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Objective:To assess whether the effect of intravenous thrombolysis in patients with large-vessel occlusion differed between patients directly admitted to thrombectomy-capable centers and patients transferred from local stroke centers without thrombectomy capabilities.Methods:We included 3206 patients with an acute ischemic large-vessel stroke with first imaging within 7 hours after onset that were directly admitted to thrombectomy-capable centers and treated with thrombectomy, or transferred from local stroke centers for thrombectomy evaluation, between 2017 and 2021 in Catalonia, Spain. Primary outcome was the degree of disability at 90 days, as evaluated by the shift analysis on the mRs score. Secondary outcomes included mortality at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse-probability weighting clustered at the type of stroke center was used to estimate the effects.Results:The analysis included 2268 patients (975[49%] treated with thrombolysis) directly admitted to thrombectomy-capable centers and 938 patients (580[66%] treated with thrombolysis and 616[67%] treated with thrombectomy) transferred from local stroke centers (mean age 72±13 years, median NIHSS score 17[IQR 12-21], 1363 female[48%]). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image acquisition, and higher rates of wake-up stroke, atrial fibrillation and anticoagulation intake. The effect of intravenous thrombolysis on the primary outcome was similar in patients directly admitted to thrombectomy-capable centers (acOR 1.50, 95% CI 1.24-1.81) and patients transferred from local stroke centers (acOR 1.44, 95% CI 1.04 to 2.01)(pinteraction=0.68). Patients treated with intravenous thrombolysis had lower mortality rate, higher rate of parenchymal hematoma and similar rate of successful reperfusion, with no difference according to type of center (pinteraction>0.1).Conclusion:Administration of intravenous thrombolysis in patients with a large-vessel stroke with intention to thrombectomy was associated with higher odds of good functional outcome and higher rates of parenchymal hematoma, independently of the type of stroke center were it was administered.

Background:In drip-and-ship protocols, vascular imaging at Primary Stroke Centers (PSC), although recommended, is not usually performed in many PSC, and its value is uncertain. Our aim was to evaluate the role of performing vascular imaging at PSC, comparing patients with vascular imaging at PSC (VI+) Vs. those without vascular imaging (VI-) in several outcomes.Methods:Observational, multicenter study from a prospective, government-mandated, population-based registry of ischemic stroke code patients firstly evaluated at a PSC from January-2016 to June-2020. We determined and compared rates of Mechanical Thrombectomy (MT) candidates transferred to CSC from all ischemic stroke codes at PSC, MT treated at CSC patients from all MT candidates transferred, and metrics related to drip-and-ship paradigm between VI + and VI- groups. A multivariate analysis to determine PSC related factors associated with receiving EVT at CSC was performed.Results:From 5792 ischemic stroke code patients at PSC, 3384 (58.4%) received a vascular imaging at PSC (VI+). Among all, 32.6% were transferred to CSC as MT candidates, and finally, 10.6% were treated with MT at CSC. The rate of transferred MT candidates was lower in the VI+ than VI- group (n: 783, 23.1% Vs. n: 1109, 46 %, p< 0.001). Among the transferred MT candidates, MT treatment at CSC was more common in the VI+ than VI- (n: 377, 48.1% Vs: n: 239, 21.5%, p<0.001). In patients transferred with baseline mild strokes (NIHSS <6), the rate of MT treated patients was higher in VI+ than VI- (n: 31, 29% Vs. n: 20, 7% p<0.001). Interval times as DIDO (median minutes 84 Vs. 81) and DTP time (188 Vs. 182) did not show differences between VI+ and VI-. In multivariate analysis adjusted by age, the independent factors associated to receiving MT at CSC were VI+ (OR: 2,128, CI95%:1,549-2,922, p<0.001), baseline NIHSS, and RACE scale.Conclusion:In the present study, performing vascular imaging at PSC diminishes unnecessary transfers to CSC and is associated with a higher probability of receiving MT at CSC in transferred patients. In mild strokes, performing a vascular imaging at PSC increases the probability of receiving MT at CSC. Metrics related to drip-and-ship model were not affected by performing a vascular imaging at PSC.

The value of multimodal CT to assist thrombolysis has received little attention in stroke.

Valsalva maneuver (VM) precedes frequently transient global amnesia (TGA) and up to 84% of the patients with TGA present hippocampal diffusion-weighted imaging-positive (DWI+) lesions on brain magnetic resonance imaging (MRI). We studied 20 patients with TGA and hippocampal DWI+ lesions. Median age (range) of the patients was 67 (57-80) years and 55% were women. TGA had been preceded by a VM-associated activity in 14 patients (70%), and brain MRI had been performed at a median (range) of 47.5 (42-79) h after TGA. These patients underwent a second MRI after a controlled-induced VM at least 3 months after TGA. This MRI was performed at a median (range) of 46.8 (41-138) h after the controlled-induced VM. None of the patients who reproduced TGA symptoms presented new DWI+ lesions on the second MRI. In patients with a previous episode of TGA, VM cannot elicit TGA in isolation and the interplay of other simultaneous factors is needed., (© 2019 S. Karger AG, Basel.)