Lipid profile, lipid-lowering medications, and intracerebral hemorrhage after tPA in get with the guidelines-stroke.

BACKGROUND AND PURPOSE: Symptomatic intracerebral hemorrhage (sICH) after tissue plasminogen activator for acute ischemic stroke is associated with poor outcome. There are conflicting data on sICH risk related to lipid levels and use of lipid-lowering medications. We evaluated whether there are associations between lipid levels, lipid-lowering medications, and sICH in Get With the Guidelines-Stroke. METHODS: We identified acute ischemic stroke patients in the Get With the Guidelines-Stroke data set who were treated with IV tissue plasminogen activator between April 2003 and September 2009 and had complete data on lipid profiles and complications. Potential predictors of sICH were tested in univariate and multivariate analysis. RESULTS: The analysis included 22 216 IV tissue plasminogen activator-treated acute ischemic stroke patients. Overall, 1104 (4.97%) experienced sICH (National Institute of Neurological Disorders and Stroke definition). In univariate analysis, patients with sICH were more often taking antihypertensive, lipid-lowering, and diabetes mellitus medications. There was no relationship between low density lipoprotein or total cholesterol and sICH in univariate analysis. However, the risk of sICH increased with higher high density lipoprotein, 6.1% in Q4 versus 4.7% in Q1, P=0.0013; and lower triglyceride levels, 5.9% in Q1 versus 4.2% in Q4, P<0.0001. In multivariable models, although the high density lipoprotein and triglyceride levels were modestly associated with sICH, low density lipoprotein and total cholesterol were not. Lipid-lowering medications were not independently associated with sICH. CONCLUSIONS: We found that low density lipoprotein and total cholesterol levels are not associated with risk of sICH after tissue plasminogen activator, although higher high density lipoprotein and lower triglyceride levels were modest risk factors. Lipid-lowering medications are not associated with risk of sICH.

Ischemic stroke and transient ischemic attack in young adults: risk factors, diagnostic yield, neuroimaging, and thrombolysis.

BACKGROUND: Approximately 10% to 14% of ischemic strokes occur in young adults. OBJECTIVE: To investigate the yield of diagnostic tests, neuroimaging findings, and treatment of ischemic strokes in young adults. DESIGN: We retrospectively reviewed data from our Get with the Guidelines-Stroke database from 2005 through 2010. SETTING: University hospital tertiary stroke center. PATIENTS: A total of 215 consecutive inpatients aged 18 to 45 years with ischemic stroke/transient ischemic attack. The mean (SD) age was 37.5 (7) years; 51% were male. RESULTS: There were high incidence rates of hypertension (20%), diabetes mellitus (11%), dyslipidemia (38%), and smoking (34%). Relevant abnormalities were shown on cerebral angiography in 136 of 203 patients, on cardiac ultrasonography in 100 of 195, on Holter monitoring in 2 of 192; and on hypercoagulable panel in 30 of 189 patients. Multiple infarcts were observed in 31% and were more prevalent in individuals younger than age 35 years. Relevant arterial lesions were frequently detected in the middle cerebral artery (23%), internal carotid artery (13%), and vertebrobasilar arteries (13%). Cardioembolic stroke occurred in 47% (including 17% with isolated patent foramen ovale), and 11% had undetermined stroke etiology. The median National Institutes of Health Stroke Scale score was 3 (interquartile range, 0-9) and 81% had good outcome at hospital discharge. Of the 29 patients receiving thrombolysis (median National Institutes of Health Stroke Scale score, 14; interquartile range, 9-17), 55% had good outcome at hospital discharge and none developed symptomatic brain hemorrhage. CONCLUSIONS: This study shows the contemporary profile of ischemic stroke in young adults admitted to a tertiary stroke center. Stroke etiology can be determined in nearly 90% of patients with modern diagnostic tests. The causes are heterogeneous; however, young adults have a high rate of traditional vascular risk factors. Thrombolysis appears safe and short-term outcomes are favorable.

Predictors of increased intravenous tissue plasminogen activator use among hospitals participating in the Massachusetts Primary Stroke Service Program.

