Symptomatic Intracranial Hemorrhage With Tenecteplase vs Alteplase in Patients With Acute Ischemic Stroke: The Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) Collaboration.

Importance: Symptomatic intracranial hemorrhage (sICH) is a serious complication of stroke thrombolytic therapy. Many stroke centers have adopted 0.25-mg/kg tenecteplase instead of alteplase for stroke thrombolysis based on evidence from randomized comparisons to alteplase as well as for its practical advantages. There have been no significant differences in symptomatic intracranial hemorrhage (sICH) reported from randomized clinical trials or published case series for the 0.25-mg/Kg dose. Objective: To assess the risk of sICH following ischemic stroke in patients treated with tenecteplase compared to those treated with alteplase. Design, Setting, and Participants: This was a retrospective observational study using data from the large multicenter international Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) collaboration comprising deidentified data on patients with ischemic stroke treated with intravenous thrombolysis. Data from more than 100 hospitals in New Zealand, Australia, and the US that used alteplase or tenecteplase for patients treated between July 1, 2018, and June 30, 2021, were included for analysis. Participating centers included a mix of nonthrombectomy- and thrombectomy-capacity comprehensive stroke centers. Standardized data were abstracted and harmonized from local or regional clinical registries. Consecutive patients with acute ischemic stroke who were considered eligible and received thrombolysis at the participating stroke registries during the study period were included. All 9238 patients who received thrombolysis were included in this retrospective analysis. Main Outcomes and Measures: sICH was defined as clinical worsening of at least 4 points on the National Institutes of Health Stroke Scale (NIHSS), attributed to parenchymal hematoma, subarachnoid, or intraventricular hemorrhage. Differences between tenecteplase and alteplase in the risk of sICH were assessed using logistic regression, adjusted for age, sex, NIHSS score, and thrombectomy. Results: Of the 9238 patients included in the analysis, the median (IQR) age was 71 (59-80) years, and 4449 patients (48%) were female. Tenecteplase was administered to 1925 patients. The tenecteplase group was older (median [IQR], 73 [61-81] years vs 70 [58-80] years; P < .001), more likely to be male (1034 of 7313 [54%] vs 3755 of 1925 [51%]; P < .01), had higher NIHSS scores (median [IQR], 9 [5-17] vs 7 [4-14]; P < .001), and more frequently underwent endovascular thrombectomy (38% vs 20%; P < .001). The proportion of patients with sICH was 1.8% for tenecteplase and 3.6% for alteplase (P < .001), with an adjusted odds ratio (aOR) of 0.42 (95% CI, 0.30-0.58; P < .01). Similar results were observed in both thrombectomy and nonthrombectomy subgroups. Conclusions and Relevance: In this large study, ischemic stroke treatment with 0.25-mg/kg tenecteplase was associated with lower odds of sICH than treatment with alteplase. The results provide evidence supporting the safety of tenecteplase for stroke thrombolysis in real-world clinical practice.

Racial Disparity in Mechanical Thrombectomy Utilization: Multicenter Registry Results From 2016 to 2020.

Background Previous studies on racial disparity in mechanical thrombectomy (MT) treatment of acute large vessel occlusion stroke lack individual patient data that influence treatment decision-making. We assessed patient-level data in a large US health care system from 2016 to 2020 for racial disparities in MT utilization and eligibility. Methods and Results A retrospective study was performed of 34 596 patients admitted to 43 hospitals from January 2016 to September 2020. Data included patient age, sex, race, residential zip code median income and population density, presenting hospital stroke certification, baseline ambulation, and National Institutes of Health stroke scale. The cohort included 26 640 White, non-Hispanic (77.0%), and 7956 African American/Black (23.0%) patients. In multivariable logistic regression, Black patients were less likely to undergo MT (adjusted odds ratio [OR], 0.65; 95% CI, 0.54-0.76), arrive within 5 hours of "last known well" (adjusted OR, 0.73; 95% CI, 0.69-0.78), and have documented anterior circulation large vessel occlusion (adjusted OR, 0.78; 95% CI, 0.64-0.96). Race was not associated with MT rate among patients arriving within 5 hours of last known well with documented acute large vessel occlusion. Conclusions Black patients with stroke underwent MT less frequently than White patients, likely in part because of longer times from last known well to hospital arrival and a lower rate of documented acute large vessel occlusion. Further studies are needed to assess whether extending the MT time window and more aggressive large vessel occlusion screening protocols mitigate this disparity.

