【ISC2016】Progress in non-vascular treatment of ischemic stroke

There are more than 10 microbleeds in the brain, and the risk of cerebral hemorrhage after intravenous thrombolysis is high

Symptomatic intracranial hemorrhage (sICH) is the most worrisome complication of intravenous thrombolysis of tissue plasminogen activator (tPA) for ischaemic stroke, while patients with intracerebral microhaemorrhage (CMB) are potentially at greater
risk.
The aim of the study from the University of Tennessee Health Sciences Research Center was to evaluate the relationship between
the number and location of CMB on magnetic resonance imaging (MRI) and the risk of sICH after tPA thrombolysis.

The study included seven tertiary stroke centers between 2010 and 2014 who underwent intravenous thrombolysis of tPA and completed MRI before or within 24 hours after treatment
.
The definition of sICH is ECASS-III, and clinical neurological deterioration is a National Institutes of Health Stroke Scale (NIHSS) ≥ 4 or death
.
CMB is defined as a circular or oval low-signal region on MRI T2* with a diameter of up to 10 mm
.
Among the 672 patients included, 103 had CMB in the brain, of which 10 had more than 10 CMBs, and the proportion of hypertension and prior ischemic stroke increased significantly in patients with CMB (P<0.
05).
<b13> Compared with patients without CMB, there was no significant increase in the incidence of sICH (P=0.
27), but the incidence of sICH in patients with a CMB > 10 was significantly increased compared with patients with CMB of 1~10 (P=0.
0009).

After adjusting for confounders, 10 CM>Bs on T2*-MRI were independent risk factors for sICH (P=0.
0004).

Patients with 10 CMBs > were more severely disabled at discharge than patients with CMB of 1~10 [median Rankin score (mRS) was 4 to 2], and in-hospital mortality was also significantly increased (20% vs.
5.
4%)
.

Take home message: The risk of sICH increases significantly after intravenous thrombolysis of tPA when there are more than 10 CMBs on the MRI-T2* sequence, but not in patients with less than 10 CMBs
.
The number of CMBs can be used as an indicator to
assess the risk of intravenous thrombolysis beyond the time window.

Thrombolysis of prehospital stroke helps improve functional outcomes and quality of life

The effectiveness of thrombolytic therapy is closely related to time, and the STEMO mobile stroke unit improvement project promoted in Germany uses special stroke ambulances equipped with CT to shorten the window for initiation of intravenous thrombolysis (IVT) treatment for acute ischemic stroke, but the effect of prehospital thrombolysis on functional outcomes is unknown
.

Scholars from the Berlin Stroke Research Centre in Germany compared the clinical outcomes
of prehospital thrombolysis using the STEMO Mobile Stroke Emergency System with traditional ambulance first aid for in-hospital thrombolysis.
The primary endpoint was a three-month mRS score of ≤1 and a secondary endpoint of a three-month mRS score of ≤3 and death
.

Between February 2011 and May 2015, a total of 751 patients from seven tertiary stroke centers received in-hospital thrombolysis, 467 patients completed STEMO prehospital thrombolysis, and finally 355 patients on intrahospital thrombolytic therapy and 306 patients on STEMO prehospital thrombolysis were included in the study
。 There were more women with prehospital thrombolysis of STEMO (47.
7% vs.
36.
6%, P<0.
01), the time from symptom onset to initiation of IVT was significantly shortened by nearly 30 minutes (72 minutes vs.
112 minutes, P<0.
01), and the proportion of patients starting treatment within 1 hour increased significantly to 1/3 (36.
9% vs.
3.
9%, P<0.
01).
<b11> There was no significant difference between prehospital thrombolysis and in-hospital thrombolysis for the primary endpoint (39.
0% versus 35.
4%, P=0.
15).

For secondary endpoints, patients with good outcomes in the STEMO prehospital thrombolysis group were significantly increased (83.
0% vs.
73.
5%, P<0.
01) and deaths were significantly reduced (5.
6% vs.
10.
4%, P=0.
02).
<b13> After adjusting for confounding factors such as age, sex, stroke severity (NIHSS score), atrial fibrillation, and diabetes, patients treated with STEMO prehospital thrombolysis significantly improved
functional outcomes.

Take home message:The prehospital thrombolysis system of STEMO Mobile Stroke Emergency System has advantages over traditional hospital thrombolysis, which can significantly shorten the initiation time of thrombolysis therapy, thereby improving the safety and effectiveness of thrombolysis, and improving the functional outcome and quality of
life of patients.

Intravenous thrombolysis is relatively safe for patients with pseudo-stroke

The benefits of intravenous thrombolysis of tPA are time-dependent, and prehospital emergency care systems play an important role
in underdeveloped rural areas.
However, this time urgency has led to misidentification and thrombolysis in patients with suspected stroke
.
Researchers at the University of Louisville (ULH), which is the center for stroke network transport, conducted 24-hour telephone advanced stroke consultations in rural southwest Indiana, Kentah, investigated the safety of the phenomenon
.

The study reviewed and compared all tPA-treated sham stroke patients who were discharged from hospital with non-stroke who were transferred to ULH School of Medicine between 2013 and 2015 and
were first diagnosed with ULH.
The proportion of patients with sham stroke treated with tPA in the transport group was twice as high as in the ULH first care group (27.
4% versus 13.
5%), and there was no difference in clinical features between the two groups, only one patient in the transport group had mild hemoptysis, and all patients were discharged with good outcomes
.
The causes of pseudostroke patients are, in order, psychogenic, complex migraine, hypertensive/metabolic/hypotensive encephalopathy,

There were no significant differences
between the two groups for seizures, syncope, and other causes.
< psychogenic and complex migraine were common causes of sham stroke in the 65-year-old group, and encephalopathy and epilepsy<b11> were common in the > 65-year-old group.

Take home message: Intravenous thrombolytic therapy is relatively safe for patients with false stroke, < 65-year-old young and middle-aged people are psychogenic and complex migraine, and > 65-year-old elderly false stroke common diseases are encephalopathy and epilepsy, which should be carefully screened
.