Epidemiological investigation on the local epidemic situation in Zhengzhou High-Tech Zone caused by SARS-CoV-2 Delta variant / 中华预防医学杂志

This study collected epidemic data of COVID-19 in Zhengzhou from January 1 to January 20 in 2022. The epidemiological characteristics of the local epidemic in Zhengzhou High-tech Zone caused by the SARS-CoV-2 Delta variant were analyzed through epidemiological survey and big data analysis, which could provide a scientific basis for the prevention and control of the Delta variant. In detail, a total of 276 close contacts and 599 secondary close contacts were found in this study. The attack rate of close contacts and secondary close contacts was 5.43% (15/276) and 0.17% (1/599), respectively. There were 10 confirmed cases associated with the chain of transmission. Among them, the attack rates in close contacts of the first, second, third, fourth and fifth generation cases were 20.00% (5/25), 17.86% (5/28), 0.72% (1/139) and 14.81% (4/27), 0 (0/57), respectively. The attack rates in close contacts after sharing rooms/beds, having meals, having neighbor contacts, sharing vehicles with the patients, having same space contacts, and having work contacts were 26.67%, 9.10%, 8.33%, 4.55%, 1.43%, and 0 respectively. Collectively, the local epidemic situation in Zhengzhou High-tech Zone has an obvious family cluster. Prevention and control work should focus on decreasing family clusters of cases and community transmission.

Effects of emergency medical service on prognosis of ischemic stroke patients treated with intravenous thrombolysis / 浙江大学学报·医学版

OBJECTIVE@#To investigate the effect of emergency medical service (EMS) on the prognosis of ischemic stroke patients treated with intravenous thrombolysis.@*METHODS@#Clinical data of 2123 ischemic stroke patients treated with intravenous thrombolysis in 70 hospitals in Zhejiang province were retrospectively analyzed. There were 808 patients sent to the hospital by ambulance (EMS group) and 1315 patients by other transportations (non-EMS group). Good outcome was defined as modified Rankin Scale (mRS) ≤ 2 at 3-month. The onset to needle time (ONT), onset to door time (ODT), door to needle time (DNT) and outcome were compared between EMS group and non-EMS group. Binary logistic regression was used to explore the influencing factors for the outcome at 3-month.@*RESULTS@#Compared with the non-EMS group, patients in the EMS group were older, with higher baseline National Institute of Health Sroke Scale (NIHSS) score, and had a higher proportion of atrial fibrillation (all 0.05). Binary logistic regression showed that EMS was not independently associated with good outcome (=0.856, 95%:0.664-1.103, >0.05).@*CONCLUSIONS@#EMS had not improve the outcome of patients receiving intravenous thrombolysis in Zhejiang province.

Advanced treatment time improves outcomes of patients with ischemic stroke undergoing reperfusion therapy / 浙江大学学报·医学版

OBJECTIVE@#To investigate the effect of treatment time on the outcome of patients with ischemic stroke undergoing reperfusion therapy.@*METHODS@#The clinical data of 3229 ischemic stroke patients who received intravenous thrombolysis with or without arterial thrombolysis from 71 hospitals in Zhejiang province from June 2017 to September 2018 were retrospectively reviewed. The good outcome was defined as modified Rankin Scale (mRS) ≤ 2. Binary logistic regression analysis was used to investigate the association of door to needle time (DNT), or door to reperfusion time (DRT) with the outcomes in patients treated by intravenous thrombolysis or bridging arterial thrombolysis, respectively.@*RESULTS@#Binary logistic regression showed that DNT (=0.994, 95%:0.991-0.997, <0.01) or DRT (=0.989, 95%:0.983-0.995, <0.01) were independently associated with good outcomes, respectively. Every hour decreases in DNT resulted in a 4.7%increased probability of functional independence (mRS 0-2) in patients treated by intravenous thrombolysis; Every hour decreases in DRT was associated with a 11.4%increased probability of functional independence in patients treated by intravenous thrombolysis with arterial thrombolysis.@*CONCLUSIONS@#Good outcomes are associated with lower DNT in ischemic stroke patients treated by intravenous thrombolysis or lower DRT in patients treated by intravenous thrombolysis bridging arterial thrombolysis.