Ceribell EEG shortens seizure diagnosis and workforce time and is useful for COVID isolation.

OBJECTIVE: To determine whether the portable Ceribell® electroencephalograph (EEG) (Mountain View, CA) used for suspected status epilepticus (SE) can reduce time to diagnosis and on-call workforce demands and whether it can be applied to patients in respiratory isolation. METHODS: A multidisciplinary team developed a protocol for the use of the Ceribell EEG. The staff deploying the device, the attending physician, and the interpreting neurologist completed evaluation tools for each patient. Data maintained for quality and resource planning of 18-channel electroencephalography ordered for suspected SE were used as controls. Times to diagnosis were compared by application of Welch-Satterthwaite tests and workforce call-in demands by Fisher's exact t test. We evaluated qualitative data related to the use of the EEG in COVID-19 isolation rooms and on its technical aspects and acceptance by staff members. RESULTS: The Ceribell EEG reduced diagnosis time (P = .0000006) and on-call workforce demand (P = .02). The device can be used at any time of day in any hospital care area and has advantages in respiratory isolation rooms. SIGNIFICANCE: Compared with a standard 18-channel EEG, the Ceribell device allowed earlier diagnosis of SE and non-SE conditions and reduced workforce demands. Due to the ease of its use and its simple components, which can be readily disinfected, it is advantageous for COVID-19 patients in isolation.

Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes During the Early COVID-19 Pandemic.

BACKGROUND AND PURPOSE: Delayed evaluation of stroke may contribute to COVID-19 pandemic-related morbidity and mortality. This study evaluated patient characteristics, process measures and outcomes associated with the decline in stroke presentation during the early pandemic. METHODS: Volumes of stroke presentations, intravenous thrombolytic administrations, and mechanical thrombectomies from 52 hospitals from January 1-June 30, 2020 were analyzed with piecewise linear regression and linear spline models. Univariate analysis compared pandemic (case) and pre-pandemic (control) groups defined in relation to the nadir of daily strokes during the study period. Significantly different patient characteristics were further evaluated with logistic regression, and significantly different process measures and outcomes were re-analyzed after propensity score matching. RESULTS: Analysis of 7,389 patients found daily stroke volumes decreased 0.91/day from March 12-26 (p < 0.0001), reaching a nadir 35.0% less than expected, and increased 0.15 strokes/day from March 27-June 23, 2020 (p < 0.0001). Intravenous thrombolytic administrations decreased 3.3/week from February 19-March 31 (p = 0.0023), reaching a nadir 33.4% less than expected, and increased 1.4 administrations/week from April 1-June 23 (p < 0.0001). Mechanical thrombectomy volumes decreased by 1.5/week from February 19-March 31, 2020 (p = 0.0039), reaching a nadir 11.3% less than expected. The pandemic group was more likely to ambulate independently at baseline (p = 0.02, OR = 1.60, 95% CI = 1.08-2.42), and less likely to present with mild stroke symptoms (NIH Stroke Scale ≤ 5; p = 0.04, OR = 1.01, 95% CI = 1.00-1.02). Process measures and outcomes of each group did not differ, including door-to-needle time, door-to-puncture time, and successful mechanical thrombectomy rate. CONCLUSION: Stroke presentations and acute interventions decreased during the early COVID-19 pandemic, at least in part due to patients with lower baseline functional status and milder symptoms not seeking medical care. Public health messaging and initiatives should target these populations.

Diagnosing deep cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) is a relatively rare vascular disorder involving the formation of a thrombus in the venous system of the cerebral vasculature. The nonspecificity of clinical symptoms seen with CVT elicits significant diagnostic challenges with the potential of serious morbidity and mortality associated with delays in therapeutic intervention. We present a case of CVT in a young patient who presented with loss of consciousness with no headache or focal deficits, the usual type of presentation.

A regional system of stroke care provides thrombolytic outcomes comparable with the NINDS stroke trial.

