Ultraearly Intravenous Thrombolysis for Acute Ischemic Stroke in Mobile Stroke Unit and Hospital Settings

So we still have NO fucking clue how fast tPA needs to be delivered to get full recovery. Until we know that we don't know what the goal in minutes is. Better functional outcome is NOT the goal, FULL RECOVERY is the goal. GET THERE!

Ultraearly Intravenous Thrombolysis for Acute Ischemic Stroke in Mobile Stroke Unit and Hospital Settings

A Comparative Analysis

Georgios Tsivgoulis

,

Frederik Geisler

,

Aristeidis H. Katsanos

,

Janika Kõrv

,

Alexander Kunz

,

Robert Mikulik

,

Michal Rozanski

,

Matthias Wendt

and

Heinrich J. Audebert

Originally published9 Jul 2018Stroke. 2018;49:1996-1999

Abstract

Background and Purpose—

Mobile stroke units (MSUs) are known to increase the proportion of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) in the first golden hour (GH) after onset compared with hospital settings (HS). However, because of the low number of AIS patients treated with intravenous thrombolysis within this ultraearly time window in conventional care, characteristics, and outcome of this subgroup of AIS patients have not been compared between MSU and HS.

Methods—

MSU-GH patients were selected from the Berlin-based MSU (STEMO [Stroke Emergency Mobile]), whereas HS-GH patients were selected from the SITS-EAST (Safe Implementation of Treatments in Stroke-East) registry. The outcome events of interest included the rates of favorable functional outcome (modified Rankin Scale scores of 0 or 1), distribution of the modified Rankin Scale scores, and mortality after 3 months between MSU-GH and HS-GH groups.

Results—

We identified 117 MSU-GH (38.4% of 305 MSU-treated patients) and 136 HS-GH (0.9% of 15 591 HS-treated patients) eligible patients without prestroke disability. No significant differences were documented in the rates of favorable functional outcome (51.3% versus 46.2%, P=0.487) and mortality (7.7% versus 9.9%, P=0.576) at 3 months, or in the distribution of 3-month modified Rankin Scale scores between the 2 groups (P=0.196). In multivariable logistic regression analyses, adjusting for potential confounders, MSU treatment was not associated with a significantly different likelihood of favorable functional outcome (odds ratio, 1.84 for MSU patients; 95% CI, 0.86–3.96) or mortality (odds ratio, 0.95; 95% CI, 0.28–3.20) at 3 months.

Conclusions—

There is no evidence that safety and efficacy of ultraearly intravenous thrombolysis for AIS differs when used in MSUs or in HS.

Introduction

Time from acute ischemic stroke (AIS) onset to the initiation of intravenous thrombolysis (IVT) with tPA (tissue-type plasminogen activator) is known to be associated with a higher likelihood of both successful recanalization and long-term functional outcome.^1,2 However, only a negligible proportion of AIS patients receive IVT treatment within the ultraearly time window of the first 60 minutes from symptom onset, known as the golden hour (GH),³ when IVT is presumed to have its greatest benefit.^4–6
Randomized clinical trial data indicate that prehospital care in mobile stroke units (MSU) lead to shorter onset-to-treatment times of IVT administration with no increase in adverse events compared with hospital settings (HS).^7,8 Recent analyses suggest that ultraearly treatment is indeed associated with better functional outcome.^6,9 However, for the low number of AIS patients treated with IVT within 60 minutes from onset in hospitals, characteristics, and outcome of the specific GH subgroup of AIS patients have not been compared between MSU (MSU-GH) and HS (HS-GH).
Given the aforementioned considerations, we sought to evaluate the role of treatment location on the outcome of IVT-treated AIS patients within the GH, by comparing safety and efficacy measures in the 2 different settings.
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