Association of atrial fibrillation with hemorrhagic transformation after intravenous thrombolysis in patients with ischemic stroke / 浙江大学学报·医学版

OBJECTIVE@#To investigate the association of atrial fibrillation (AF) with hemorrhagic transformation (HT) in patients with ischemic stroke treated by intravenous thrombolysis.@*METHODS@#Clinical data of 3272 patients treated by intravenous thrombolysis from 71 hospitals in Zhejiang Province during June 2017 and December 2018 were retrospectively reviewed. Intracranial HT was defined as intracranial hemorrhage suggested by imaging examination 24 hours after intravenous thrombolysis. Patients were dichotomized into HT group (=533) and non-HT group (=2739). The association of AF and HT was analyzed by univariate analysis and binary logistic regression.@*RESULTS@#Compared with the non-HT group, the HT group were older, had longer onset to needle time (ONT), higher baseline National Institute of Health Stroke Scale (NIHSS) score, higher baseline glucose level, and higher AF rate (<0.05 or <0.01). Binary logistic regression analysis revealed that AF was independently associated with HT (=2.527, 95%:2.030-3.146, <0.01).@*CONCLUSIONS@#AF is independently associated with the occurrence of HT in ischemic stroke patients treated with intravenous thrombolysis.

Analysis of intravenous thrombolysis time and prognosis in patients with in-hospital stroke / 浙江大学学报·医学版

OBJECTIVE@#To compare the time delay between in-hospital stroke and out-of-hospital stroke patients, and to explore the influence factors for the prognosis of in-hospital stroke patients treated by intravenous thrombolysis.@*METHODS@#Clinical data of 3050 patients with ischemic stroke who received intravenous thrombolysis in 71 hospitals in Zhejiang province from June 2017 to September 2018 were analyzed. Differences of time delay including door to imaging time (DIT), imaging to needle time (INT) and door to needle time (DNT) between in-hospital stroke (=101) and out-of-hospital stroke (=2949) were observed. The influencing factors for the outcome at 3 month after intravenous thrombolysis in patients with in-hospital stroke were analyzed using binary logistic regression analysis.@*RESULTS@#Patients with in-hospital stroke had longer DIT[53.5 (32.0-79.8) min vs. 20.0 (14.0-28.0) min, <0.01], longer IDT[47.5(27.3-64.0)min vs. 36.0(24.0-53.0)min, <0.01], and longer DNT[99.0 (70.5-140.5) min vs. 55.0 (41.0-74.0) min, <0.01], compared with patients with out-of-hospital stroke; patients in comprehensive stroke center had longer DIT[59.5(44.5-83.3) min vs. 37.5(16.5-63.5) min, <0.01], longer DNT[110.0(77.0-145.0) min vs. 88.0 (53.8-124.3) min, <0.05], but shorter INT[36.5(23.8-60.3)min vs. 53.5 (34.3-64.8) min, <0.05], compared with patients in primary stroke center. Age (=0.934, 95% 0.882-0.989, <0.05) and baseline National Institute of Health Stroke Scale score (=0.912, 95% 0.855-0.973, <0.01) were independent risk factors for prognosis of in-hospital stroke patients.@*CONCLUSIONS@#In-hospital stroke had longer DIT and DNT than out-of-hospital stroke, which suggests that a more smooth thrombolysis process of in-hospital stroke should be established.

Effect of different working time on the prognosis of ischemic stroke patients undergoing intravenous thrombolysis / 浙江大学学报·医学版

OBJECTIVE@#To investigate the effect of working time on the prognosis of patients with ischemic stroke undergoing intravenous thrombolysis.@*METHODS@#Clinical data of 3050 patients with ischemic stroke received intravenous thrombolysis from 71 hospitals in Zhejiang Province during June 2017 and September 2018 were retrospective analyzed. Whole day of Saturday and Sunday were defined as weekend; whole day of Monday to Friday were defined as weekdays; Monday to Friday 8:00-17:00 were defined as daytime of weekdays; Monday to Friday 17:01-07:59 on next day were defined as nights of weekdays; unconventional working time were defined as weekend and nights of weekdays. Good outcome was defined as mRS 0-2 at 3 months. Univariate analyses of baseline and prognostic variables in group of weekend and weekdays, nights of weekdays and daytime of weekdays, unconventional working time and daytime of weekdays were performed. Binary logistic regression was used to investigate whether weekend, nights of weekdays and unconventional working time were independent predicting factors of outcome after intravenous thrombolysis, respectively.@*RESULTS@#There was no difference in 7-day mortality, 3-month mortality and good outcome at 3-month between weekend group and weekdays group, nights of weekdays group and daytime of weekdays group, unconventional working time group and daytime of weekdays group (all >0.05). Binary logistic regression results showed that weekends, nights of weekdays and unconventional working time were not independent predicting factors for outcome after intravenous thrombolysis (all >0.05).@*CONCLUSIONS@#The working time has not affected the outcomes of patients with ischemic stroke undergoing intravenous thrombolysis in studied hospitals of Zhejiang province.

