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    Emergency Department Workflow Times of Intravenous Thrombolysis with Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Prospective Cohort Study before and during the COVID-19 Pandemic
    (S. Karger AG, 2025-02-03)
    Matias Guzman
    ;
    LAVADOS GERMAIN, PABLO MANUEL  
    ;
    Gabriel Cavada
    ;
    Alejandro M. Brunser
    ;
    Veronica V. Olavarria
    Introduction: Tenecteplase (TNK) has demonstrated to be non-inferior to alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center. Methods: We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models. Results: 110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD = 164) min for TNK users versus 240 (SD = 148) min for ALT (p = 0.62). Mean DTN was 43 (SD = 25) min for TNK versus 46 (SD = 27) min for ALT users (p = 0.39). Mean DTN under 60 min was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups, respectively (p = 1.0). DTN under 45 min was achieved in 65.4% and 58.6% (p = 0.65) of the TNK and ALT groups, respectively. DTG time was 114 (SD = 43) min for TNK versus 111 (58 = SD) min in the ALT group (p = 0.88). DTG under 90 min was achieved in 32% of the TNK group and 35% of the ALT group (p = 0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days. Conclusions: The adoption of TNK during COVID-19 pandemic did not result in a change in EDLOS, DTN, or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.
    Scopus© Citations 2  2
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    Patient centered outcomes in stroke: utility-weighted modified Rankin Scale results in a community-based study
    (Frontiers Media SA, 2025-03-21)
    Carlos Delfino
    ;
    Gabriel Cavada
    ;
    HOFFMEISTER ARCE, LORENA  
    ;
    LAVADOS GERMAIN, PABLO MANUEL  
    ;
    MUÑOZ VENTURELLI, PAULA ANDREA  
    Background and aims</jats:title><jats:p>The transformation of modified Rankin Scale (mRS) scores based on the corresponding utilities of health-related quality of life questionnaires can facilitate the capture of Patient-Centered Outcomes (PCO) in stroke. We aimed to derive utility-weighted modified Rankin Scale (UW-mRS) values by mapping mRS functional status to EQ-5D-3L scores in a population-based cohort of stroke patients.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>The UW-mRS was obtained by analyzing the EQ5-D-3 L and mRS scores at 180 days after any stroke in the ÑANDU study, a large prospective community-based study in Chile. The mRS prediction was estimated using a linear regression adjusted by the EQ-5D-3L value. Generalized linear and binary logistic regression models were constructed to determine influencing factors of the UW-mRS, using STATA software (version 18.0).</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We included 773 patients presenting with any stroke during 2015–2016: 48% were female, with a mean age of 71 years (SD 13.8), and 85% had an acute ischemic stroke (AIS). 82% of patients had a low socioeconomic status, 50% had less than 12 years of formal education, and only 32% lived in urban areas. UW-mRS values for mRS categories 0–6 at 180 days were 0.913, 0.694, 0.425, 0.249, −0.102, −0.347 and 0, respectively. Multivariable analysis identified age &amp;gt; 70 years (Coefficient <jats:italic>β</jats:italic> [β] -0.038 [Standard error SE 0.018], <jats:italic>p</jats:italic> = 0.032), prior mRS score 3–5 (<jats:italic>β</jats:italic> −0.556 [SE 0.197], <jats:italic>p</jats:italic> &amp;lt; 0.001), ischemic stroke (β −0.066 [SE 0.025], <jats:italic>p</jats:italic> = 0.010), and National Institutes of Health Stroke Scale (NIHSS) at admission&amp;gt;5 (<jats:italic>β</jats:italic> −0.015 [SE 0.002], <jats:italic>p</jats:italic> &amp;lt; 0.001) as significant predictors of worse UW-mRS scores (R<jats:sup>2</jats:sup> = 70%) in the overall group. Sex-disaggregated analysis showed that age &amp;gt; 70 years was a significant predictor in males (β −0.069 [SE 0.024], <jats:italic>p</jats:italic> = 0.006), while presenting an AIS had a greater impact on female’s worse UW-mRS score (β −0.087 [SE 0.033], <jats:italic>p</jats:italic> = 0.010).</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>These results present UW-mRS values derived from a population-based stroke study. Key determinants of health-related quality of life in post-stroke patients included age, prior disability, and stroke severity. Sex-disaggregated analysis revealed age being significant for males and AIS for females. Incorporating PCO as UW-mRS in stroke research can provide a more nuanced understanding of the impact of stroke on survivors, offering valuable insights for clinical decision-making and rehabilitation strategies across diverse healthcare contexts.<
    Scopus© Citations 1  6
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      2Scopus© Citations 15
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    Clinical and Radiological Differences between Patients Diagnosed with Acute Ischemic Stroke and Chameleons at the Emergency Room: Insights from a Single-Center Observational Study
