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Acute massive pulmonary thromboembolism (PTE) is a potentially life-threatening condition requiring urgent management to decrease mortality. However, in the peripheral setting, managing the emergency can be challenging. We report a case of massive PTE presenting with cardiopulmonary arrest, successfully managed with advanced cardiac life support, early initiation of anticoagulants (heparin), and thrombolytics. This case report explores the successful management of a critically ill patient presenting with massive pulmonary embolism in a peripheral healthcare facility, emphasizing the importance of a well-coordinated approach in such challenging environments. The approach in the case included recognizing the challenge with timely provisional diagnosis, initial stabilization, hemodynamic support, early consideration for anticoagulants, and thrombolysis after supporting provisional diagnosis with point-of-care ultrasonography (POCUS), team effort, and administrative support in Cas Evac to the tertiary care center. Timely administration of heparin and thrombolytics may serve as potential life-saving measures in peripheral settings, along with the availability of an ultrasound machine. Managing acute life-threatening massive PTE in peripheral settings requires a strategic and resourceful approach. Timely administration of heparin and thrombolytics may serve as potential life-saving measures. However, the administration of thrombolytics in PTE needs the support of POCUS to make quick decisions in peripheral settings. Collaboration between peripheral and advanced tertiary care healthcare facilities is crucial to ensure optimal outcomes for patients experiencing this critical condition. [ABSTRACT FROM AUTHOR]

This article details the experience at a single center with the evolving trends in management of pulmonary embolism (PE). Treatment is guided by proper identification and risk stratification. Direct oral anticoagulants are now the preferred method for outpatient management of PE, especially in low-risk populations, in which they were used for 56% of discharge medications. PE response teams have grown in popularity and are activated for intermediate and high-risk PE to determine whether advanced therapies are warranted. Intermediate-risk patients were mostly treated with anticoagulation, but approximately 22% received ultrasound-assisted thrombolysis with EKOS. High-risk PE is the most fatal and required advanced therapies in more than 70% of the patients, and 51% received some form of thrombolytic therapy. Objective: Pulmonary embolism (PE) is the third leading cause of cardiovascular death. The objective of this study was to examine the current management of pulmonary embolism at a single academic institution. Methods: With institutional review board approval, we conducted a retrospective chart review of 805 encounters among 775 patients presenting with acute PE from January 1, 2016 to June 30, 2019. We used American Heart Association guidelines for PE risk stratification. Results: In total, 409 patients were given the low-risk designation, 377 of these patients (92%) were anticoagulated with heparin or enoxaparin, and 32 patients (8%) were given a direct oral anticoagulant alone. There were two in-hospital mortalities (0.5%) in the low-risk group; 322 patients were in the true intermediate-risk category (ie, did not progress to high risk), and 320 patients received anticoagulation with heparin or enoxaparin (99.4%). Seventy-three patients (22%) received catheter-directed thrombolysis. There were eight in-hospital mortalities (2.5%) among the intermediate-risk group; eight intermediate-risk patients progressed to high-risk during their hospital stay, resulting in 6 in-hospital mortalities (75%) in this group. There were 66 patients designated as high-risk upon presentation. Sixty patients (91%) received heparin for anticoagulation and 47 patients (71%) required advanced therapies. Fourteen high-risk patients (21%) had bleeding complications, and there were 26 (39%) in-hospital mortalities. Conclusions: The management of PE has evolved, and proper risk stratification is key. Largely speaking, low- and intermediate-risk patients can be treated with anticoagulation, whereas patients with severe right ventricular strain and hemodynamic instability may require more advanced therapies. [ABSTRACT FROM AUTHOR]

Hemodynamic management, specifically blood pressure, is essential to reduce mortality and preserve functional capacity. However, the literature is uncertain about the best blood pressure target to be adopted after performing mechanical thrombectomy in patients with acute ischemic stroke. Randomized clinical trials that compared blood pressure goals after mechanical thrombectomy were searched in the following databases: MEDLINE/PubMed, Embase, Scopus, Biomedcentral, and Cochrane Library. The last search was on September 19, 2023. The results obtained were used to construct network meta-analyses. A total of 1556 participants were enrolled from 4 randomized controlled trials (OPTIMAL-BP, ENCHANTED2/MT, BP-TARGET, BEST-II). The last article was not included in the network meta-analysis because it did not have common blood pressure targets. The outcomes compared were: mRS (modified Rankin scale), eTICI/mTICI scale scores, symptomatic and any intracerebral hemorrhage, post-intervention NIHSS, and post-intervention infarct volume. The outcomes using the mRS scale showed that better outcomes were reached with less intensive blood pressure targets when comparing < 120 mmHg vs. ≤ 180 mmHg, OR: 0.71 (95% CI 0.54 – 0.94), in the outcome of mRS 0–1. And for the mRS 0–2 outcome with comparisons < 120 mmHg vs. ≤ 180 mmHg, with OR: 0.59 (95% CI 0.44 – 0.77) and < 140 mmHg vs. ≤ 180 mmHg, with OR: 0.61 (95% CI 0.41 – 0.89). In patients with large vessel occlusion treated with mechanical thrombectomy and who achieved good reperfusion, intensive blood pressure lowering is not effective and might be harmful respect to non intensive blood pressure control in recanalized patients. [ABSTRACT FROM AUTHOR]

Background: Early ischemic changes on baseline imaging are commonly evaluated for acute stroke decision-making and prognostication. Aims: We assess the association of early ischemic changes on clinical outcomes and whether it differs between intravenous tenecteplase and Alteplase. Methods: Data are from the phase 3, Alteplase compared to Tenecteplase (AcT) trial. Subjects with anterior circulation stroke were included. Early ischemic changes were assessed using the Alberta Stroke Program Early CT score (ASPECTS). Efficacy outcomes included modified Rankin scale (mRS) 0–1, mRS 0–2, and ordinal mRS at 90 days. Safety outcomes included 24-h symptomatic intracerebral hemorrhage (sICH), any hemorrhage on follow-up scan, and 90-day mortality rate. Mixed-effects logistic regression was used to assess the association of ASPECTS (continuous and categorical (0–4 vs 5–7 vs 8–10)) with outcomes and if these associations were modified by thrombolytic type after adjusting for age, sex, and baseline stroke severity. Results: Of the 1577 patients in the trial, 901 patients (56.3%; median age 75 years (IQR 65–84), 50.8% females, median National Institute of Health Stroke Scale (NIHSS) 14 (IQR 17–19)) with anterior circulation stroke were included. mRS 0–1 at 90 days was achieved in 1/14 (0.3%), 43/160 (14.7%), and 252/726 (85.1%) in the ASPECTS 0–4, 5–7, and 8–10 groups respectively. Every one-point decrease in ASPECTS was associated with 2.7% and 1.9% decrease in chances of mRS 0–1 and mRS 0–2 at 90 days, respectively, and 1.9% chances of increase in mortality at 90 days. Subgroup analysis in endovascular thrombectomy (EVT)-treated population showed similar results. Thrombolytic type did not modify this association between ASPECTS and 90-day mRS 0–1 (P-interaction 0.75). There was no significant interaction by thrombolytic type with any other outcomes. Conclusion: Similar to prior studies, we found that every one-point decrease in ASPECTS was associated with poorer clinical and safety outcomes. This effect did not differ between alteplase and tenecteplase. Data access statement: Data shall made available on reasonable request from the PI (BMM). [ABSTRACT FROM AUTHOR]

Acute myocardial infarction is a critical medical condition that poses a significant risk to life. It is distinguished by the abrupt cessation of blood flow to a specific segment of the cardiac muscle. Acute myocardial infarction accounts for more than 15 % of global mortality annually. A total of 433 young patients admitted with acute coronary syndrome – myocardial infarction underwent thrombolysis with fibrin specific agents followed by underwent diagnostic coronary angiogram between 01.09.2021 and 31.10.2022. The odds ratio showed a value of 1.973, which is much higher than the individuals with diabetes (0.306). Young individuals (25.9 %) with hypertension have a greater chance of recovery by thrombolysis. The factors that contribute for the myocardial infarction should be recognized and addressed. Recognizing and addressing these risk factors through education, lifestyle modifications, and early intervention are crucial for preventing myocardial infarction and promoting good health. [ABSTRACT FROM AUTHOR]