Clinical features and validation of Brighton criteria in Guillain-Barré syndrome in southern China:retrospective analysis of 1358 hospitalized patients in four years / 中华神经科杂志

Objective To analyze the clinical features and validation of Brighton criteria in Guillain-Barré syndrome (GBS) patients from southern China.Methods The clinical data of hospitalized GBS patients from 69 hospitals of 14 provinces/cities in southern China,the area south of the Huaihe River,between 1 January 2013 and 30 September 2016,were collected and analyzed retrospectively,and patients were classified according to the Brighton criteria of case definition,ranging from a highest (defined as level one) to a lowest (level four) level of diagnostic certainty.Results A total of 1 358 GBS patients were collected,including 51 cases with cranial nerve variants,157 with Miler-Fisher syndrome and 1 150 with classic GBS characterized by flaccid weakness of limbs.Among 1 150 cases of classic GBS,49.57％ (570/1 150) patients had antecedent events,with respiratory infection predominated (71.23％,406/570);83.74％ (963/1 150) presented limb weakness at onset,99.21％ (1 124/1 133) reached the peak within four weeks,with a score of 3.15 ± 1.16 for Hughes Disability Scale;99.56％ (1 128/1 133)developed bilateral weakness and 95.39％ (1 097/1 150) manifested flexia or hyporeflexia;the cerebrospinal fluid showed albuminocytologic dissociation in 80.58％ (772/958) patients whose lumbar puncture was performed;demyelinating GBS accounted for 48.14％ (401/833) and axonal subtype 18.01％ (150/833) respectively in patients with findings of nerve conduction studies available.According to Brighton criteria,the patients were stratified as level one in 44.09％ (507/1 150),level two in 45.74％ (526/1 150),level three in 7.57％ (87/1 150) and level four in 2.61％ (30/1 150) of all the patients,and 69.55％ (507/729),28.67％ (209/729),0％ (0/729) and 1.78％ (13/729),respectively in the patients with complete data (n =729).Conclusions In southern China,demyelinating subtype of GBS is predominant,whereas the proportion of axonal subtype is remarkably lower than that in northern China.The Brighton criteria have a high sensitivity for the diagnosis of GBS in southern China,and examination of cerebrospinal fluid and electrodiagnostic studies are necessary for stratified diagnosis.

Relationship between dynamic CT angiography-based collateral flow evaluation and outcome of patients with stroke induced by acute basilar artery occlusion / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To evaluate the collateral flow in patients with ischemic stroke due to acute basilar artery occlusion by dynamic CT angiography and to predict the outcome after reperfusion therapy.</p><p><b>METHODS</b>Forty-five patients with stroke due to acute basilar artery occlusion undergoing reperfusion treatment in the Second Affiliated Hospital of Zhejiang University School of Medicine during January 2012 and August 2016 were retrospectively reviewed. Univariate and binary logistic regression model were used to identify the independent predictors of patient's outcome, and the receiver operating characteristic (ROC) curve was used to determine the optimal threshold of the posterior circulation collateral score (PC-CS) in predicting the prognosis of the patients.</p><p><b>RESULTS</b>Binary logistic regression analysis indicated that the baseline National Institutes of Health Stroke Scale (NIHSS) score (=0.886, 95%:0.802-0.979,<0.05) and PC-CS (=1.962, 95%:1.026-3.752,<0.05) were independent predictors of patient's outcome, and PC-CS 4.5 was the optimal threshold (AUC:0.837, sensitivity of 68.2%, specificity of 87.0%).</p><p><b>CONCLUSIONS</b>Dynamic CT angiography based on CT perfusion imaging can be used to evaluate collaterals in posterior circulation, and to predict clinical outcome after reperfusion therapy in patients with acute basilar artery occlusion.</p>

