Background and Purpose-Guidelines for intravenous tissue plasminogen activator (tPA) use in stroke emphasize the importance of limiting its use to facilities with imaging capabilities and stroke expertise. This prospective case series set out to evaluate the safety of tPA use in patients referred from rural communities to a tertiary center. Methods-Prospective data of 82 consecutive patients treated with tPA in London, Ontario, were reviewed. Results-Twenty-three patients were transferred to London from a rural hospital (non-London patients); 49 were first evaluated in a London emergency room (London ER); and 10 were inpatients in a London hospital at the time of stroke onset. Mean transfer time and distance to London for non-London patients were 89 minutes and 41 miles. Although symptom onset to London ER times were longer for non-London than for London ER patients (123 versus 53 minutes), the door to needle times were significantly shorter for the former (49 versus 95 minutes, PϽ0.005). Imaging to needle times were longer for London inpatients compared with London ER patients (55 versus 36 minutes, Pϭ0.16). The proportion of patients with Ͼ4-point improvement on the NIH Stroke Scale or cure at 24 hours was 57%, with no difference among groups (Pϭ0.46). The overall symptomatic hemorrhage rate at 36 hours was 2%. No significant differences in outcomes were observed at 3 months. Conclusions-This prospective study suggests that it is feasible and safe to treat rural patients referred to a tertiary care center with tPA, thus extending the benefits of thrombolysis for acute stroke to a wider population. Key Words: Canada Ⅲ stroke, acute Ⅲ stroke management Ⅲ thrombolytic therapy Ⅲ tissue plasminogen activator T he National Institute of Neurological Disorders and Stroke (NINDS) tPA Stroke Study Group showed in 1995 that intravenous tissue plasminogen activator (tPA) was an efficacious treatment for acute ischemic stroke. 1 Since its approval by the FDA in 1996, tPA has been used safely and effectively in routine clinical practice in urban academic medical centers 2-7 and in community hospitals. 2,8 Strategies to extend thrombolysis to rural community hospitals with imaging and intensive care facilities but with limited stroke expertise 5,9 and referral protocols for urban community hospitals that have limited access to imaging facilities 10 have been implemented successfully.Guidelines have been developed to ensure safety in the use of tPA for acute ischemic stroke. [11][12][13] Routine tPA use is currently restricted to those patients who can be treated within 3 hours of symptom onset. All the guidelines emphasize the importance of involving physicians with expertise in the diagnosis of stroke and in the interpretation of CT scans and restrict treatment to facilities that have the ability to handle hemorrhagic complications. Many hospitals, particularly outside the United States, 10,14 lack the staff or the facilities required to meet these criteria.In February 1999, the Health Protection Branch of Canada granted a ...

Background: Collateral circulation stabilizes cerebral blood flow in patients with acute occlusion, but its prognostic role is less studied in intracranial atherosclerosis and appears different in moderate to severe stenosis. We aimed to study the associations between antegrade flow across stenosis, collateral flow via leptomeningeal anastomosis, and the neurological outcome and recurrence risk in patients with symptomatic intracranial stenosis. Methods: We examined a cohort of consecutive patients admitted for stroke or transient ischemic attack (TIA) with symptomatic intracranial stenosis confirmed by digital subtraction angiography in a single-center retrospective study. Angiograms were graded systematically in a blinded fashion for antegrade and collateral flow, using Thrombolysis in Cerebral Infarction (TICI) and American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) grading, respectively, and integrated to a simple composite circulation score. Demographic and clinical variables, modified Rankin Scale (mRS) scores at 3 months, recurrent stroke or TIA in 12 months were collected. Uni- and multivariate analyses were performed to identify independent predictors of good outcome (mRS 0–2) and recurrence in a logistic regression model. Results: Among 69 patients with pure intracranial atherosclerosis ≥50%, compromised antegrade flow (TICI 0–2a) was observed in 26 (36%) patients and was associated with more severe arterial stenosis (mean 86 vs. 74%, p = 0.001). Poor collateral compensation resulting in a poor composite circulation score was observed in 8 (12%) patients. Patients with a good circulation score (n = 61, 88%) had preserved flow, which was associated with more favorable outcome (OR 7.50, 95% CI 1.11–50.7, p = 0.04) and less recurrent TIA or stroke (OR 0.18, 95% CI 0.04–0.96, p = 0.04). Prognosis was not significantly associated with antegrade or collateral grade per se. Conclusion: Good collateral compensations are more important in patients with symptomatic intracranial stenosis and compromised antegrade flow, and are associated with favorable outcome and less recurrence risk. The feasibility of composite flow assessment should be explored in future studies to identify high-risk intracranial stenosis with compromised hemodynamics.