Objectives: Delirium is a common and serious post-stroke complication. Early reperfusion by ameliorating brain damage could potentially prevent delirium after ischemic stroke, but the impact of this therapy on delirium remains unclear. We aimed to explore the association between reperfusion therapy (RT) and post-stroke delirium. Methods: We retrospectively analyzed data from the PRospective Observational POLIsh Study on post-stroke delirium. Symptoms of delirium were examined during the first 7 days after admission and a diagnosis of delirium was made using Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. We used logistic regression to examine the association between RT and delirium. Results: We included 301 acute stroke patients (median age: 77; median NIHSS: 14; 55.1% female). In the whole group of patients, RT was associated with a lower odds of delirium (34.2% vs 44.8%; adjusted OR: 0.56, 95% CI: 0.32–0.96, p = 0.035). There was a significant interaction between RT and pre-stroke cognitive status. As a result, RT was associated with a lower odds of delirium in patients without premorbid cognitive decline (28.8% vs 48.2%; adjusted OR: 0.34, 95% CI: 0.17–0.66, p = 0.002) and a higher odds of delirium in patients with pre-stroke cognitive decline (72.7% vs 41.0%; adjusted OR: 3.55, 95% CI: 1.03–12.20, p = 0.040). Discussion: The association between RT and delirium is modified by pre-stroke cognitive status. In patients without cognitive decline, RT is associated with a lower likelihood of delirium. Delirium should be considered as a relevant outcome in future controlled trials. [ABSTRACT FROM AUTHOR]

Purpose of Review: This paper summarizes recent literature on the pandemic's effects on IS treatment. The literature is searched in popular databases, including PubMed, ScienceDirect, Springer, Wiley Online, and Google Scholar. Cerebral infarction (CI) or ischemic stroke (IS) refer to a stroke caused by the blockage of blood in the brain. Ischemic stroke is a common disorder among all types of strokes. We discuss the challenges and opportunities about the coronavirus (COVID-19) pandemic and its impacts on the IS treatment in different settings. Recent Findings: The search strategy resulted in 107 research articles following the studies’ exclusion\inclusion criteria. This paper identifies several challenges and opportunities arising from COVID-19 pandemic for IS patients tested positive for COVID-19 infection. One potential solution to prevent IS in COVID-positive patients is the use of statins to counteract the scenarios. It is concluded that septic and post-procedural complications are among the more common complications found in infected patients. Summary: Access to medical services for stroke patients during COVID-19 pandemic is very crucial across the globe. A healthcare system with the established emergency plan could reduce the mortality rate among IS patients during pandemic times. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome (ACS), including acute myocardial infarction (MI) and unstable angina, is characterized by ischemia due to plaque instability, thrombosis, and vasospasm. Right ventricular (RV) infarction, commonly seen in inferior wall MI (IWMI), worsens prognosis with increased risk of complications. While proximal right coronary artery (RCA) occlusion is the primary cause of RV infarction, some distal occlusions also result in RV dysfunction. This study evaluates if echocardiographic RV function parameters can predict proximal RCA stenosis in IWMI patients. In this prospective study, 60 IWMI patients were divided into two groups based on coronary angiography: Group A (35 with proximal RCA stenosis) and Group B (25 with distal RCA stenosis). Echocardiographic parameters, including TAPSE, RVFAC, MPI, and Sm, were measured within 24 hours of symptom onset. Results showed significantly lower RVFAC and TAPSE, and higher MPI, in the proximal RCA stenosis group. Echocardiography effectively identified proximal RCA stenosis, offering valuable insights for improved patient management and outcomes. [ABSTRACT FROM AUTHOR]

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Background: 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). Methods: We conducted a post-hoc 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. Results: 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 m2), mildly (60–89), and moderate-to-severely impaired (<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; p = 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 (p for interaction = 0.545). Discussion: 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. [ABSTRACT FROM AUTHOR]

Context: This study will emphasise the importance of Tenecteplase being ideally suited as a first-choice drug for thrombolysis in AIS in developing countries, considering the numerous challenges which are faced in these parts of the world. Aim: To observe the effectiveness of Tenecteplase as a thrombolytic agent in AIS and also estimate the pre-hospital and in-hospital time delays in the treatment of such patients. Material and methods: Eighteen patients with non-haemorrhagic strokes who presented within the window period were included. Eight patients were thrombolysed with Tenecteplase after due consent and ruling out contraindications. Reasons for the time delay, Ictus to Needle time and NIHSS scores were noted in each case. Results: The mean time from onset of symptoms to arrival at the hospital was 2.06 (± 1.08) h while the mean ictus to needle time was 4.29 (± 0.20) h The delay in carrying out a CT scan in these patients was 47.5 (± 16.69) min and mean time taken in procuring Tenecteplase was 27.5 (± 18.51) min. All patients were thrombolysed within 4.5 h of the onset of stroke and seven patients had statistically significant improved NIHSS scores in the post-thrombolysis period. Conclusions: This paper highlights the constraints in the management of AIS in a developing country, where late presentation is the norm. In-hospital delays lead to diminishing window period available for thrombolysis. This paper highlights the successful use of Tenecteplase even in the late window period and emphasises Tenecteplase as a highly effective thrombolytic agent of choice in our setting. Further studies are likely to confirm these observations in the future. [ABSTRACT FROM AUTHOR]

Acute pulmonary embolism (APE) is a life-threatening complication that is primarily caused by the migration of deep vein thrombosis to the lungs. However, current drug treatments have limited efficacy and can lead to lung ischemia–reperfusion injury (LIRI) after thrombolysis. Inhaled nitric oxide has shown potential for APE therapy, but its clinical feasibility is still uncertain. In this study, nitric oxide (NO) was directly encapsulated by nanobubbles to form NO-loaded nanobubbles (NanoNO) as a potential treatment for APE and subsequent LIRI. NanoNO, with a size of 219.27 ± 2.42 nm and a polydispersity index of 0.17, could encapsulate up to 1.1 mM NO. In the LIRI cell model, NanoNO increased NO concentration and superoxide dismutase (SOD) enzyme activities while reducing reactive oxygen species (ROS) and malondialdehyde (MDA) levels (2.80-fold), leading to decreased cell apoptosis. In a rabbit model of APE, NanoNO was compared to sodium nitroprusside (SNP, a positive control) for thrombolysis efficacy by using blood gas analysis, pulmonary angiography, echocardiography, and hematoxylin–eosin staining. The results demonstrated that NanoNO was more effective than SNP in thrombolysis, as evidenced by its better ability to remove blood clots, normalize pulmonary arteries, and relieve right ventricular (RV) dilatation. In the LIRI rabbit model, NanoNO decreased serum MDA, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) while increasing serum SOD. Collectively, these findings highlight the potential of NanoNO as a promising therapeutic approach for the treatment of APE and the mitigation of LIRI. [ABSTRACT FROM AUTHOR]

Background/Objectives: Acute ischemic stroke is an uncommon but potentially devastating complication of Transcatheter Aortic Valve Implantation (TAVI). Despite improvements in device technology and procedural techniques, stroke rates have remained stable, with cerebral embolic protection devices demonstrating only limited efficacy to date. Therefore, the management of acute ischemic stroke complicating TAVI (AISCT) remains a key priority. We conducted a systematic review of the management of AISCT and provided multidisciplinary consensus recommendations for optimal management. Methods: PubMed, Google Scholar, and Cochrane databases were searched from inception to October 2023. All the original studies focusing on the treatment of AISCT were included. Non-English language studies, review articles, and studies in pediatric populations were excluded. Consensus recommendations were made by a working group comprising experts in stroke medicine and structural interventional cardiology. Results: A total of 18 studies met the inclusion criteria, including 14 case reports/series and 4 observational studies. No clinical trials were identified. The included case reports and series suggest that tissue-type plasminogen activator (tPA) and mechanical thrombectomy (MT) might be effective strategies for managing AISCT. However, significant bleeding complications were reported in two out of the four patients receiving tPA. Four observational studies also suggest an association between tPA and/or MT and improved functional outcomes and survival compared to conservative management. Higher bleeding rates were reported following tPA. Observational data suggest that there is currently little real-world utilization of either reperfusion strategy. Conclusions: There is an absence of high-quality randomized data to guide clinical decision making in this important area. Observational data suggest reperfusion strategies are associated with improved clinical outcomes once important confounders such as stroke severity have been accounted for. While MT can be recommended as the standard of care in appropriately selected patients, significantly increased rates of bleeding with tPA following large-bore arterial access raise important safety concerns. We present simple clinical guidance for AISCT based on the limited available data. Close multidisciplinary work and patient-specific consideration of ischemic and bleeding risk is essential. [ABSTRACT FROM AUTHOR]