Collateral score based on CT perfusion can predict the prognosis of patients with anterior circulation ischemic stroke after thrombectomy / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To evaluate the value of collateral score based on CT perfusion (CTP-CS) in predicting the clinical outcome of patients with anterior circulation ischemic stroke after thrombectomy.</p><p><b>METHODS</b>Clinical data of acute ischemic stroke patients with anterior artery occlusion undergoing endovascular treatment in the Second Affiliated Hospital, Zhejiang University School of Medicine during October 2013 and October 2016 were retrospectively reviewed. Collateral scores were assessed based on CTP and digital subtraction angiography (DSA) images, respectively. And DSA-CS or CTP-CS 3-4 was defined as good collateral vessels. Good clinical outcome was defined as a modified Rankin Scale (mRS) ≤ 2 at 3 months after stroke. The binary logistic regression model was used to analyze the correlation between the collateral score and clinical outcome, and the receiver operating characteristic (ROC) curve was used to analyze the value of DSA-CS and CTP-CS in predicting the clinical outcome.</p><p><b>RESULTS</b>Among 40 patients, 33 (82.5%) acquired recanalization and 16 (40.0%) got good outcome. Compared with poor outcome group, the collateral score (all<0.05) and the rate of good collateral vessels were higher in good outcome group (all<0.01). After adjust baseline National Institute of Health Stroke Scale (NIHSS) and onset to recanalization time (ORT), good collateral vessels were independent factor of good outcome (CTP-CS:=48.404, 95%:1.373-1706.585,<0.05; DSA-CS:=34.651, 95%:1.147-1047.018,<0.05). Collateral scores based on CTP and DSA had good consistency (=0.697,<0.01), and ROC curve showed that the predictive value of CTP-CS and DSA-CS were comparable (both AUC=0.726, 95%:0.559-0.893,<0.05).</p><p><b>CONCLUSIONS</b>CTP-CS can predict the clinical outcome of patients with anterior circulation ischemic stroke after thrombectomy.</p>

Maximal infarct volume to benefit from intravenous thrombolysis and its relation with onset to treatment time / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate the relationship between maximal infarct volume to benefit from intravenous thrombolysis (IVT) and onset to needle time (ONT).</p><p><b>METHODS</b>The clinical and image data of acute ischemic stroke patients who received IVT in the second Affiliated Hospital, Zhejiang University School of Medicine during May 2009 to June 2016 were retrospectively reviewed. Patients were classified into within-time-window group (ONT ≤ 4.5 h) and beyond-time-window group (ONT>4.5 h). Good and poor outcome were defined as modified Rankin scale (mRS) ≤ 2 or >2 at 3 months, respectively. The maximal infarct volume was analyzed by receiver operating characteristic (ROC) curve.</p><p><b>RESULTS</b>Among 587 patients (465 cases were within-time-window, 122 cases were beyond-time-window), baseline core volume was 15(2-46)mL,and 324 (55.2%) patients achieved good outcome. Compared with the good-outcome group, the baseline core volume was larger in the poor-outcome group (32 mL vs 5 mL,=-9.766,<0.01). After adjusting age, ONT, baseline National Institutes of Health Stroke Scale (NIHSS) and atrial fibrillation, baseline infarct core volume independently predicted poor outcome (=1.014, 95%:1.008-1.020,<0.01). The ROC curve analysis showed that the maximal infarct core volume for achieving good outcome in the within-time-window group and beyond-time-window group were 152 mL and 71mL, respectively. The maximal infarct volume to benefit from IVT diminished with the increasing delayed ONT of every 30 min (=-0.691,<0.05).</p><p><b>CONCLUSIONS</b>The maximal infarct volume to benefit from thrombolysis is larger in patients treated within time window than those beyond the time window, and that volume diminishes with ONT delay.</p>

Association of serum folate level with severity of white matter hyperintensity and presence of cerebral microbleeds / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate the association of serum folate level with the severity of white matter hyperintensity (WMH) and presence of cerebral microbleeds (CMB).</p><p><b>METHODS</b>Clinical data of WMH patients from the second affiliated Hospital, Zhejiang University school of Medicine during July 2011 and February 2016 were retrospectively reviewed. According to Fazekas score based on T2-Flair images, patients were classified into mild WMH (0-3) and severe WMH (4-6). The presence of CMB was assessed on susceptibility weighted imaging (SWI). Binary logistic analysis was conducted to identify the independent predictors for severe WMH and the presence of CMB.</p><p><b>RESULTS</b>Two hundred and twenty eight patients with WMH were included, among whom 149(65.35%)had severe WMH. In patients with high folate (≥ 15.68 nmol/L), low folate (6.8-15.67 nmol/L) and folate deficiency (<6.8 nmol/L), the proportions of severe WMH were 52.88%, 73.33% and 89.47%, respectively. Binary logistic regression analysis revealed that compared with high folate group, severe WMH was more common in groups with low folate (=2.109, 95%:1.112-4.001,<0.05) and folate deficiency (=6.383, 95%:1.168-34.866,<0.05). Eighty-eight(48.09%) of 183 patients receiving SWI scan presented with CMB. Although the subjects with CMB had lower serum folate level than those without CMB(13.42 vs 16.51 nmol/L,<0.01), binary logistic regression analysis did not reveal the independent association between serum folate level and the presence of CMB after adjusting for hyperhomocysteinemia (>0.05).</p><p><b>CONCLUSIONS</b>Lower serum folate level is independently associated with severe WMH, but not with the CMB concurrence.</p>

