated with PTCA and 13% in the patients treated with thrombolysis but the difference was not significant because of the little number of the dead patients. CONCLUSION: The sensitivity (62%) and the specificity (100%) of the diagnosis of AMI defined in the ER demonstrate the utility of a Cardiologic Service in ER.