Pulmonary embolism is the third most common cardiovascular reason for death after myocardial infarction and stroke. The principles of thromboembolic disease prophylaxis are an integral part of care in both surgical and internal medicine. The severity of pulmonary embolism ranges across the spectrum, from completely asymptomatic forms to obstructive shock, where the first and only symptom is sudden death. The mainstay of treatment for low- and intermediate-risk patients is anticoagulation therapy. For high-risk patients, effective thrombolytic therapy is available, but it has a number of contraindications and, even if these are respected, carries a risk of bleeding, including fatal. Until recently, the only alternative, cardiosurgical embolectomy, is now being replaced by widening spectrum of cathetrization techniques. [ABSTRACT FROM AUTHOR]

Objective To investigate the predictive effects of systemic immune-inflammation index (SII) and CRP/albumin (ALB) on short-term prognosis of acute ischemic stroke (AIS) patients receiving thrombolytic therapy with rt-PA. Methods The clinical data of AIS patients who received rt-PA thrombolytic therapy in The People’s Hospital of Pengzhou from January to December 2022 were retrospectively analyzed. The mRS was used to evaluate the prognosis of patients 30 days after the onset of the disease. The mRS score of≤2 points was considered a good prognosis, while mRS score>3 points was considered a poor prognosis. SII and CRP/ALB were calculated from peripheral blood test results at admission. The factors influencing prognosis of AIS patients were analyzed by univariate and logistic multivariate analysis. The predictive effects of SII and CRP/ALB on the prognosis of AIS patients were analyzed using the ROC curve. Results A total of 134 AIS patients were included in this study, of which 29 patients (21.64%) had poor prognosis. Univariate analysis showed that NIHSS score, platelet count, D-dimer, prothrombin time, TC, CRP, SII, and CRP/ALB in patients with poor prognosis were higher than those with good prognosis, and the differences were statistically significant (P<0.05). The lymphocyte count and ALB in patients with poor prognosis were lower than those with good prognosis, and the differences were statistically significant (P<0.05). Logistic multivariate analysis showed that NIHSS score (OR 19.028, 95%CI 2.785-27.348, P<0.001), TC (OR 6.979, 95%CI 1.851-12.191, P=0.009), CRP (OR 7.830, 95%CI 2.559-14.252, P=0.002), ALB (OR 0.192, 95%CI 0.101-0.662, P＜0.001), SII (OR 9.244, 95%CI 2.571-19.379, P<0.001), and CRP/ALB (OR 11.100, 95%CI 3.570-22.451, P<0.001) were independent influencing factors of poor prognosis. ROC curve analysis showed that SII and CRP/ALB had predictive value for poor prognosis, with AUC of 0.648 (95%CI 0.529-0.767, P=0.015) and 0.749 (95%CI 0.664-0.883, P<0.001), sensitivity of 0.448 and 0.931, and specificity of 0.876 and 0.562, respectively. Conclusions SII and CRP/ALB are independent influencing factors for poor prognosis of patients, and combined assessment of SII and CRP/ALB is helpful for early identification of high-risk AIS patients. [ABSTRACT FROM AUTHOR]

Serum sickness is rare; however, there is a significant hypersensitivity reaction to streptokinase used in different cardiac problems. Treatment often involves discontinuing the offending agent and administering corticosteroids. This case underscores the complexities of managing prosthetic valve thrombosis and highlights the importance of monitoring and addressing complications of thrombolytic therapy. [ABSTRACT FROM AUTHOR]

To compare the effects of ticagrelor combined with prourokinase and reteplase thrombolysis on cardiac function and blood-related indexes in patients with ST-segment elevation myocardial infarction (STEMI), 280 patients hospitalized between January 2017 and December 2021 were randomly assigned into two groups: the experimental group and the control group, each comprising 140 cases. The control group received ticagrelor combined with prourokinase thrombolysis, while the experimental group received ticagrelor combined with reteplase thrombolysis. The impact of these treatments on cardiac function and blood-related indexes in STEMI patients was assessed. Results revealed that CK-MB, AST, and LDH levels significantly decreased after 7 d of treatment compared to pre-treatment levels, with the experimental group exhibiting lower levels compared to the control group. Additionally, NT-proBNP levels decreased in both groups after 24 h of treatment, with the experimental group showing a greater reduction compared to the control group. Furthermore, LVEF and E/A values significantly increased after 7 d of treatment in both groups, while LVEDd and LVESd values notably decreased, indicating improved cardiac function in the experimental group compared to the control group. Following treatment, levels of PT, TT, and APTT increased in both groups, while FIB levels decreased significantly, with noticeable differences between the two groups. The incidence of major adverse cardiovascular events (MACE) in the experimental group was significantly lower compared to the control group, although the rate of mild bleeding did not significantly differ. In conclusion, the combination of ticagrelor and reteplase demonstrated superior efficacy in reducing myocardial enzyme and NT-proBNP levels, improving cardiac function, and enhancing safety compared to ticagrelor and prourokinase. These findings suggested that ticagrelor combined with reteplase thrombolysis held promise for clinical application. [ABSTRACT FROM AUTHOR]

Background: Intravenous thrombolysis (IVT) is an approved treatment for patients with acute ischemic stroke irrespective of sex. However, the current literature on sex differences in functional outcomes following IVT is inconsistent. So far, a number of studies—including a previous analysis based on data from the Austrian Stroke Unit Registry (ASUR)—detected significant sex-related differences in functional outcome, while others did not report any differences between women and men. In addition, currently there is a lack of data on how sex-related differences evolve over time. Aims: To assess time trends of sex-related differences in functional outcome of ischemic stroke in a large nationwide cohort and to investigate associations of patient characteristics with functional outcome post thrombolysis in women and men. These data will offer crucial insights into whether sex differences in functional outcome persist despite the large advances in acute stroke treatment. Methods: We analyzed retrospective data of consecutive patients with acute ischemic stroke treated with IVT in 39 stroke centers contributing to the ASUR between 2006 and 2021. We included patients over 18 years of age diagnosed with an acute ischemic stroke who received IVT and with available data on functional outcome at 3 months after treatment. The primary outcome parameter was favorable functional outcome (modified Rankin Scale (mRS) of 0–2) at 3 months. Multivariable logistic regression analysis was performed in the overall population and stratified by sex to assess associations of baseline characteristics with functional outcome. Results: Among 11,840 patients receiving IVT, 2489 of 5503 (45.4%) women achieved favorable functional outcome compared to 3787 of 6337 (59.8%) men. Overall, female sex was a statistically significant predictor of functional outcome after thrombolysis, but additional predictors of outcome differed between women and men. Female sex was independently associated with decreased chances of achieving functional independency (adjusted odds ratio (adjOR) = 0.87, 95% confidence interval (CI) = 0.79–0.96, p = 0.005) and we detected a statistically significant improvement in functional outcome over time only in men (year of treatment, adjOR (per year) = 1.04, 95% CI = 1.02–1.06, p < 0.001) but not in women (adjOR (per year) = 1.01, 95% CI = 0.99–1.03, p = 0.280). Hypertension, smoking, and longer or unknown onset-to-door times were statistically significant predictors of outcome only in male patients, whereas atrial fibrillation, prior myocardial infarction, and longer door-to-needle times were significantly associated with outcome only in women. Conclusions: Sex differences in functional outcome after IVT for acute ischemic stroke are persisting over the past years. Results of our analysis can increase awareness and a resulting focus on sex differences in predictors of outcome could be helpful in mitigating these differences in the future by supporting a more individualized patient care in clinical routine. Follow-up analyses are needed to assess this potential impact and its effect in the future. Data access statement: Data from the Austrian Stroke Unit Registry can only be accessed by the employed statistician (D.M.), access inquiries have to be addressed to the registry's academic review board. [ABSTRACT FROM AUTHOR]