Safety of tirofiban in patients with acute cerebral infarct receiving endovascular therapy / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate the effect of tirofiban on hemorrhagic transformation and neurological outcome in patients with acute cerebral infarct treated with endovascular therapy.</p><p><b>METHODS</b>One hundred and fifteen patients with acute cerebral infarct who received endovascular stent mechanical thrombectomy in the Second Affiliated Hospital, Zhejiang University School of Medicine during October 2013 and April 2017 were included in the study. Among 115 patients, 30 received tirofiban treatment. Hemorrhagic transformation and neurological outcomes were assessed using the ECASS Ⅱ criteria and modified Rankin scale (mRS), respectively. Unfavorable outcome was defined as mRS>2. Binary logistic regression model was used to analyze the independent predictors of hemorrhagic transformation and neurological outcome.</p><p><b>RESULTS</b>Binary logistic regression analysis showed that tirofiban treatment did not increase the risk of hemorrhagic transformation (=0.437, 95%:0.168-1.132,>0.05); baseline NIHSS (=1.136, 95%:1.014-1.273,<0.05), recanalization (=0.060, 95%:0.010-0.365,<0.01), hypertension (=4.233, 95%:1.320-13.570,<0.05) and onset to treatment time(=1.006, 95%:1.001-1.011,<0.05) were independently associated with unfavorable outcome, while such association was not observed in tirofiban treatment (=1.923, 95%:0.536-6.568,>0.05).</p><p><b>CONCLUSIONS</b>Tirofiban appears to be safe for patients with acute cerebral infarct receiving endovascular therapy.</p>

Factors related to therapeutic outcomes of intravenous thrombolysis in stroke patients with different severity / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate the factors related to therapeutic outcomes of intravenous thrombolysis in patients with acute ischemic stroke (AIS) of different severity.</p><p><b>METHODS</b>Clinical data of patients with AIS treated with intravenous thrombolysis in the Second Affiliated Hospital, Zhejiang University School of Medicine between June 2009 and December 2013 were retrospectively reviewed. According to National Institutes of Health Stroke Scale (NIHSS), patients were categorized as mild stroke (≤8, n=134), moderate stroke (9-15, n=121) and severe stroke(≥16, n=110). The good outcome was defined as modified Rankin Scale ≤ 2. The factors related to functional outcomes and hemorrhagic transformation (HT) were analyzed and compared among 3 groups.</p><p><b>RESULTS</b>Among 365 enrolled patients, good outcomes in 3 groups were 78.4% (105/134), 47.9% (58/121) and 24.5%(27/110), respectively. In patients with mild stroke, age (OR=0.937, 95%CI: 0.898-0.978; P=0.003), baseline NIHSS (OR=0.732, 95%CI:0.564-0.950; P=0.019), onset to needle time (ONT) within 270 min (OR=4.109, 95%CI:1.441-11.719; P=0.008) independently predicted good outcome, while baseline glucose (OR=1.326, 95%CI:1.009-1.743; P=0.043) was independently associated with parenchymal hematoma (PH). In patients with moderate stroke, age (OR=0.954, 95%CI: 0.924-0.984; P=0.003) and baseline NIHSS (OR=0.760, 95%CI: 0.619-0.933; P=0.009) independently predicted good outcome, while atrial fibrillation (OR=3.307, 95%CI: 1.140~9.596; P=0.028) and systolic pressure (OR=0.967, 95%CI: 0.943~0.991; P=0.008) was independently associated with hemorrhagic infaction. Atrial fibrillation (OR=36.972, 95%CI: 1.770-772.462; P=0.02) was independently associated with PH. In patients with severe stroke, baseline NIHSS (OR=0.808, 95%CI:0.677-0.963; P=0.018) independently predicted good outcome, while no independent risk factors of HT was found.</p><p><b>CONCLUSION</b>For different severity of AIS patients, the related factors of functional outcome and HT after thrombolysis were different.</p>