STUDY OBJECTIVE: Administration of tissue plasminogen activator (tPA) for acute ischemic stroke remains controversial in community practice. Well-organized hierarchic systems of acute stroke care have been proposed to link community hospitals to comprehensive stroke centers. We report safety and functional outcomes in patients treated with tPA in our regional emergency stroke network and compare them with results reported from the trial conducted by the National Institute of Neurological Disorders and Stroke (NINDS). METHODS: Through a statewide communications and transport network, our brain attack center gives emergency medicine staff in the state and surrounding area immediate access to stroke specialists. The team provides consultation about the administration of tPA for ischemic stroke, using the NINDS protocol. Consultations, treatment, and outcomes are documented in our database. RESULTS: From 1996 to 2005, the brain attack center completed 2,670 consultations and diagnosed 1,788 patients with ischemic stroke. Two hundred forty patients (9% of all consultations; 13.4% of those with acute ischemic stroke) received tPA. Percentages of patients with symptomatic intracranial hemorrhage and 3-month modified Rankin scale scores less than or equal to 1, compared with those in the NINDS trial, were as follows: 3.3% versus 6.4% and 53% versus 43% (P=.04). Mortality rates were 13% (network) versus 17% (NINDS). CONCLUSION: During a 9-year period, an emergency medicine network with stroke consultants achieved patient outcomes comparable to those reported from the NINDS trial. These results indicate that the NINDS tPA protocol is applicable to community practice, with the support of a university-based brain attack center.

Ensuring emergency medicine performance standards for stroke and transient ischemic attack care.

This article reviews emergency medicine evaluation and management performance standards for cerebrovascular event patients and provides a practical process for ensuring high quality care. Areas of practice that most frequently generate questions and controversy are highlighted. The term "cerebrovascular event" is used throughout the text when both stroke and transient ischemic attack apply to the discussion. Recommendations are based on literature review and the author's experience with the successful certification of multiple primary stroke centers and appointments in neurology, emergency medicine, and nursing specialties.

Outcomes from a comprehensive stroke telemedicine program.

Our team has studied the use of telemedicine to overcome obstacles to providing acute stroke care and expanding stroke education. We report a summary of our outcomes to provide evidence supporting greater development of stroke telehealth systems. Stroke telemedicine is audio-video communication (teleconferencing) between a stroke specialist and a remote party requiring stroke services. Using several models, we tested the validity, reliability, and effectiveness of telemedicine versus telephone consultations and face-to-face (traditional) medical care and education. Because of the challenges inherent to technology studies, we found a prospective, case control design most practical for testing hypotheses related to a comparison of telemedicine and traditional service delivery. Telemedicine-assisted neurologic evaluation and stroke diagnosis were as valid and reliable as traditionally delivered services. Clinical effectiveness was demonstrated by shortening times to treatment (17 [telemedicine] vs. 33 [control] minutes; p = 0.003) and increasing tissue plasminogen activator use at a remote hospital (from 5% to 24%). Evaluation of telemedicine as a means to expand stroke education to distant communities revealed that telemedicine and direct education achieve equivalent academic results. Stroke services delivered by telemedicine are safe, efficacious, and comparable to those rendered face-to-face. Telemedicine is a means of providing disability-reducing therapies earlier to a large number of patients. The current, geographically defined scheme for telemedicine service reimbursement fails to recognize that the main barrier to stroke care is lack of available stroke specialists. Contractual and third-party reimbursement structures should be modified to surmount this impediment to extending stroke specialty care and community education.

Evaluation and management of transient ischemic attacks.

The risk for disabling stroke is greatest in the period immediately following a transient ischemic attack (TIA), thus, TIA is a medical emergency. A universities medical center's emergency department-based TIA evaluation and management program is presented as an example of the pragmatic enactment of current guidelines for TIA evaluation and management. A discussion of modifications that can be made for an outpatient setting evaluation and a review of the literature follow.

Anticoagulation strategies for treatment of ischemic stroke and antiphospholipid syndrome: case report and review of the literature.

A 49-year-old Caucasian man with antiphospholipid syndrome who experienced an ischemic stroke required multidisciplinary decisions regarding acute and long-term care. The patient first received warfarin and unfractionated heparin, followed by low-molecular-weight heparin. However, he developed complications from these drugs (warfarin-induced necrosis and heparin-induced thrombocytopenia), resulting in thigh necrosis and multiple additional cerebral and peripheral infarcts. His condition improved after warfarin and the heparins were discontinued, and a direct thrombin inhibitor, argatroban, was given intravenously for acute treatment. Argatroban is the only anticoagulant known to be safe in patients who experience an acute ischemic stroke in the setting of heparin-induced thrombocytopenia. For long-term anticoagulation, fondaparinux, an indirect, selective factor Xa inhibitor, was given subcutaneously. The patient received intravenous dexamethasone, later changed to azathioprine, for immunomodulatory treatment. He had significant improvement in his neurologic deficits without recurrent events over the next 18 months. Management of anticoagulation therapy in patients with antiphospholipid syndrome is complex and challenging, and therapeutic strategies need to be evaluated further.