Introduction: Thrombolysis and endovascular thrombectomy (EVT) are standard treatments after stroke. We previously reported that these therapies benefit stroke patients over 80 years old. Now, we aimed to study reperfusion therapies specifically in nonagenarians, hypothesizing a poorer prognosis in this group. Methods: Nonagenarian stroke patients were identified from our prospective monocentric cohort, which included consecutive patients ≥80 years old treated with thrombolysis and/or EVT from 2015 to 2019. Baseline characteristics, treatments, and outcomes, as well as complications and mortality were analyzed. Results: Ninety-six nonagenarians were treated with thrombolysis (69.8%) and/or EVT (81.1%). A total of 51% had a pre-stroke modified Rankin score (mRS) ≤2. Cardioembolism was the most common etiology (67.7%). Age was associated with a higher mRS after stroke with a turning point at 90 years old: (90–99 years old: odds ratio [OR] = 0.33, 95% confidence interval [95% CI]: 0.13–0.83, p = 0.02) versus (85–89 years old: OR = 0.72, 95% CI: 0.34–1.50, p = 0.38), with 80- to 84-year-old patients as the reference. In nonagenarians, previous coronary artery disease (OR = 8.02, 95% CI: 1.66–38.68, p = 0.01), initial National Institute of Health Stroke Score (NIHSS) (OR = 1.11, 95% CI: 1.03–1.19, p = 0.01), pre stroke independence (OR = 0.25, 95% CI: 0.08–0.71, p = 0.01), and "drip-and-ship" status (OR = 3.35, 95% CI: 1.22–9.16, p = 0.02) were associated with 3-month mortality. Nonagenarians had more baseline comorbidities (p = 0.003) and lower levels of pre-stroke independence (p = 0.002) than octogenarians (n = 261). Despite no difference in the use of acute treatments, timelines, and rates of successful reperfusion, a good functional status at 3 months was less common in nonagenarians than octogenarians (14.3% vs. 34.0%, p < 0.001) with a higher mortality (60.2% vs. 16.4%, p < 0.001). A total of 9.5% of nonagenarians experienced a symptomatic intracranial hemorrhage. Conclusions: Age is a crucial factor affecting prognosis after stroke with a turning point at 90 years old. However, age alone should not be a limiting factor for treatment decision. Despite higher mortality and poorer functional prognosis overall, some nonagenarians may benefit from reperfusion therapies. [ABSTRACT FROM AUTHOR]

Background Frailty—the loss of physiological reserve to withstand a stressor event—is associated with poorer outcomes following acute stroke reperfusion therapies. However, the mechanisms underlying this relationship are poorly understood. This study investigated the association between frailty and penumbral volumes in hyperacute ischemic stroke. Methods Total ischemic lesion volumes (comprising infarct core and penumbral volumes) were measured using computed tomography (CT) perfusion imaging to give the penumbral fraction within the ischemic lesion. Pre-stroke frailty was measured using a validated frailty index. The relationship between frailty and penumbral fraction was adjusted for age, onset-to-CT interval, collateral scores, small vessel disease burden and vascular comorbidities. Stroke severity was measured using the National Institutes of Health Stroke Scale at baseline and after 24 h. Results In 55 individuals receiving thrombolysis for ischemic stroke, increasing frailty was associated with a reduction in penumbral fraction (rs  = −0.36, P  < 0.01). This remained significant after adjustment for age, onset-to-imaging time and collateral score (beta = −1.16, P  < 0.001). Correspondingly, frailty was independently negatively associated with proportional improvement in stroke severity following treatment (beta = −2.00, P  < 0.01). C-reactive protein (CRP) on presentation was associated with frailty index (rs  = 0.38, P  < 0.01) and penumbral fraction (rs  = −0.30, P  = 0.02). Discussion A reduction in salvageable penumbra in frailty may explain the treatment-attenuating effects of frailty on reperfusion therapies. The association with CRP motivates further research into a possible inflammatory component of this relationship. Conclusion Frailty is independently associated with reduced penumbra and poorer neurological recovery in acute stroke. These findings may explain the attenuated response to stroke reperfusion therapies seen in frailer individuals. [ABSTRACT FROM AUTHOR]

Background & Objective: There is insufficient research on the use of population data to construct a predictive model of blood pressure variability (BPV) after thrombolysis to estimate the subsequent development of acute ischemic stroke (AIS) patients. The aim of this study is to construct and validate a model that uses BPV 24 hours after thrombolytic therapy to predict outcome in patients with AIS. Methods: To construct and validate a model that uses BPV 24 hours after thrombolytic therapy to predict outcome in patients with AIS. Results: A total of 503 patients with acute ischemic stroke who received intravenous thrombolytic therapy were enrolled in the study. The multivariate analysis outcomes have delineated several pivotal factors that are significantly prognostic of adverse outcomes in AIS patients post-thrombolysis: The initial National Institutes of Health Stroke Scale score, a recorded history of hypertension, the variability in systolic and diastolic blood pressure as indicated by their standard deviation, and the blood pressure measurements recorded 24 hours subsequent to thrombolytic therapy. These determinants have emerged as substantial predictors, shedding light on the complex interplay of clinical parameters that influence patient prognosis following AIS treatment. Within the development and validation cohorts, the area under the curve for the nomogram, which estimates the probability of an unfavorable prognosis, was determined to be 0.876 (95%CI: 0.84-0.913) and 0.849 (95%CI: 0.784-0.913), respectively. The calibration curve revealed a striking congruence between the predicted probabilities by the nomogram and the actual outcomes observed in the validation set. Furthermore, the decision curve analysis underscored the significant clinical utility and robust applicability of the prognostic model, illustrating its potential to guide clinical decision-making effectively. Conclusion: Because of its superior predictive accuracy, discriminative power, and clinical utility, the nomogram is an important adjunct tool for the assessment of possible adverse outcomes in patients with AIS following thrombolytic therapy. [ABSTRACT FROM AUTHOR]

Background: Stroke is a major global health concern, ranking second in terms of fatality worldwide, following ischaemic heart disease. However, few stroke patients arrive at the hospital within the optimal time for thrombolysis, and even among those who do, not all receive this therapy. Therefore, the objective of the study was to examine the factors that influence the treatment of acute ischaemic stroke (AIS), particularly with intravenous thrombolysis and to evaluate the short-term outcomes. Methods: This prospective observational study was carried out between August 2019 and August 2021 in the emergency department of a tertiary care hospital. Patients with AIS who were eligible for intravenous thrombolysis within 4.5 hours of the beginning of symptoms were included in the study. Comprehensive assessments, including history, examinations and blood investigations, were conducted. Thrombolytic treatment was administered within the specified time frame, while antiplatelets were given in other cases. Follow-up evaluations were conducted at discharge and 90 days. Results: The age distribution, comorbidities and CT-MRI findings were similar between individuals who received thrombolysis and those who did not. Among the thrombolysis group, 84% had no complications, while 8% experienced intracerebral haemorrhage and 8% had an extension of the infarction. The overall mortality rate was 13.33% for non-thrombolysis patients and 12% for thrombolysis recipients, with no statistically significant difference between the two groups. Conclusion: The results highlight the need for careful consideration when deciding to use thrombolysis for AIS cases. Additionally, they emphasise the importance of actively monitoring and effectively managing any potential treatment complications. [ABSTRACT FROM AUTHOR]

Acute lower extremity deep vein thrombosis (DVT) is a common disorder with significant associated morbidity, including pain and swelling, as well as the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE) and chronic debilitating post-thrombotic syndrome (PTS). Anticoagulation is standard of care for DVT treatment. It assists in reducing thrombus progression and the occurrence of PE, but incomplete DVT resolution increases the risk of recurrent VTE, valvular insufficiency, and PTS. Endovascular DVT interventions, such as catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy offer an alternative therapeutic strategy for DVT management. This paper will discuss technical factors and current issues when performing lower extremity DVT interventions including patient selection, anticoagulation, choice of device for endovascular thrombus removal, adjunctive techniques, and venous stent management. Level of Evidence: No level of evidence for: review articles, basic science, laboratory investigations, and experimental study articles. [ABSTRACT FROM AUTHOR]