Relationship between early blood pressure variability and reperfusion in acute ischemic stroke patients with intravenous thrombolysis / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate the impacts of blood pressure (BP) variability on reperfusion and long-term outcome in patients with acute ischemic stroke after intravenous thrombolysis (IVT).</p><p><b>METHODS</b>The clinical data of 188 patients with acute ischemic stroke receiving IVT in Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine from June 2009 to September 2014, including hour-to-hour BP measurements, clinical manifestations, laboratory tests and radiologic findings were retrospectively analyzed. The mean 24-h BP values, and BP variability profiles, including standard deviation (sd), average squared difference between successive measurements (sv), average squared difference between rise and drop successive measurements (sv-rise and sv-drop) were calculated. Reperfusion, defined as >50% reduction in Tmax >6 s perfusion lesion volume from baseline to follow-up scans, and clinical neurological outcome based on modified Rankin scale (mRS) at 3 months after onset were also analyzed. The favorable outcome was defined as mRS 0-1 and unfavorable outcome as mRS 2-6. The binary logistic-regression model was performed to determine the independent risk factors of reperfusion and favorable outcome, respectively.</p><p><b>RESULTS</b>Among 188 patients, 114 (60.6%) achieved reperfusion. During the 0-to-24 h blood pressure course, only systolic blood pressure (SBP) variability parameters were negatively correlated with reperfusion (sv: OR=0.421, 95% CI:0.187-0.950, P=0.037; sv-rise: OR=0.311, 95% CI:0.137-0.704, P=0.005) and long-term clinical outcomes (sv: OR=6.381, 95% CI:2.132-19.096, P=0.001; sv-rise: OR=5.615, 95% CI:2.152-14.654, P<0.001; sv-drop: OR=3.009, 95% CI:1.263-7.169, P=0.013).</p><p><b>CONCLUSION</b>SBP variability during the first 24 hours after IVT is negatively associated with cerebral reperfusion and unfavorable neurological outcome in patients with acute ischemic stroke receiving IVT.</p>

Influence of atrial fibrillation on intravenous thrombolysis of acute ischemic stroke patients within different time window / 中华神经科杂志

Objective To assess the influence of atrial fibrillation on post-thrombolytic hemorrhagic transformation and functional prognosis in acute ischemic stroke patients within different time window.Methods We retrospectively reviewed the clinical and imaging data of patients of acute ischemic stroke with intravenous thrombolysis admitted from June 2009 to October 2013.According to onset-to-needle time,we divided patients into 3 groups and then assessed the effect of the comorbidity with atrial fibrillation on the occurrence of hemorrhagic transformation and favorable outcome (defined as modified Rankin Scale score≤2 at 90 days) after thrombolysis within different time window.Results A total of 345 patients were included in this study,among whom 101 (29.3％) were treated by intravenous thrombolysis within 3.0 h (≤3.0 h),157(45.5％) ＞3.0 h and≤4.5 h,87(25.2％) over 4.5 h(＞4.5 h).Atrial fibrillation was observed in 50.5％ (51/101) patients in ≤3.0 h group,37.6％ (59/157) in ＞3.0 h and≤4.5 h group and 40.2％ (35/87) in ＞ 4.5 h group (x2 =4.362,P =0.113).There were no statistically significant differences among these three groups about the rate of hemorrhagic transformation (hemorrhagic infarction:16.8％ (17/101),22.3％ (35/157),20.7％ (18/87),and parenchymal hematoma:5.0％ (5/101),10.2％ (16/157),10.3％ (9/87),x2 =4.278,P =0.370) and favorable outcome (51.5％ (52/101),53.5％ (84/ 157),47.1％ (41/87),x2 =0.913,P =0.633).Multivariate analysis demonstrated that atrial fibrillation was associated with hemorrhagic infarction for patients in ＞ 4.5 h group (OR =3.637,95％ CI 1.101-12.013,P =0.034),and the presence of atrial fibrillation independently predicted parenchymal hematoma for patients in ＞ 3.0 h and ≤4.5 h group (OR =3.757,95％ CI 1.133-12.457,P =0.030).There was no significant association between atrial fibrillation and favorable outcome at 90 days.Conclusions The presence of atrial fibrillation is not associated with the prognosis in thrombolytic patients.However,it enhanced the risk of parenchymal hematoma if patients were treated within the time window ＞ 3.0 h and ≤4.5h.