    (S. Karger AG, 2024-07-18)
    BRUNSER RABOVICH, ALEJANDRO MICHEL  
    ;
    LAVADOS GERMAIN, PABLO MANUEL  
    ;
    MUÑOZ VENTURELLI, PAULA ANDREA  
    ;
    OLAVARRIA IANISZEWSKY, VERONICA VIVIANA  
    ;
    Gabriel Cavada
    <jats:p>&lt;b&gt;&lt;i&gt;Introduction:&lt;/i&gt;&lt;/b&gt; Scarce data exist about clinical/radiological differences between acute ischemic strokes diagnosed in the emergency room (AISER) and stroke chameleons (SCs). We aimed at describing the differences observed in a comprehensive stroke center in Chile. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; Prospective observational study of patients with ischemic stroke syndromes admitted to the emergency room (ER) of Clínica Alemana between December 2014 and October 2023. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; 1,197 patients were included; of these 63 (5.2%, 95% CI: 4.1–6.6) were SC; these were younger (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001), less frequently hypertensive (&lt;i&gt;p&lt;/i&gt; = 0.03), and they also had lower systolic (SBP) (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001), diastolic blood pressures (DBP) (&lt;i&gt;p&lt;/i&gt; = 0.011), and NIHSS (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001). Clinically, they presented less frequently gaze (&lt;i&gt;p&lt;/i&gt; = 0.008) and campimetry alterations (&lt;i&gt;p&lt;/i&gt; = 0.03), facial (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001) and limb weakness (left arm [&lt;i&gt;p&lt;/i&gt; = 0.004], right arm (&lt;i&gt;p&lt;/i&gt; = 0.041), left leg (&lt;i&gt;p&lt;/i&gt; = 0.001), right leg &lt;i&gt;p&lt;/i&gt; = 0.0029), sensory abnormalities (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001), and dysarthria (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001). Neuroradiological evaluations included less frequently large vessel occlusions (&lt;i&gt;p&lt;/i&gt; = 0.01) and other stroke locations (&lt;i&gt;p&lt;/i&gt; = 0.005); they also differed in their etiologies (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001). Brainstem strokes (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001) and extinction/inattention symptoms (&lt;i&gt;p&lt;/i&gt; &amp;lt; 0.001) were only seen in AISER. In multivariate analysis, younger age (OR: 0.945; 95% CI: 0.93–0.96), DBP (OR: 0.97; 95% CI, 0.95–0.99), facial weakness (OR: 0.39; 95% CI: 0.19–0.78), sensory abnormities (OR: 0.16.18; 95% CI, 0.05–0.4), infratentorial location (OR: 0.36; 95% CI, 0.15–0.78), posterior circulation involvement (OR: 3.02; 95% CI, 1.45–6.3), cardioembolic (OR: 3.5; 95% CI, 1.56–7.99), and undetermined (OR: 2.42; 95% CI, 1.22–4.7; 95%) etiologies, remained statistically significant. A stepwise analysis including only clinical elements present on the patient’s arrival to the ER, demonstrates that age (OR: 0.95; 95% CI: 0.94–0.97), DBP (OR: 0.97; 95% CI, 0.95–0.99), the presence of atrial fibrillation (OR: 2.22; 95% CI, 1.04–4.75, NIHSS (OR: 0.88; 95% CI, 0.71–0.89) and the presence in NIHSS of 1a level of consciousness (OR: 5.66; CI: 95% 1.8–16.9), 1b level of consciousness questions (OR: 3.023; 95% CI, 1.35–6.8), facial weakness (OR: 0.3; CI: 95% 0.17–0.8), and sensory abnormalities (OR: 0.27; 95% CI, 0.1–0.72) remained statistically significant. &lt;b&gt;&lt;i&gt;Conclusion:&lt;/i&gt;&lt;/b&gt; SC had clinical and radiological differences compared to AISER. An additional relevant finding is that neurological symptoms in a patient with atrial fibrillation, even with a negative diffusion-weighted imaging, should be carefully evaluated as a potential stroke until other causes are satisfactorily ruled out. </jats:p>
    Scopus© Citations 1  6
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    Influence of renal function on blood pressure control and outcome in thrombolyzed patients after acute ischemic stroke: post-hoc analysis of the ENCHANTED trial
    (Frontiers Media SA, 2024-12-09)
    Xinwen Ren
    ;
    Chen Chen
    ;
    Xia Wang
    ;
    Qiang Li
    ;
    Yang Zhao
    <jats:sec><jats:title>Background</jats:title><jats:p>The effect of renal impairment in patients who receive intravenous thrombolysis for acute ischemic stroke (AIS) is unclear. We aimed to determine the associations of renal impairment and clinical outcomes and any modification of the effect of intensive versus guideline-recommended blood pressure (BP) control in the BP arm of the International Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We conducted a <jats:italic>post-hoc</jats:italic> analysis of the ENCHANTED BP arm, which involved 2,196 thrombolyzed AIS patients. Logistic regression models were used to define the association between eGFR and clinical outcomes of death, death or major disability [modified Rankin scale (mRS) scores 3–6], and major disability (mRS 3–5) at 90 days.