Imaging plays an important role in the identification and assessment of clinically suspected venous pathology. The purpose of this article is to review the spectrum of image-based diagnostic tools used in the investigation of suspected deep vein disease, both obstructive (deep vein thrombosis and post-thrombotic vein changes) as well as insufficiency (e.g., compression syndromes and pelvic venous insufficiency). Additionally, specific imaging modalities are used for the treatment and during clinical follow-up. The use of duplex ultrasound, magnetic resonance venography, computed tomography venography and intravascular ultrasound as well as conventional venography will be discussed in this pictorial review. [ABSTRACT FROM AUTHOR]

Acute lower extremity deep vein thrombosis (DVT), specifically proximal iliofemoral DVT, is a relatively common disorder that can result in a chronic debilitating post-thrombotic syndrome (PTS), with a significant effect on a patient's quality of life. Anticoagulation is first-line therapy; however, percutaneous interventions have emerged as treatment options for patients where there is concern that anticoagulation alone will not resolve the DVT as well as prevent PTS. This paper will discuss the existing data on these interventions and review current endovascular techniques, including catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy in the management of DVT. [ABSTRACT FROM AUTHOR]

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Abstract Introduction Stroke-associated pneumonia (SAP) is a major cause of mortality during the acute phase of stroke. The A2DS2 score is widely used to predict SAP risk but does not include 24-h non-contrast computed tomography-Alberta Stroke Program Early CT Score (NCCT-ASPECTS) or red cell distribution width (RDW). We aim to evaluate the added prognostic value of incorporating 24-h NCCT-ASPECTS and RDW into the A2DS2 score and to develop a novel prediction model for SAP following thrombolysis. Methods This retrospective cohort study included thrombolyzed AIS patients at Saraburi Hospital, Thailand. The combined A2DS2-MFP model incorporated 24-h NCCT-ASPECTS and RDW, along with non-linear continuous predictors, using multivariable fractional polynomial (MFP) regression. Predictive performance was evaluated using the area under the receiver operating characteristic curve (AuROC), calibration plots, and decision curve analysis (DCA), comparing it with the traditional A2DS2 model and a model with continuous predictors. The goodness of fit for logistic regression models in relation to the observed data was determined through the Hosmer–Lemeshow method, and the accuracy of the probability predictions was examined using a calibration curve. Internal validation was performed using a bootstrapping approach. The predicted probability equation obtained from the final model after optimism correction was developed into a web-based application for predicting the risk of SAP, using PHP and JavaScript. Results Of 345 AIS patients, 20.3% developed SAP. The combined A2DS2-MFP model demonstrated excellent discriminative performance (AuROC: 0.917) compared to the traditional A2DS2 model (AuROC: 0.868) and the model with continuous predictors (AuROC: 0.888). Both the calibration curve and the Hosmer–Lemeshow test indicated that the predicted probabilities and observed frequencies were in acceptable agreement. Incorporating 24-h NCCT-ASPECTS and RDW significantly improved risk prediction and clinical utility, as shown by improved reclassification indices and DCA. The model was internally validated with a C-statistic of 0.912, confirming its robustness. Conclusions The combined A2DS2-MFP calculation showed superior performance, enabling early SAP detection and improving survival outcomes. This novel model offers a practical tool for resource-limited settings, supporting better SAP risk stratification and clinical management.

Abstract Background Concurrent ST-elevation myocardial infarction (STEMI) and acute ischemic stroke (AIS) are extremely rare, and their management remains perplexing due to the absence of high-quality evidence and limited resources. For the first time, we report a rare, preventable, and suboptimally managed case of concurrent AIS and STEMI in a patient with non-Hodgkin lymphoma (NHL) who received cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy. Case presentation A 59-year-old postmenopausal woman of African origin with a background history of type 2 diabetes mellitus presented to the Jakaya Kikwete Cardiac Institute with sudden onset of left-sided weakness and typical ischemic chest pain for 3 days. The patient was recently diagnosed with NHL and started CHOP chemotherapy 3 weeks prior. Physical examination revealed left-sided hemiplegia. Emergency brain computed tomography and 12-lead echocardiography (ECG) revealed AIS and STEMI, respectively. A diagnosis of concurrent AIS and STEMI was reached, and the patient was loaded with dual antiplatelets and heparin and rushed for emergency coronary angiography (GAG) and percutaneous coronary intervention (PCI). CAG revealed massive thrombotic occlusion of the mid-segment of the left anterior descending coronary artery (mLAD) and proximal segment of the right coronary artery. Revascularization was achieved in both vessels with a resultant TIMI flow grade of 3. The post-PCI period was marked by significant improvement in chest pain and resolution of ST-elevation, as revealed by 12-lead ECG. However, the patient remained hemiplegic. Conclusion We have described a rare case of concurrent AIS and STEMI in a postmenopausal woman who had a significant risk of thromboembolism. The patient had uncontrolled type 2 diabetes and received CHOP chemotherapy for NHL, which was diagnosed 3 weeks prior. This case underscores the need for thromboembolic prophylaxis for selected cancer patients receiving chemotherapy. The need to individualize management is also emphasized, as both PCI and thrombolysis carry the risk of serious repercussions. In our patient, if thrombolysis was attempted it would have caused myocardial rupture and immediate death. The patient would have benefited from endovascular mechanical embolectomy for AIS; however, this practice is lacking at our institution. This calls for the establishment and strengthening of neurointerventional practices in our tertiary healthcare facilities.

BACKGROUND: The role of arterial collateral and venous outflow status on the response to intravenous tissue plasminogen activator (IV-tPA) has not been sufficiently clarified in acute major cerebral occlusions. PATIENTS AND METHODS: A total of 130 patients (mean age: 71 years; 73 females) with acute middle cerebral artery M1/M2 segment or terminal internal carotid artery occlusion treated solely with IV-tPA were analyzed. Regional leptomeningeal score (rLMC) was used for cerebral arterial collateral scoring, and the cortical vein opacification score (COVES) and modified Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) superficial and deep scores were used for venous outflow profile. Exploratory logistic models for response to IV-tPA [positive response: National Institutes of Health Stroke Scale (NIHSS) decrease 4 (or decrease to 0) at 24 h; dramatic response: NIHSS decrease ≥8 (or decrease to 0 or 1)], functional outcome (modified Rankin’s score 0–1 as “excellent” and 0–2 “good”) and tPA-associated hemorrhagic transformation were constructed. RESULTS: IV-tPA efficacy was positive in 47% and dramatic in 32%. Dramatic response was linked to better arterial collateral status (exp[B] =1.115 [95% confidence interval (CI), 1.016–1.223]). Excellent outcome was noted in 26% and good in 45%. One-point increase in rLMC score independently increased good prognosis (exp[B] =1.209 [1.034–1.412]). Patients with good prognosis had higher (by 0.5 points) modified PRECISE deep score (P = 0.047) and less frequent nonsufficient modified PRECISE deep score (0–2) (P = 0.017) in univariate analyses. However, these associations failed to survive in multiple regression. Any type tPA-associated cerebral hemorrhagic transformation was observed in 23% and parenchymal hemorrhage type 2 in 5.4%. While rLMC score showed a borderline strength correlation to hemorrhage (exp[B] =0.899 [95% CI, 0.808–1.001]), outflow scores not. CONCLUSION: While arterial collateral status modifies the effect of tPA in acute anterior circulation major artery occlusions, venous outflow capacity is not so critical.

Ischemic stroke caused by the obstruction of the artery of Percheron is a rare type of ischemic stroke, in which one arterial branch supplying blood to both thalamuses and the middle brain is occluded, which leads to the depression of consciousness, paresis of vertical vision, and cognitive impairment. Due to the atypical symptoms ("stroke-chameleon"), the diagnosis is often not verified in time, which deprives the patient of the most effective treatment – thrombolytic therapy. The review aims to increase clinicians' awareness of this subtype of stroke.

Left atrial appendage occlusion affects systemic coagulation parameters, leading to additional patient-related benefits. The aim of this study was to investigate the differences in coagulation factor changes 6 months after epicardial left atrial appendage occlusion in patients with different LAA morphometries. This is the first study to analyze these relationships in detail. A prospective study of 22 consecutive patients was performed. Plasminogen, fibrinogen, tPA concentration, PAI-1, TAFI and computed tomography angiograms were performed. Patients were divided into subgroups based on left atrial appendage body and orifice diameter enlargement. The results of blood tests at baseline and six-month follow-up were compared. In a population with normal LAA body size and normal orifice diameter size, a significant decrease in analyzed clotting factors was observed between baseline and follow-up for all parameters except plasminogen. A significant decrease between baseline and follow-up was observed with enlarged LAA body size in all parameters except TAFI, in which it was insignificant and plasminogen, in which a significant increase was observed. Occlusion of the left atrial appendage is beneficial for systemic coagulation. Patients with a small LAA may benefit more from LAA closure in terms of stabilizing their coagulation factors associated with potential thromboembolic events in the future.