Thrombus length evaluated by CT perfusion imaging and its value in prediction of recanalization after intravenous thrombolysis therapy / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To evaluate the thrombus length on CT perfusion imaging and to assess its predictive value for recanalization and clinical outcome after intravenous thrombolysis therapy (IVT).</p><p><b>METHODS</b>Fifty-six consecutive acute ischemic stroke patients with proximal middle cerebral artery (M1 segment) occlusion underwent CT perfusion imaging examination before IVT between June 2009 and May 2015. The onset-to needle time was (214.3 ± 82.0) min, and the pretreatment NIHSS score of patients was 13 (IQR 8-17). The thrombus length was determined as the distance between the proximal and distal thrombus end delineated on dynamic angiography, which was reconstructed from CT perfusion source images. Recanalization was evaluated according to Arterial Occlusive Lesion (AOL) scale, and functional outcome was based on modified Rankin scale (mRS) 3 months after IVT. Logistic regression model was used to investigate the relationship between thrombus length and recanalization, and the optimal cut-off points were determined by receiver operating characteristic curve (ROC).</p><p><b>RESULTS</b>Among 56 patients, 42 (75%) achieved recanalization 24 h after IVT with mean thrombus length of (9.0 ± 4.7) mm; and 14 (25%) patients remained occlusion with mean thrombus length of (10.0 ± 5.4) mm. Logistic regression analysis demonstrated that thrombus length was an independent predictor for both recanalization (OR=0.869; 95% CI:0.764-0.987; P=0.031) and unfavorable outcome (OR=1.180;95% CI:1.023-1.362; P=0.023). Thrombus length of 11.3 mm was identified as the optimal cut-off value for recanalization (AUC=0.697, sensitivity 71.4%, specificity 76.2%), while thrombus length of 9.9 mm was the optimal cut-off value for unfavorable functional outcome (AUC=0.689, sensitivity 64.7%, specificity 71.4%).</p><p><b>CONCLUSION</b>The thrombus length evaluated on CT perfusion imaging is an effective predictor for recanalization and unfavorable outcome after IVT in acute ischemic stroke patients with middle cerebral artery occlusion.</p>

Safety of intravenous thrombolysis in cerebral microbleeds patients with prior antiplatelet therapy / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To evaluate the safety of intravenous thrombolysis (IVT) in cerebral microbleeds (CMBs) patients with prior antiplatelet therapy.</p><p><b>METHODS</b>Four hundred and forty nine patients with acute ischemic stroke aged (66.8 ± 12.9) years, including 298 males and 151 females, underwent susceptibility-weighted imaging (SWI) examination and MRI-guided IVT therapy between June 2009 and June 2015. The presence of CMBs, previous antiplatelet therapy, HT subtypes according to ECASS II criteria and functional outcome based on modified Rankin scale (mRS) at 3 months were analyzed in logistic regression model.</p><p><b>RESULTS</b>Total 934 CMBs were detected in 172 (38.3%) patients, among whom 63 (14.0%) previously received antiplatelet therapy. All patients received intravenous recombinant tissue-plasminogen activator (rt-PA) for thrombolysis with the onset-to needle time of (229.0 ± 103.7) min. The pretreatment National Institutes of Health Stroke Scale (NIHSS) score was 10 (IQR 5-15). Logistic regression analysis indicated that prior antiplatelet use increased neither risk of parenchymal hematoma (PH) (OR=0.809,95% CI:0.201-3.262, P=0.766) nor adverse functional outcome (OR=1.517, 95% CI:0.504-4.568, P=0.459) in patients with CMBs; while in patients with multiple CMBs (≥ 3) prior antiplatelet use increased risk of hemorrhagic transformation (OR=9.737, 95% CI: 1.364-69.494, P=0.023), but not adverse functional outcome (OR=1.697, 95% CI:0.275-10.487, P=0.569).</p><p><b>CONCLUSION</b>The study indicates that in patients with CMBs, thrombolytic therapy should not be excluded due to the prior use of antiplatelet; however, the larger prospective studies are needed in future for patients with multiple CMBs.</p>

