The efficacy of thrombolysis in lacunar stroke - evidence from the Austrian Stroke Unit Registry.

BACKGROUND AND PURPOSE: Intravenous thrombolysis (ivT) with recombinant tissue plasminogen activator is established in acute ischaemic stroke. Little is known, however, about its efficacy in different stroke subtypes. METHODS: A retrospective analysis of 128 733 patients from the Austrian Stroke Unit Registry was performed. Patients were classified as lacunar (LacS) or non-lacunar ischaemic stroke (nonLacS) by use of the clinical syndrome and technical findings. Outcome parameters were the short term improvement in the stroke unit [the difference of the National Institutes of Health Stroke Scale (NIHSS) score at admission and at discharge] and the modified Rankin Scale (mRS) score at 3 months. Patients were assigned to four groups according to thrombolysis and stroke subtype. To control for confounding, patients were matched for variables identified with impact outcome and for variables of general interest (NIHSS at admission, mRS before stroke and general risk factors). RESULTS: There were four matched groups of 401 cases each. In LacS median short term improvement was 3 [interquartile range (IQR) 2-5] NIHSS points in the thrombolysed patients and 2 (IQR 1-4) in the non-thrombolysed patients (P < 0.001). In the nonLacS groups median short term improvement was 3 (IQR 1-5) in the thrombolysed and 2 (IQR 0-4) in the non-thrombolysed patients (P < 0.001). At 3-month follow-up, ivT was significantly associated with a better functional outcome in LacS (P < 0.001) and nonLacS patients (P < 0.001). Taking magnetic resonance imaging as a requirement for stroke subtyping led to similar results. CONCLUSIONS: Patients with both lacunar and non-lacunar stroke benefitted from ivT. The degree of improvement was similar in both groups.

Endovascular stroke therapy in Austria: a nationwide 1-year experience.

BACKGROUND AND PURPOSE: Based on a tight network of stroke units (SUs) and interventional centres, endovascular treatment of acute major intracranial vessel occlusion has been widely implemented in Austria. Documentation of all patients in the nationwide SU registry has thereby become mandatory. METHODS: Demographic, clinical and interventional characteristics of patients who underwent endovascular treatment for acute ischaemic stroke in 11 Austrian interventional centres between 1 October 2013 and 30 September 2014 were analysed. RESULTS: In total, 301 patients (50.5% women; median age 70.5 years; median National Institutes of Health Stroke Scale score 17) were identified.193 patients (64.1%) additionally received intravenous thrombolysis. The most frequent vessel occlusion sites were the M1 segment of the middle cerebral artery (n = 161, 53.5%), the intracranial internal carotid artery (n = 60, 19.9%) and the basilar artery (n = 40, 13.3%). Stent retrievers were used in 235 patients (78.1%) and adequate reperfusion (modified Thrombolysis in Cerebral Infarction scores 2b and 3, median onset to reperfusion time 254 min) was achieved in 242 patients (81.4%). Symptomatic intracranial haemorrhage occurred in 7%. 43.8% of patients (n = 132) had good functional outcome (modified Rankin Scale score 0-2) and the mortality rate was 20.9% (n = 63) after 3 months. Compared to the anterior circulation, vertebrobasilar stroke patients had higher mortality. Patients with secondary hospital transportation had better outcomes after 3 months than in-house treated patients. CONCLUSION: Our results document nationwide favourable outcome and safety rates of endovascular stroke treatment comparable to recent randomized trials. The ability to provide such data and the need to further optimize such an approach also underscore the contribution of respective registries.

Diabetes and thrombolysis for acute stroke: a clear benefit for diabetics.