Background: Thrombolysis is recommended in the setting of massive pulmonary embolism (PE) for reperfusion of vessels but carries a serious concern for increased bleed risk. In October 2022, our institution adopted tenecteplase as the formulary thrombolytic. Previous literature is unclear regarding the bleed risk of tenecteplase in massive PE, and no study has yet compared safety outcomes with the current standard of care, alteplase. Objective: The objective of this study was to compare the incidence of bleeding with tenecteplase versus alteplase in massive PE patients. Methods: This was a retrospective, observational cohort study that included adults who received tenecteplase or alteplase for massive PE. The primary outcome was major bleeding as defined by the International Society on Thrombosis and Hemostasis (ISTH). Secondary outcomes included incidence of symptomatic intracranial hemorrhage (ICH), in-hospital mortality, administration of reversal agents, and length of stay. Results: A total of 44 patients met inclusion criteria with 20 patients in the alteplase cohort and 24 in the tenecteplase cohort. Seventeen percent of tenecteplase patients compared with 5% of alteplase patients experienced bleeding. The mortality rate was 83% vs 75%, respectively. In addition, 1 patient in the tenecteplase cohort experienced a symptomatic ICH and 2 patients required initiation of massive transfusion protocol. Conclusion and Relevance: Although this study was limited in sample size, these results suggest that there may be reason for concern of higher bleeding rates in patients treated with tenecteplase in the setting of massive PE. [ABSTRACT FROM AUTHOR]

Chutithep Teekaput,1,2,&ast; Chayasak Wantaneeyawong,1,2,&ast; Chaiwet Jakrachai,3 Sarocha Nuttawut,3 Soraya Nuttawut,3 Saranya Bowornsomboonkun,3 Kanokkarn Teekaput,1 Kitti Thiankhaw1,2 1Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 2The Northern Neuroscience Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand&ast;These authors contributed equally to this workCorrespondence: Kitti Thiankhaw, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110, Inthawaroros Road, Sriphum, Chiang Mai, 50200, Thailand, Tel +66 (0) 5393 5899, Fax +66 (0) 5393 5481, Email kitti.th@cmu.ac.thPurpose: The association between the Alberta Stroke Programme Early CT Score (ASPECTS) and intracranial hemorrhage (ICH) in acute ischemic stroke (AIS) patients undergoing thrombolysis remains unclear. This study aimed to determine the relationship between ASPECTS and thrombolysis-associated outcomes, focusing on symptomatic (sICH) and asymptomatic (aICH) ICH.Patients and methods: AIS patients with middle cerebral artery (MCA) territory treated with thrombolysis were enrolled. Patients were categorized into favorable (8– 10) and unfavorable (7 or less) ASPECTS. The primary outcomes were sICH and aICH. Secondary outcomes included ICH management, modified Rankin Scale (mRS), and mortality. Multivariable logistic regression analysis evaluated the risk of unfavorable ASPECTS and its association with study outcomes.Results: We included 622 patients (mean age 66.1 ± 13.5 years; 50.5% male); 95 (15.3%) had unfavorable ASPECTS. Patients with unfavorable ASPECTS had higher sICH but not aICH (21.1% vs 4.9%, P < 0.001 and 16.9% vs 17.3%, P = 1.00). Unfavorable ASPECTS was associated with sICH (adjusted odds ratio 5.1; 95% confidence interval 2.7– 9.7, P < 0.001). Factors associated with lower ASPECTS included age ≥ 65 years, body weight < 60 kg, atrial fibrillation, onset-to-needle time ≥ 120 minutes, and anemia. Patients with lower ASPECTS had higher mortality and unfavorable mRS (> 2) at discharge, 14 days, and 90 days (74.7% vs 50.1%, P < 0.001 for 90-day mRS > 2).Conclusion: ASPECTS is a simple tool to predict thrombolysis-associated sICH but not aICH. Patients with unfavorable ASPECTS are at higher risk of complications and poor functional outcomes. Alternative treatments, such as mechanical thrombectomy, might be advisable for these patients.Keywords: ischemic stroke, intracranial hemorrhage, thrombolysis, outcome, neuroimaging, ASPECTS

Abstract Background Pulmonary intravascular thrombus formation has been widely observed in patients with respiratory failure, for example, in patients with SARS-CoV-2 infection (COVID-19). The aim of this study was to evaluate the efficacy/safety of alteplase thrombolysis in COVID-19 severe hypoxemic respiratory failure. In this multicenter, open-label study, patients were randomized to receive alteplase (low- or high-dose) over 5 days plus standard of care (SOC), or SOC alone. The primary endpoint was time to clinical improvement (≥ 2-point decrease on WHO Clinical Progression Scale, or hospital discharge) up to Day 28. Secondary endpoints included all-cause mortality at Day 28, treatment failure at Day 28 and change in arterial oxygen partial pressure/fractional inspired oxygen (PaO2/FiO2) ratio at Day 6 versus baseline. Results Sixty-nine patients were randomized to alteplase (low- or high-dose) and 35 to SOC; 65% were on high-flow oxygen or non-invasive ventilation at baseline. Median time to clinical improvement was 25 days in the alteplase group and > 28 days (median not reached) in the SOC group. All-cause mortality was 8/69 (12%) versus 10/35 (29%) in the alteplase versus SOC groups, respectively (unadjusted risk difference [RD], − 17% [95% confidence interval (CI) − 34 to 0], p = 0.047; adjusted RD, − 16% [95% CI − 31 to 1], p = 0.058). The PaO2/FiO2 ratio (mean [standard deviation]) increased by + 30 (84) mmHg in the alteplase group and decreased by − 12 (59) mmHg in the SOC group (adjusted mean difference vs. SOC, p = 0.052). Differences were greater in patients receiving high-dose alteplase, and in those not receiving invasive ventilation. Eighteen patients (26.1%) in the alteplase group discontinued treatment due to adverse events. Major bleeding was more frequent with alteplase than with SOC (9 vs. 0 patients); no bleeding was fatal. The study closed early due to insufficient patient recruitment. Conclusion Alteplase was not associated with faster clinical recovery from COVID-19 severe hypoxemic respiratory failure. A numerical difference in survival and PaO2/FiO2 ratio was observed, particularly in patients not receiving invasive ventilation. These exploratory findings merit further investigation in larger patient cohorts that are adequately powered to confirm the hypotheses generated in this study regarding the impact of alteplase on treatment outcomes. Trial registration ClinicalTrials.gov: NCT04640194 (November 23, 2020); https://clinicaltrials.gov/study/NCT04640194 (early discontinuation due to insufficient patient recruitment).

Background: The incidence of Non communicable diseases (NCDs) including stroke is increasing in India over the past few years. Thrombolysis therapy has revolutionized management of acute ischemic stroke. In spite of such recent advances in stroke therapy, the public remains uninformed about stroke symptoms and management. Objective: To assess the public awareness of stroke risk factors, symptoms, treatment and rehabilitation measures. Methods: The study was a community-based cross-sectional study, designed as an online survey. The tool used for the survey was a semi-structured online questionnaire. Results: Regarding the risk factors of stroke, of the participants, 41 (14.8%) were aware of valvular heart diseases, 18 (6.5%) of lack of exercise, 238 (85.9%) of dyslipedemia, 236 (85.2%) of hypertension, 222 (80.1%) of smoking, and 154 (55.6%) of diabetes. Regarding symptoms of stroke, of the participants, 209 (75.5%) were aware of loss of balance, 240 (86.6%) of speech abnormalities, 261 (94.2%) of facial weakness, and 234 (84.5%) of weakness. Conclusion: Efforts should be made to educate the public regarding uncommon symptoms of stroke, thrombolysis treatment and rehabilitation measures, so that people make beneficial health care decisions in stroke management.

