Shorter Door-to-Needle Times are Associated with Better Outcomes after Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke

Man, Shumei; Solomon, Nicole; Grory, Brian Mac; Uchino, Ken; Saver, Jeffrey; Smith, Eric E.; Xia, Ying; Bhatt, Deepak L.; Schwamm, Lee H; Hussain, Muhammad Shazam; Fonarow, Gregg

doi:10.2139/ssrn.4258949

Cited by 4 publications

(9 citation statements)

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“…22 These findings support further efforts to accelerate thrombolytic administration in all eligible patients. 22,23…”

Section: Stroke Applicationssupporting

confidence: 53%

“…In patients with stroke treated with either rtPA only or rtPA+MT, shorter “door‐to‐needle” (DTN) times are associated with better long‐term functional outcomes and lower mortality 22 . These findings support further efforts to accelerate thrombolytic administration in all eligible patients 22,23 …”

Section: Discussionmentioning

confidence: 77%

“…The MDS will shorten the time (disregarding patient‐dependent factors such as the speed of reaction to symptoms and time to alarm (call)) from stroke onset to therapy, which includes the following: Travel to the patient, dependent on distance, weather conditions, and road infrastructure. On‐the‐scene diagnostics (standard EMS, 12–25 min, mean 15 min; MSU, 30 min; and MSD (estimation), 20–22 min) 24–27 Transport to the stroke unit (depending on the distance to the nearest one, approximately equal to the time to travel to the patient); for the MDS and MSU, time will be saved because the patient receives treatment during transportation. Carrying out examinations in the hospital, DTN time (possible sources of delay: intrahospital transports, imaging tests (and further delays resulting from and waiting for the test), interpretation of imaging tests and decision‐making process (according to the guidelines, mean DTN time should be no longer than 60 min, with a tendency toward 30 min)) 22–27 …”

Section: Discussionmentioning

confidence: 99%

“…of imaging tests and decision-making process (according to the guidelines, mean DTN time should be no longer than 60 min, with a tendency toward 30 min)). [22][23][24][25][26][27] However, in the study by Fonarow et al, for 85% of hospitals included in the Get With The Guideliness (GWTG) study, the time from "alarm to needle" was 67 min (interquartile range, 51-87 min), despite the introduction of various organizational improvements. 23 When the MDS and MSU are used, only the first two sources of delay (A + B) occur, reducing the total time to therapy.…”

Section: Advantages Inconveniences and Risksmentioning

confidence: 99%

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Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield—General concept and medical aspects

Kaźmierski

2023

J of Clinical Ultrasound

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To present the concept of a portable ultrasound tomography device for diagnosing traumatic and vascular brain lesions. The device consisting of multiple transcranial ultrasound probes placed on the surface of the head, specifically but not exclusively in natural acoustic windows. An integral part of the mobile diagnostic system (MDS) is a decision support system based on artificial intelligence algorithms utilizing information from: head images, laboratory data, and assessment of the patient's clinical condition. The MDS can significantly reduce the time from stroke onset to rtPA therapy in civilian medical services and support therapeutic and evacuation strategies in instances of brain and skull trauma on the battlefield.

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“…22 These findings support further efforts to accelerate thrombolytic administration in all eligible patients. 22,23…”

Section: Stroke Applicationssupporting

confidence: 53%

Section: Discussionmentioning

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Section: Advantages Inconveniences and Risksmentioning

confidence: 99%

See 2 more Smart Citations

Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield—General concept and medical aspects

Kaźmierski

2023

J of Clinical Ultrasound

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“…Certain subgroups of patients may benefit from a treatment strategy that combines IVT with thrombectomy, while other subgroups may not benefit or may experience harm from prior IVT . The time from stroke symptom onset to treatment is one potential factor that could influence the relative effectiveness and safety of administering IVT before thrombectomy …”

Section: Introductionmentioning

confidence: 99%

Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke

Kaesmacher,

Cavalcante,

Kappelhof

et al. 2024

JAMA

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ImportanceThe benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy.ObjectiveTo determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset.Design, Setting, and ParticipantsIndividual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313).ExposureInterval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone.Main Outcomes and MeasuresThe primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT.ResultsIn 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, −3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes.Conclusions and RelevanceIn patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.

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Roles and mechanisms of leptomeningeal collaterals in human distal MCA territory ischemia

Zou,

Mei,

et al. 2024

Preprint

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Objective: Leptomeningeal collaterals (LMCs) provided hemodynamic support and reperfusion during acute ischemic stroke (AIS). Although regulation details have been deeply acquired from animal models, human cortex may share limited hemodynamic patterns due to larger physical scale that needs further investigation. Approach and Results: We performed 'sequential hierarchical blocking' during awake craniotomy on fourteen human subjects to mimic AIS in middle cerebral artery (MCA) M4 segment territory. Widefield microscope was applied to reveal microcirculation of LMCs. Relative flow rate (RFR) was measured to evaluate the impact of LMCs hierarchy on microcirculation maintenance. Single-cell sequencing and spatial transcriptomics were further performed to analyze the mechanism of different LMCs recruitment abilities. LMCs RFR decreased to 30.75% immediately (95% CI, 6.64 - 54.86%, P < 0.001), and about 80.25% RFR was finally recovered within 5 minutes (95% CI, 55.2 - 105.3%, P = 0.0034) during M4 occlusion. For M5 and pial branches occlusion, RFR decreased to 55.78% with no further recovery (95% CI, 22.50-89.05%, P = 0.014), and 4 in 11 subjects had no valid microcirculation. For subjects with better recruitment ability, the proportion of arteriole is much higher in leptomeninx (76 - 79% vs. 36 - 56%). There were more significant interaction pairs associated with key signaling pathways between arteriole and neuron/astrocyte (TGF-beta signaling pathway, ECM-receptor interaction). Conclusion: Abundant LMCs supported hemodynamic stability during AIS in human subjects. The proportion of arteriole is much higher in leptomeninx for subjects with better recruitment ability. The Active neuron/astrocyte - arteriole interaction may improve LMCs recruitment.

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Shorter Door-to-Needle Times are Associated with Better Outcomes after Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke

Cited by 4 publications

References 0 publications

Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield—General concept and medical aspects

Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield—General concept and medical aspects

Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke

Roles and mechanisms of leptomeningeal collaterals in human distal MCA territory ischemia

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