BACKGROUND: We sought to determine if intravenous tissue plasminogen activator (IV tPA) use for acute ischemic stroke increased in Massachusetts in association with the Primary Stroke Service program, a statewide stroke center designation and quality improvement initiative. METHODS AND RESULTS: We analyzed prospectively acquired data from the Massachusetts Department of Public Health between October 2004 and June 2008, including 10 045 consecutive emergency department-based acute ischemic stroke encounters arriving ≤ 3 hours after stroke onset at 69 participating Massachusetts PSS hospitals. The overall rate of IV tPA use was 854 of 3866 (22.1%) of patients arriving ≤ 2 hours of symptom onset. IV tPA use increased steadily from 2005 (the first full year of the program) to 2008 (18.4%, 21.9%, 22.6%, 25.5%; P=0.001). Patients treated with IV tPA were more likely to be younger (72.3 ± 14.1 versus 74.7 ± 14.0 years, P<0.005) and to have presented after emergency medical services rerouting in July 2005 (96% versus 94%, P=0.009). Patients who arrived at hospitals with a performance achievement award from the Get With The Guidelines-Stroke program were more likely to receive IV tPA after versus before award recognition (28.1% versus 22.3%, P<0.001). CONCLUSIONS: In this nearly complete capture of statewide data, rates of IV tPA improved significantly in Massachusetts from 2005 to 2008 in association with a state Primary Stroke Service designation program. Further studies are needed to confirm that treatment disparities exist for older acute ischemic stroke patients and that the rates of thrombolysis have increased above and beyond secular trends.

Combining acute diffusion-weighted imaging and mean transmit time lesion volumes with National Institutes of Health Stroke Scale Score improves the prediction of acute stroke outcome.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether acute diffusion-weighted imaging (DWI) and mean transit time (MTT) lesion volumes and presenting National Institutes of Health Stroke Scale (NIHSS) can identify patients with acute ischemic stroke who will have a high probability of good and poor outcomes. METHODS: Fifty-four patients with acute ischemic stroke who had MRI within 9 hours of symptom onset and 3-month follow-up with modified Rankin scale were evaluated. Acute DWI and MTT lesion volumes and baseline NIHSS scores were calculated. Clinical outcomes were considered good if the modified Rankin Scale was 0 to 2. RESULTS: The 33 of 54 (61%) patients with good outcomes had significantly smaller DWI lesion volumes (P=0.0001), smaller MTT lesion volumes (P<0.0001), and lower NIHSS scores (P<0.0001) compared with those with poor outcomes. Receiver operating characteristic curves for DWI, MTT, and NIHSS relative to poor outcome had areas under the curve of 0.889, 0.854, and 0.930, respectively, which were not significantly different. DWI and MTT lesion volumes predicted outcome better than mismatch volume or percentage mismatch. All patients with a DWI volume >72 mL (13 of 54) and an NIHSS score >20 (6 of 54) had poor outcomes. All patients with an MTT volume of <47 mL (16 of 54) and an NIHSS score <8 (17 of 54) had good outcomes. Combining clinical and imaging thresholds improved prognostic yield (70%) over clinical (43%) or imaging (54%) thresholds alone (P=0.01). CONCLUSIONS: Combining quantitative DWI and MTT with NIHSS predicts good and poor outcomes with high probability and is superior to NIHSS alone.

Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe.

BACKGROUND AND PURPOSE: Because of a shortage of stroke specialists, many outlying or "spoke" hospitals initiate intravenous (IV) thrombolysis using telemedicine or telephone consultation before transferring patients to a regional stroke center (RSC) hub. We analyzed complications and outcomes of patients treated with IV tissue plasminogen activator (tPA) using the "drip and ship" approach compared to those treated directly at the RSC. METHODS: A retrospective review of our Get With the Guidelines Stroke (GWTG-Stroke) database from 01/2003 to 03/2008 identified 296 patients who received IV tPA within 3 hours of symptom onset without catheter-based reperfusion. GWTG-Stroke definitions for symptomatic intracranial (sICH), systemic hemorrhage, discharge functional status, and destination were applied. Follow-up modified Rankin Score was recorded when available. RESULTS: Of 296 patients, 181 (61.1%) had tPA infusion started at an outside spoke hospital (OSH) and 115 (38.9%) at the RSC hub. OSH patients were younger with fewer severe strokes than RSC patients. Patients treated based on telestroke were more frequently octogenarians than patients treated based on a telephone consult. Mortality, sICH, and functional outcomes were not different between OSH versus RSC and telephone versus telestroke patients. Among survivors, mean length of stay was shorter for OSH patients but discharge status was similar and 75% of patients walked independently at discharge. CONCLUSIONS: Outcomes in OSH "drip and ship" patients treated in a hub-and-spoke network were comparable to those treated directly at an RSC. These data suggest that "drip and ship" is a safe and effective method to shorten time to treatment with IV tPA.