Hanna Pawluk,1 Renata Ko&lstrok;odziejska,1 Grzegorz Grze&sacute;k,2 Mariusz Kozakiewicz,3 Agnieszka Kosinska,4 Mateusz Pawluk,1 El&zdot;bieta Grzechowiak,5 Jakub Wojtasik,6 Grzegorz Kozera7 1Department of Medical Biology and Biochemistry, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toru&nacute;, Bydgoszcz, Poland; 2Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toru&nacute;, Bydgoszcz, Poland; 3Faculty of Health Science, The Masovian Academy in P&lstrok;ock, P&lstrok;ock, Poland; 4Centre for Languages & International Education, University College London, London, UK; 5Department of Neurology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toru&nacute;, Bydgoszcz, Poland; 6Statistical Analysis Centre, Nicolaus Copernicus University in Toru&nacute;, Toru&nacute;, Poland; 7Centre of Medical Simulations, Faculty of Medicine, Medical University of Gda&nacute;sk, Gda&nacute;sk, PolandCorrespondence: Hanna Pawluk; Renata Ko&lstrok;odziejska, Department of Medical Biology and Biochemistry, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toru&nacute;, Kar&lstrok;owicza 24, 85– 092, Bydgoszcz, Poland, Tel +48 52 585 37 37, Fax +48 52 585 37 42, Email hannapawluk1@wp.pl; renatak@cm.umk.plPurpose: Glial fibrillary acidic protein (GFAP) and neuroglobin (NGB) are important biomarkers of cerebral hypoxia. For this reason, an attempt was made to assess their concentrations in various time intervals and their impact on the severity of neurological symptoms and functional prognosis of thrombolytic ischemic stroke patients.Patients and Methods: The study involved 94 patients reporting to the emergency department of the Collegium Medicum University Hospital in Bydgoszcz within < 4.5 hours of the onset of stroke symptoms. GFAP and neuroglobin levels were measured in plasma at indicated times using a commercial ELISA kit.Results: Based on the data gathered, statistically significant differences were found between the concentration of biomarkers in stroke patients and the control group. The concentrations of both biomarkers, GFAP and NGB, were elevated in patients after ischemic stroke and the changes in their concentrations in the subsequent stages of stroke may suggest their prognostic value strictly dependent on time. NGB was determined on the 7th day, and mRS - after a year (0.35). GFAP measured after 24 h and on day 7 could be a promising biomarker of functional outcome after one year (cut-off point ≤ 0.231 ng/mL, sensitivity 75.0%, specificity 61.2%, cut off point ≤ 0.235 ng/mL, sensitivity 75.0%, specificity 73.9%, respectively) and the severity of the patient’s neurological condition. At GFAP concentrations above 0.25 ng/mL, measured within 24 hours, a sharp increase in mortality was observed in stroke patients. In the case of NGB, at the time of stroke occurrence (14 ng/mL) and after 24 hours (10– 60 ng/mL). Differences in the concentrations of these biomarkers have been demonstrated in different stroke subtypes.Conclusion: NGB and GFAP are important biomarkers of ischemic brain injury and may also participate in predicting neurological outcomes.Keywords: GFAP, NGB, stroke, oxidative stress, inflammation, thrombolysis

Background and Purpose Tenecteplase is a thrombolytic agent with pharmacological advantages over alteplase and has been shown to be noninferior to alteplase for acute ischemic stroke in randomized trials. However, evidence pertaining to the safety and efficacy of tenecteplase in patients from different ethnic groups is lacking. The aim of this systematic review and metaanalysis was to investigate ethnicity-specific differences in the safety and efficacy of tenecteplase versus alteplase in patients with acute ischemic stroke. Methods Following an International Prospective Register of Systematic Reviews (PROSPERO)- registered protocol (CRD42023475038), three authors conducted a systematic review of the PubMed/MEDLINE, Embase, Cochrane Library, and CINAHL databases for articles comparing the use of tenecteplase with any thrombolytic agent in patients with acute ischemic stroke up to November 20, 2023. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two independent authors extracted data onto a standardized data collection sheet. A pairwise meta-analysis was conducted in risk ratios (RR). Results From 34 studies (59,601 participants), the rate of complete recanalization was significantly higher (P

Catastrophic spontaneous spinal epidural hematoma (SSEH) following thrombolysis poses a complex intersection of neurosurgical and cardiological challenges. This case report presents the institutional experience of a 66-year-old female who developed rapid-onset compressive myelopathy after thrombolysis for inferior wall myocardial infarction with injection streptokinase. SSEH, although rare, demands prompt recognition due to its potential for permanent neurologic injury and mortality. The discussion highlights the clinical significance, anatomical considerations, and multidisciplinary approach requisite for accurate diagnosis and effective management of SSEH. The conclusion underscores the necessity for clinicians, particularly cardiologists administering thrombolytic therapies, to consider SSEH in postthrombolysis patients presenting with neurological deficits.

Acute ischemic stroke represents a critical, life-threatening condition affecting the central nervous system. Intravenous thrombolysis with tissue plasminogen activator (tPA) remains a cornerstone for achieving vascular recanalization in such patients; however, its therapeutic utility is limited, with only approximately 10% of patients benefiting due to the narrow therapeutic window and significant risk of hemorrhagic transformation. Enhancing the efficacy of tPA thrombolysis is therefore imperative. Neutrophils have been identified as key modulators of thrombolytic outcomes, interacting with tPA post-stroke to influence treatment effectiveness. The binding of tPA to low-density lipoprotein receptor-related protein 1 (LRP-1) on neutrophil surfaces induces degranulation and formation of neutrophil extracellular traps (NETs). Conversely, neutrophils impede the thrombolytic action of tPA by obstructing its interaction with fibrin and activating platelets. These findings suggest that targeting neutrophils may hold promise for improving thrombolysis outcomes. This review explores the role of neutrophils in tPA-mediated thrombolysis following acute ischemic stroke, examines neutrophil-associated biomarkers, and outlines potential strategies for enhancing tPA efficacy. [ABSTRACT FROM AUTHOR]

Retinal artery occlusion (RAO) is an emergency condition causing acute retinal ischemia and is considered an equivalent of ischemic stroke. The occurrence of an episode of RAO is associated with significant impairment of visual functions and correlates with an increased risk of future vascular events. Although RAO requires immediate diagnosis and treatment, there are currently no clear guidelines specifying optimal management. This review discusses current and future therapeutic strategies following an episode of RAO, including secondary prevention. [ABSTRACT FROM AUTHOR]

Background: Pulmonary intravascular thrombus formation has been widely observed in patients with respiratory failure, for example, in patients with SARS-CoV-2 infection (COVID-19). The aim of this study was to evaluate the efficacy/safety of alteplase thrombolysis in COVID-19 severe hypoxemic respiratory failure. In this multicenter, open-label study, patients were randomized to receive alteplase (low- or high-dose) over 5 days plus standard of care (SOC), or SOC alone. The primary endpoint was time to clinical improvement (≥ 2-point decrease on WHO Clinical Progression Scale, or hospital discharge) up to Day 28. Secondary endpoints included all-cause mortality at Day 28, treatment failure at Day 28 and change in arterial oxygen partial pressure/fractional inspired oxygen (PaO2/FiO2) ratio at Day 6 versus baseline. Results: Sixty-nine patients were randomized to alteplase (low- or high-dose) and 35 to SOC; 65% were on high-flow oxygen or non-invasive ventilation at baseline. Median time to clinical improvement was 25 days in the alteplase group and > 28 days (median not reached) in the SOC group. All-cause mortality was 8/69 (12%) versus 10/35 (29%) in the alteplase versus SOC groups, respectively (unadjusted risk difference [RD], − 17% [95% confidence interval (CI) − 34 to 0], p = 0.047; adjusted RD, − 16% [95% CI − 31 to 1], p = 0.058). The PaO2/FiO2 ratio (mean [standard deviation]) increased by + 30 (84) mmHg in the alteplase group and decreased by − 12 (59) mmHg in the SOC group (adjusted mean difference vs. SOC, p = 0.052). Differences were greater in patients receiving high-dose alteplase, and in those not receiving invasive ventilation. Eighteen patients (26.1%) in the alteplase group discontinued treatment due to adverse events. Major bleeding was more frequent with alteplase than with SOC (9 vs. 0 patients); no bleeding was fatal. The study closed early due to insufficient patient recruitment. Conclusion: Alteplase was not associated with faster clinical recovery from COVID-19 severe hypoxemic respiratory failure. A numerical difference in survival and PaO2/FiO2 ratio was observed, particularly in patients not receiving invasive ventilation. These exploratory findings merit further investigation in larger patient cohorts that are adequately powered to confirm the hypotheses generated in this study regarding the impact of alteplase on treatment outcomes. Trial registration ClinicalTrials.gov: NCT04640194 (November 23, 2020); https://clinicaltrials.gov/study/NCT04640194 (early discontinuation due to insufficient patient recruitment). [ABSTRACT FROM AUTHOR]