Signifiance of brush sign on susceptibility-weighted imaging predicts hemorrhagic transformation after intravenous thrombolysis in patients with acute ischemic stroke / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To assess brush sign (BS) on susceptibility-weighted imaging (SWI) in prediction of hemorrhagic transformation (HT) in patients with acute ischemic stroke (AIS) after intravenous thrombolysis(IVT).</p><p><b>METHODS</b>Patients with acute cerebral ischemic stroke, who had major cerebral artery occlusion (internal carotid artery, middle cerebral artery M1 and M2), treated with intravenous recombinant tissue plasminogen activator (rt-PA) from August 2009 to October 2014 in the Second Affiliated Hospital, Zhejiang University School of Medicine, were enrolled in the study. All patients underwent SWI scanning. The asymmetry index (AI) was defined as the difference of intensity between ischemic and normal hemispheres on the SWI phase map; according to AI values patients were divided into 3 groups: BS=0(n=9), BS=1 (n=39) and BS=2 (n=18). The relationships between BS and HT and the clinical outcome among the 3 groups were analyzed.</p><p><b>RESULTS</b>Sixty-six patients aged 68 ± 13 years were included in the study, including 44 males (67%) and 22 females (33%), and 44 (67%) with acute ischemic stroke. The mean pre-treatment National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-17), and the onset to needle time was (252 ± 88) min. Twenty-six (39.4%) patients had HT, including 18 cases (27.3%) with HI and 8 cases (12.1%) with PH; BS was observed more frequently in HT group than non-HT group. Binary logistic regression analysis showed that BS was independently associated with HT of patients with acute ischemic stroke following IVT (OR=2.589, 95% CI: 1.080-6.210, P=0.033). In those without reperfusion after IVT, patients with higher BS grade had higher HT rate (P=0.023).</p><p><b>CONCLUSION</b>Brush sign on SWI can be used for predicting hemorrhagic transformation after intravenous thrombolysis in patients with acute ischemic stroke.</p>

Older age is not related to hemorrhagic transformation and favorable outcomes in patients with wake-up ischemic stroke undergoing intravenous thrombolytic therapy / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate factors related to hemorrhagic transformation and favorable outcomes in wake-up ischemic stroke (WUIS) patients undergoing intravenous thrombolytic therapy.</p><p><b>METHODS</b>Clinical data of 600 patients undergoing multimodal image-guided intravenous recombinant tissue plasminogen activator (rt-PA) therapy in Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine center from May 2009 to May 2015 were retrospectively analyzed. Among 600 patients, 68 were diagnosed as WUIS including 17 cases aged 80 or older. Hemorrhagic transformation within the first 24 h after thrombolysis was assessed according to ECASS II criteria. Favorable outcome was defined as three-month modified Rankin Scale (mRS) 0-3. Univariate and binary logistic regression were used to analyze the risk factors of hemorrhagic transformation and poor clinical outcomes in WUIS patients.</p><p><b>RESULTS</b>Univariate analysis showed that WUIS patients aged ≥ 80 years had a lower rate in males (41.2% vs 76.5%, P=0.007), smokers (11.8% vs 43.1%, P=0.019) and favorable outcome (52.9% vs 78.4%, P=0.043); and a higher rate of cardiac embolism (64.7% vs 35.3%, P=0.034) compared with those aged <80 years. Binary logistic regression showed that age was not an independent risk factor for favorable outcome (OR=0.524, 95% CI:0.141-1.953, P=0.336) or hemorrhagic transformation (OR=1.039, 95% CI: 0.972-1.111, P=0.262).</p><p><b>CONCLUSION</b>Older age is not related to the favorable outcome or hemorrhagic transformation in WUIS patients undergoing multimodal image-guided intravenous thrombolytic therapy.</p>

Thrombolysis in acute ischemic stroke: issues and options / 浙江大学学报·医学版

China is one of the countries with highest incidence of stroke in the world. However, the rate of intravenous thrombolysis for ischemic stroke is extremely low in China, which is related to traditional triage system and inefficient management, the potential of hemorrhagic transformation, and narrow therapeutic time window. In order to improve the clinical implementation of thrombolysis, it is necessary to look at the related issues and to refine the therapeutic protocol according to the international experiences. Careful screening of eligible patients is crucial to reduce the rate of symptomatic intracranial hemorrhage. The advanced penumbral imaging is believed to enhance patient selection and extend the therapeutic time window. In addition, endovascular therapy is increasingly utilized to raise the recanalization rate. All these measures would enhance the improvement of the clinical management for acute stroke patients.