BACKGROUND AND PURPOSE: Diabetes is a predictor for poor outcome after thrombolysis in stroke patients, and early post-stroke glycaemia is associated with higher rates of post-thrombolytic symptomatic intracerebral haemorrhages (SICHs). Diabetic stroke patients may nevertheless profit from thrombolysis. Here, we compared outcome data of matched thrombolysed and non-thrombolysed diabetic and non-diabetic stroke patients from a national database. METHODS: The outcomes of 1079 matched quadruples, each consisting of a thrombolysed diabetic, a non-thrombolysed diabetic, a thrombolysed non-diabetic and a non-thrombolysed non-diabetic case (a total of 4316 cases), enrolled in the Austrian Stroke Unit Registry (2004-2013), were compared. Patients were matched according to sex, age, stroke severity, pre-stroke disability and prior stroke. RESULTS: A regression model with improvement as depending variable found no effect of diabetes (P = 0.158) or the interaction diabetes × thrombolysis (P = 0.507), whereas the effect of thrombolysis itself was highly significant (P < 0.001). Functional outcome (modified Rankin Scale) was significantly better in thrombolysed than in non-thrombolysed diabetic patients at discharge from the stroke-unit (P < 0.001) and 3 months later (P = 0.006). No significant differences were found in the number of SICHs after thrombolytic treatment between diabetic (4.9%) and non-diabetic strokes (3.5%). Both groups had a higher risk of SICH compared with the non-thrombolysed groups (diabetics 2.6%, non-diabetics 2.5%). Due to lack of documentation, the effect of admission blood glucose on SICH was not investigated. CONCLUSIONS: Data from this nationwide survey show that diabetic stroke patients receive a substantial benefit from thrombolysis, and therefore diabetic strokes should not be excluded from thrombolytic treatment.

Functional recovery after ischemic stroke--a matter of age: data from the Austrian Stroke Unit Registry.

OBJECTIVE: To analyze the association between patient age and good functional outcome after ischemic stroke with special focus on young patients who were numerically underrepresented in previous evaluations. METHODS: Of 43,163 ischemic stroke patients prospectively enrolled in the Austrian Stroke Unit Registry, 6,084 (14.1%) were ≤55 years old. Functional outcome was available in a representative subsample of 14,256 patients free of prestroke disability, 2,223 of whom were 55 years or younger. Herein we analyzed the effects of age on good functional outcome 3 months after stroke (modified Rankin Scale score ≤2). RESULTS: Good outcome was achieved in 88.2% (unadjusted probability) of young stroke patients (≤55 years). In multivariable analysis, age emerged as a significant predictor of outcome independent of stroke severity, etiology, performance of thrombolysis, sex, risk factors, and stroke complications. When the age stratum 56-65 years was used as a reference, odds ratios (95% confidence interval [95% CI]) of good outcome were 3.4 (1.9-6.4), 2.2 (1.6-3.2), and 1.5 (1.2-1.9) for patients aged 18-35, 36-45, and 46-55 years and 0.70 (0.60-0.81), 0.32 (0.28-0.37), and 0.18 (0.14-0.22) for those aged 66-75, 76-85, and >85 years (p < 0.001). In absolute terms, the regression-adjusted probability of good outcome was highest in the age group 18-35 years and gradually declined by 3.1%-4.2% per decade until age 75 with a steep drop thereafter. Findings applied equally to sexes and patients with and without IV thrombolysis or diabetes. CONCLUSIONS: Age emerged as a highly significant inverse predictor of good functional outcome after ischemic stroke independent of stroke severity, characteristics, and complications with the age-outcome association exhibiting a nonlinear scale and extending to young stroke patients.

Early clinical worsening in patients with TIA or minor stroke: the Austrian Stroke Unit Registry.

OBJECTIVE: TIA is associated with a substantial short-term risk of stroke and is thus increasingly recognized as an unstable condition necessitating full medical attention. Our study sought to assess the rate of and predictors for early deterioration after TIA or minor stroke in a large nationwide survey among Austrian stroke units. METHODS: Of the 29,287 patients prospectively enrolled in the Austrian Stroke Unit Registry (2003-2008), 8,291 presenting with a TIA or minor ischemic stroke, defined by an NIH Stroke Scale (NIHSS) score <4, were included in the current evaluation. Worsening was defined as clinical deterioration during stroke unit stay by > or = 2 points on the NIHSS. RESULTS: A total of 374 patients (4.5%) experienced early clinical worsening during a mean stroke unit stay of 2.97 days (median 2 [interquartile range,1-4] days). In a multivariate stepwise regression analysis hypertension, diabetes, cardiac decompensation, acute infection, and stroke etiology emerged as independent risk predictors for early deterioration. The ABCD2 score could be estimated in a subgroup of 3,886 subjects and closely correlated with the risk of neurologic worsening. CONCLUSIONS: Our study revealed a high rate of early clinical deterioration (4.5%) among 8,291 patients with TIA or minor stroke despite immediate admission to specialized stroke units. Predictors for neurologic deterioration apart from diabetes, hypertension, and the estimated ABCD2 score were stroke etiology, reinforcing the relevance of an immediate diagnostic workup, and coexistent acute infection and cardiac decompensation, both conditions necessitating adequate attention in the emergency setting.