Introduction: 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). Methods: 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 <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 (∆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. Results: 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]; p < 0.0001), variation (15.1 ± 5.4 vs. 14.0 ± 5.6 mm Hg; p < 0.0001), and magnitude of reduction (44.6 ± 16.2 vs. 38.7 ± 17.6 mm Hg; p < 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 ∆eGFR (adjusted mean difference −1.10, 95% confidence interval [CI] −3.14 to −0.94; p = 0.29) between the intensive and guideline groups, respectively. The neutral effect on ∆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 ∆eGFR (per 5 mm Hg increase by category: adjusted mean difference −1.35, 95% CI: −2.43 to −0.28; p for trend = 0.01). Conclusion: 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. [ABSTRACT FROM AUTHOR]

Thrombosis is uncommon but increasingly recognized complication in pediatric patients with Mycoplasma pneumoniae (M. pneumoniae) infection. In general, small-vessel thrombosis is treated by medication therapy. However, the management of thrombosis in large vessels is more complex and controversial due to the risks of thrombus enlargement and embolization. In this case, we report an 8-year-old boy who was hospitalized for macrolide-resistant M. pneumoniae pneumonia. After experiencing abdominal pain, he was diagnosed with thrombosis in the pulmonary artery and mesenteric vein. Additionally, massive thrombi were found in the inferior vena cava and left common iliac vein, measuring approximately 4 cm and 4.5 cm in length, respectively. Following routine therapies of anti-infection and anticoagulation, the patient continued to experience recurrent abdominal pain, and there was a risk of the deep vein thrombi detachment. To avoid the shedding of thrombi, the patient underwent inferior vena cava filter placement and catheter-directed thrombolysis with alteplase on day 8 following admission. The clinical symptoms significantly improved, and thrombosis recurrence was not observed in the subsequent follow-ups. This case report highlights the need for prompt recognition of thrombosis in M. pneumoniae infection. Massive thrombus in deep vein is extremely rare but life-threatening in children. The optimal treatments remain to be determined due to the limited experience to date. [ABSTRACT FROM AUTHOR]

Purpose of Review: Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE. Recent Findings: Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Summary: Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE. [ABSTRACT FROM AUTHOR]

Introduction: Sudden cardiac arrest is an emergency that claims millions of lives annually. The causes can be extremely varied. A thorough history, clinical examination, including effective bedside investigations like point-of-care ultrasound (POCUS), two-dimensional (2D) echo, and urgent neuroimaging, if indicated, are indispensable in diagnosis. Brief case summary: In this report, we describe the case of a 40-year-old male who presented with complaints of sudden loss of consciousness, followed by recurrent seizures. He was found to be in cardiac arrest and was successfully revived by cardiopulmonary resuscitation (CPR). Bedside evaluation using POCUS suggested right ventricular dysfunction and deep vein thrombosis (DVT) of the left popliteal vein. Clinical suspicion of pulmonary thromboembolism (PTE) was confirmed on computed tomography (CT) pulmonary angiography. The presence of stroke or cerebral venous thrombosis was ruled out. He was diagnosed with and managed for PTE that caused right heart failure and cardiac arrest. A pathological autopsy was conducted, which confirmed the presence of PTE and demonstrated evidence of acute as well as chronic thromboembolism in multiple arteries and veins. Occult malignancy was ruled out. The etiology of chronic thrombotic conditions remained elusive. Discussion: Seizures as the presenting feature of PTE have been infrequently reported. The proposed mechanism involves sudden cerebral hypoperfusion due to cardiac failure. The presence of multiple arterial and venous thromboembolisms points toward a systemic prothrombotic state. During the discussion, several potential causes were explored, including coronavirus disease (COVID), vaccination status, alcohol intake, chronic liver disease, and drug abuse, each supported by relevant findings from the case. [ABSTRACT FROM AUTHOR]

Background and purpose: Posterior circulation strokes, accounting for 20% of acute ischemic strokes, significantly contribute to morbidity and mortality. Fibrinolysis by rtPA improves outcomes in stroke but the risk of intracranial hemorrhage limits benefit. Arterial recanalization of basilar artery occlusion by thrombolysis or endovascular thrombectomy improves outcomes in posterior circulation strokes. This study investigates a VWF-targeting RNA aptamer as a safer and more effective alternative to rtPA in a canine model. Materials and methods: Autologous clots were placed into the basilar artery to induce stroke in 24 beagles. To compare reperfusion, 0.9 mg/kg rtPA, 0.5 mg/kg BB-031, or vehicle were administered 60 min after the initiation of occlusion. Digital subtraction angiography, laser speckle imaging and magnetic resonance imaging were used to assess recanalization, reperfusion and infarct volume, respectively. Results: Treatment with BB-031 resulted in recanalization of the posterior circulation on digital subtraction angiography with no evidence of microembolism assessed at sacrifice. 66.5% of animals treated with BB-031 resulted in reperfusion with a TICI score of =1 whereas vehicle remained at TICI score 0 as did all but one rtPA animal at sacrifice. Improved perfusion was seen in the basilar artery and surrounding blood vessels visualized through the cranial window with laser speckle imaging to ~47% of its original baseline in BB-031 group compared to rtPA at 37% and vehicle at 22%. Finally, BB-031-treatment resulted in an approximate 32% mean infarct volume, significantly smaller on magnetic resonance imaging compared to 56% in vehicle treated and 48% with rtPA treatment. Conclusion: Targeted inhibition of VWF by BB-031 increased recanalization and reperfusion, and reduced infarct volume in a canine model of BAO stroke. It represents a promising target based on preliminary results for treating acute ischemic stroke. [ABSTRACT FROM AUTHOR]

Background: Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men. Aim: This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea. Methods: A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality. Results: A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years. Conclusion: Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes. [ABSTRACT FROM AUTHOR]

Interventional procedures for the recanalization of blood vessels to treat deep vein thrombosis carry a high risk of vessel wall injuries or hemorrhaging. Focused ultrasound (FUS) has been used to non-invasively break down blood clots that occlude the vessels in both in vitro and in vivo studies. Previous studies have either used thrombolytic drugs or ultrasound contrast agents (e.g., microbubbles) in combination with FUS. Several studies have applied very high peak-negativepressures (PNP) during FUS treatment to achieve successful thrombolysis without the use of contrast agents. In the current study, we demonstrated that cavitation activity could be significantly enhanced by placing a nitinol wire, whose surface was roughed by laser etching, in the focal region of a FUS field. We demonstrated in vitro in a mock thrombosis that the thrombolysis efficacy of a 500 kHz FUS transducer was significantly enhanced using a surface-etched nitinol wire as compared to an unetched nitinol wire, whereas FUS-alone at the same pressure level did not result in any thrombolysis. These results suggest that a surface modified nitinol catheter exposed to FUS can result in intense cavitation activities leading to enhanced thrombolysis without the use of additional pharmacological or contrast agents. [ABSTRACT FROM AUTHOR]

Intravenous thrombolysis remains the most accessible and effective reperfusion therapy available to patients with acute ischaemic stroke. Treatment with intravenous thrombolysis improves the odds of favourable functional outcome with the unacceptably low risk of haemorrhagic complications. Even in the current era of endovascular thrombectomy, intravenous thrombolysis remains the backbone of acute stroke treatment due to its accessibility and relative ease of administration. Since intravenous alteplase was first approved for acute ischaemic stroke in the mid 1990s, there have been significant advances in expanding the indication and time window for treatment, in addition to transitioning towards tenecteplase use for stroke thrombolysis. In this review, we will provide a narrative on the use of thrombolysis in acute ischaemic stroke including an up-to-date discussion on recent advances in thrombolytic therapy. [ABSTRACT FROM AUTHOR]