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Objective: To study the effect of platelet count (PC) on bleeding risk and outcome in stroke patients treated with IV thrombolysis (IVT) and to explore whether withholding IVT in PC < 100 × 10 9 /L is supported., Methods: In this prospective multicenter, IVT register-based study, we compared PC with symptomatic intracranial hemorrhage (sICH; Second European-Australasian Acute Stroke Study [ECASS II] criteria), poor outcome (modified Rankin Scale score 3-6), and mortality at 3 months. PC was used as a continuous and categorical variable distinguishing thrombocytopenia (<150 × 10 9 /L), thrombocytosis (>450 × 10 9 /L), and normal PC (150-450 × 10 9 /L [reference group]). Moreover, PC < 100 × 10 9 /L was compared to PC ≥ 100 × 10 9 /L. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from the logistic regression models were calculated., Results: Among 7,533 IVT-treated stroke patients, 6,830 (90.7%) had normal PC, 595 (7.9%) had thrombocytopenia, and 108 (1.4%) had thrombocytosis. Decreasing PC (every 10 × 10 9 /L) was associated with increasing risk of sICH (OR adjusted 1.03, 95% CI 1.02-1.05) but decreasing risk of poor outcome (OR adjusted 0.99, 95% CI 0.98-0.99) and mortality (OR adjusted 0.98, 95% CI 0.98-0.99). The risk of sICH was higher in patients with thrombocytopenic than in patients with normal PC (OR adjusted 1.73, 95% CI 1.24-2.43). However, the risk of poor outcome (OR adjusted 0.89, 95% CI 0.39-1.97) and mortality (OR adjusted 1.09, 95% CI 0.83-1.44) did not differ significantly. Thrombocytosis was associated with mortality (OR adjusted 2.02, 95% CI 1.21-3.37). Forty-four (0.3%) patients had PC < 100 × 10 9 /L. Their risks of sICH (OR unadjusted 1.56, 95% CI 0.48-5.07), poor outcome (OR adjusted 1.63, 95% CI 0.82-3.24), and mortality (OR adjusted 1.38, 95% CI 0.64-2.98) did not differ significantly from those of patients with PC ≥ 100 × 10 9 /L., Conclusion: Lower PC was associated with increased risk of sICH, while higher PC indicated increased mortality. Our data suggest that PC modifies outcome and complications in individual patients, while withholding IVT in all patients with PC < 100 × 10 9 /L is challenged., (© 2018 American Academy of Neurology.)

Background and Purpose: Time is brain: benefits of intravenous thrombolysis (IVT) in ischemic stroke last for 4.5 hours but rapidly decrease as time progresses following symptom onset. The goal of the Acute Brain Care (ABC) intervention study was to reduce the door-to-needle time (DNT) to ≤30 minutes by optimizing in-hospital stroke treatment. Methods: We performed a single-centre before (pre-intervention period: 2000–2005) versus after (post-intervention period: 2006–2012) comparison in a cohort of consecutive patients treated with IVT. The intervention consisted of the implementation of a multidisciplinary stroke protocol combining simple strategies to reduce the DNT. Primary endpoint was the DNT, presented as proportion ≤30 minutes and median time. Secondary clinical endpoints were symptomatic intracranial hemorrhage (SICH), and favourable outcome defined as a modified Rankin scale (mRs) score of 0–2 at 3 months. Endpoints were additionally adjusted for baseline imbalances between the groups. Results: In the pre-intervention period, none (0.0%) of the 100 patients (mean age 63.8 years, median National Institutes of Health Stroke Scale [NIHSS] score 14) treated with IVT had a DNT ≤30 minutes compared to 234 (62.7%) of the 373 patients (mean age 66.7 years, median NIHSS score 10) in the post-intervention period (p<0.001). The median DNT decreased from 75 (IQR 60–105) to 28 minutes (IQR 20–37, p<0.001). SICH rate remained stable (3.0% versus 4.4%, OR 1.50, 95% CI 0.43─5.25; adjusted OR 5.47, 95% CI 0.69–42.12). The proportion of patients with a favourable outcome increased (38.9% versus 52.3%, OR 1.72, 95% CI 1.09–2.73) but lost statistical significance after adjustment (adjusted OR 1.46, 95% CI 0.82–2.61). Conclusions: Important and sustained reduction of the DNT to 30 minutes or less can be safely achieved by optimizing in-hospital stroke treatment. With its simple strategies, the ABC-protocol is a pragmatic framework for increasing the therapeutic yield in time-dependent stroke treatment. [ABSTRACT FROM AUTHOR]

The article presents information on the treatment of acute ischaemic stroke based on intravenous alteplase thrombolysis. The occurrence of reocclusion in patients after alteplase-induced recanalisation due to platelet activation is discussed along with the related randomized open label trial. The results show that this treatment causes increase in the risk of symptomatic intracranial hemorrhage. INSET: Panel: Research in context.