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Of the 2,151 patients with available baseline renal function data (mean age 66.9 years; 38% women), 993 (46.2%), 822 (38.2%), and 336 (15.6%) had normal (eGFR ≥ 90 mL/min/1.73 m<jats:sup>2</jats:sup>), mildly (60–89), and moderate-to-severely impaired (&amp;lt;60) renal function, respectively. Compared with patients with normal eGFR, mortality was higher in those with moderate-to-severe renal impairment (adjusted odds ratio 1.77, 95% confidence interval 1.05–2.99; <jats:italic>p</jats:italic> = 0.031 for trend). However, the difference in death or major disability (mRS 3–6) was not significant between groups. There was no heterogeneity in the effect of intensive versus guideline-recommended BP-lowering treatment on death by grades of renal function (<jats:italic>p</jats:italic> for interaction = 0.545).</jats:p></jats:sec><jats:sec><jats:title>Discussion</jats:title><jats:p>The presence of moderate-to-severe renal impairment is associated with increased mortality in thrombolyzed patients with AIS. Renal function does not modify the effect of early intensive BP-lowering treatment on death in this patient group.</jats:p></jats:sec>
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    Intensive Blood Pressure Lowering and Renal Function in Ischemic Stroke Patients: Secondary Analysis of the ENCHANTED Trial
    (2024)
    Chen Chen
    ;
    Xinwen Ren
    ;
    Yang Zhao
    ;
    Menglu Ouyang
    ;
    Qiang Li Mbiostat
    <jats:p>&lt;b&gt;&lt;i&gt;Introduction:&lt;/i&gt;&lt;/b&gt; Renal failure is a major safety concern of intensive systolic blood pressure (SBP) lowering. We aimed to determine the effect of this treatment on early change in renal function in participants of the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; Post hoc analysis of the ENCHANTED BP-arm in which thrombolyzed patients with acute ischemic stroke (AIS) were randomized to intensive (target 130–140 mm Hg within 1 h) or guideline-recommended (target &amp;lt;180 mm Hg) management within 6 h of symptom onset. Primary outcome is the early change in renal function, defined by a difference in estimated glomerular filtration rate (&lt;b&gt;∆&lt;/b&gt;eGFR = 24 h – baseline eGFR), analyzed using linear regression with adjustment for clinical variables. Key SBP parameters were attained (mean), variability (standard deviation), and magnitude of reduction within 24 h. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; Of 2,151 participants (mean age 66.9 years; 38% female) included with the available baseline eGFR, there were significant differences in attained 144.3 ± 10.2 versus 149.8 ± 12.0 [Δ5.5 mm Hg]; &lt;i&gt;p&lt;/i&gt; &amp;lt; 0.0001), variation (15.1 ± 5.4 vs. 14.0 ± 5.6 mm Hg; &lt;i&gt;p&lt;/i&gt; &amp;lt; 0.0001), and magnitude of reduction (44.6 ± 16.2 vs. 38.7 ± 17.6 mm Hg; &lt;i&gt;p&lt;/i&gt; &amp;lt; 0.0001) in SBP within 24 h. 1,718 (79.9%) participants with complete follow-up eGFR were included in the primary analysis, and there was no significant difference in &lt;b&gt;∆&lt;/b&gt;eGFR (adjusted mean difference −1.10, 95% confidence interval [CI] −3.14 to −0.94; &lt;i&gt;p&lt;/i&gt; = 0.29) between the intensive and guideline groups, respectively. The neutral effect on &lt;b&gt;∆&lt;/b&gt;eGFR was consistent in patients with different baseline eGFR stages and in sensitivity analysis after multiple imputations for missing follow-up eGFR. SBP variability was significantly associated with decreasing &lt;b&gt;∆&lt;/b&gt;eGFR (per 5 mm Hg increase by category: adjusted mean difference −1.35, 95% CI: −2.43 to −0.28; &lt;i&gt;p&lt;/i&gt; for trend = 0.01). &lt;b&gt;&lt;i&gt;Conclusion:&lt;/i&gt;&lt;/b&gt; Intensive SBP lowering with a target of 130–140 mm Hg had no impact on early renal function in thrombolyzed AIS patients. Wide SBP variability was associated with a larger decline in eGFR. </jats:p>
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      3Scopus© Citations 25
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      3Scopus© Citations 8
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    Scopus© Citations 5  5
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    Global impact of COVID-19 on stroke care
    (2021)
    Raul G. Nogueira
    ;
    Mohamad Abdalkader
    ;
    Muhammed M. Qureshi
    ;
    Michael R. Frankel
    ;
    Ossama Yassin Mansour
    <jats:sec><jats:title>Background</jats:title><jats:p> The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide. </jats:p></jats:sec><jats:sec><jats:title>Aims</jats:title><jats:p> We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March–31 May 2020) compared with two control three-month periods (immediately preceding and one year prior). </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, −19.7 to −18.7), 11.5% (95%CI, −12.6 to −10.6), and 12.7% (95%CI, −13.6 to −11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (−20.5%) had greater declines in mechanical thrombectomy volumes than mid- (−10.1%) and low-volume (−8.7%) centers (p &lt; 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions. </jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p> The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes. </jats:p></jats:sec>
    Scopus© Citations 112  1