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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Adherence to Third European Cooperative Acute Stroke Study 3- to 4.5-hour exclusions and association with outcome:
Carolyn A Cronin1, Kevin N Sheth1, Xin Zhao1
1From the Department of Neurology, University of Maryland School of Medicine, Baltimore (C.A.C.); Department of Neurology, Yale School of Medicine, New Haven, CT (K.N.S.); Duke Clinical Research Institute, Durham, NC (X.Z., A.F.H.); Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (S.R.M.); Department of Neurology, University of Texas Southwestern, Dallas (D.M.O.); Department of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston and Harvard Medical School, MA (L.H.S.); and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.).
Insights
Many patients treated with tissue-type plasminogen activator (tPA) beyond 3 hours have specific exclusion criteria. However, these additional criteria did not worsen outcomes compared to earlier treatment.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Emergency Medicine
Background:
- Current guidelines recommend intravenous tissue-type plasminogen activator (tPA) for ischemic stroke within 3 to 4.5 hours, based on ECASS III criteria.
- ECASS III included specific exclusions beyond standard criteria: age >80, prior stroke, diabetes mellitus, oral anticoagulant use, and NIH Stroke Scale >25.
Purpose of the Study:
- To assess adherence to ECASS III-specific exclusion criteria in patients treated with tPA between 3 to 4.5 hours from symptom onset.
- To determine the association of these exclusion criteria with patient outcomes.
Main Methods:
- Analysis of Get With The Guidelines-Stroke data from 32,019 ischemic stroke patients treated with tPA within 4.5 hours.
- Comparison of the prevalence of ECASS III exclusion criteria between the 0-3 hour and 3-4.5 hour treatment windows.
- Evaluation of the risk of symptomatic intracranial hemorrhage and hospital outcomes based on exclusion criteria.
Main Results:
- 31.5% of patients treated with tPA between 3 to 4.5 hours met at least one ECASS III exclusion criterion, most commonly age >80.
- Exclusion criteria were generally less prevalent in the 3-4.5 hour window compared to the 0-3 hour window, except for prior stroke and diabetes.
- No increased risk of symptomatic intracranial hemorrhage or worse hospital outcomes was observed for patients treated in the 3-4.5 hour window, even with additional exclusion criteria.
Conclusions:
- A significant proportion of patients treated with tPA in the 3-4.5 hour window have ECASS III-specific exclusion criteria.
- The presence of these additional exclusion criteria did not negatively impact outcomes when tPA was administered between 3 to 4.5 hours compared to 0-3 hours.
Background And Purpose:
The American Heart Association/American Stroke Association guidelines recommend intravenous tissue-type plasminogen activator (tPA) treatment 3 to 4.5 hours from symptom onset according to criteria used in the Third European Cooperative Acute Stroke Study (ECASS III). However, ECASS III excluded certain patient groups in addition to the standard exclusions used for 0 to 3 hours in the United States: age >80 years, history of stroke and diabetes mellitus, oral anticoagulant treatment, and National Institutes of Health Stroke Scale >25. We investigated adherence to these additional exclusion criteria for patients treated 3 to 4.5 hours from onset and their association with outcome.
Methods:
We analyzed data from Get With The Guidelines-Stroke on 32 019 patients with ischemic stroke from 1464 hospitals who were treated with tPA ≤4.5 hours from onset from January 2009 to January 2012, excluding patients transferred from another hospital. The percent of patients meeting versus not meeting each exclusion criterion were compared between treatment time windows.
Results:
Overall, 1544 of 4910 (31.5%) patients treated with tPA >3 to 4.5 hours had at least 1 of the additional exclusions, the most common was age >80 years. With the exception of prior stroke and diabetes mellitus, the percent of tPA-treated patients with each exclusion criterion was significantly lower at >3 to 4.5 hours compared with 0 to 3 hours. For each additional exclusion criterion, there was no increased risk of symptomatic intracranial hemorrhage or worse hospital outcome for patients treated >3 to 4.5 hours compared with 0 to 3 hours, after adjusting for baseline differences.
Conclusions:
Patients with ECASS III-specific exclusion criteria for the >3 to 4.5 hours window are frequently treated with tPA. The presence of the additional exclusion criteria was not associated with worse outcomes in the >3 to 4.5 hours window compared with the 0 to 3 hours window.
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