Purpose: To compare the inter-observer reliability of Alberta Stroke Programme Early CT Scoring (ASPECTS) with the ICE (Idealize-Close-Estimate) method of estimating > 1/3 middle cerebral artery territory (MCAT) infarction amongst stroke neurologists and to determine how well ASPECT Scoring predicts > 1/3 MCAT infarctions in acute ischemic stroke (AIS). Background: The European Cooperative Acute Stroke Study suggested that > 1/3 involvement of the MCAT on early CT scan was a risk factor for symptomatic intracerebral hemorrhage (SICH) following treatment with tissue plasminogen activator (tPA) for AIS but, in the absence of a systematic method of estimation had poor interobserver reliability (Kappa 0.49). The ICE method was developed to standardize the approach to estimating early MCAT infarct size and has very good interobserver reliability (Kappa 0.72). ASPECTS has comparable interobserver reliability and is reported to predict both neurological outcome and SICH. Methods: Five stroke neurologists were tested with 40 AIS CT scans. Each performed blinded independent assessments of early ischemic changes with both ASPECTS and ICE. The reference standard was majority opinion of 1/3 MCAT determination of five neuroradiologists. A receiver operator curve (ROC) was constructed and likelihood ratios (LR) were calculated. Chance corrected agreement (kappa) and chance independent agreement (phi) were calculated for both methods, and analysis of variance was used to calculate reliability by intraclass correlation coefficient (ICC) for ASPECTS. Results: The LR for a positive test (> 1/3 MCAT) were extremely large and conclusive (approaching infinity) for ASPECTS of 0-3; were large and conclusive (30, 20, and 10) for ASPECTS of 4, 5, and 6 respectively; was an unhelpful 1 for ASPECTS of 7, and were again extremely large and conclusive (approaching zero) for ASPECTS of 8-10. A ROC plot supported an ASPECTS cutoff of < 7 as best for 1/3 MCAT estimation (94% sensitivity and 98% specificity). Kappa and Phi statistics were moderately good for both ASPECTS and ICE (0.7). ICC for ASPECTS was 0.8. Conclusions: When experienced stroke neurologists utilize a formalized method of quantifying early ischemic changes on CT, either ASPECTS or ICE, the interobserver agreement and reliability are satisfactory. ASPECTS allows for a strong and conclusive estimation of the presence of 1/3 MCAT involvement and a cutoff point of < 7 results in best test performance.RÉSUMÉ: Le score ASPECT dans l'évaluation de l'infarctus >1/3 du territoire de l'artère cérébrale moyenne. Objectif: Comparer la fiabilité interobservateur, chez des neurologues spécialisés dans l'accident vasculaire cérébral (AVC), pour le score ASPECT et la méthode ICE (idealize-closeestimate) d'estimation de l'infarctus >1/3 du territoire de l'artère cérébrale moyenne (TACM) et déterminer si le score ASPECT prédit bien l'infarctus >1/3 du TACM dans l'AVC ischémique aigu. Contexte: Selon les données du European Cooperative Acute Stroke Study, l'atteinte >1/3 du TACM à la t...

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