(Stroke. 2000;31:77.)
© 2000 American Heart Association, Inc.
Original Contributions |
Treating Acute Stroke Patients With Intravenous tPA
The OSF Stroke Network Experience
From the OSF Stroke Network and Department of Neuroscience at OSF Saint Francis Medical Center, Peoria, Ill (D.Z.W., J.A.R., D.S.H., D.J.G., J.C.M.), and Departments of Neurology (D.Z.W., D.J.G., J.C.M.) and Biomedical and Therapeutic Sciences (D.Z.W., J.C.M.), University of Illinois College of Medicine at Peoria.
Correspondence to Dr David Z. Wang, Director, OSF Stroke Network, 503 NE Glen Oak, Peoria, IL 61637. E-mail dwang{at}uic.edu
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
Background and Purpose—Since the FDA approved tissue plasminogen activator (tPA) in 1996 for acute ischemic stroke, few data have been obtained during the postmarketing phase, and applicability in rural hospitals does not exist. We attempt to examine the safety and outcome of intravenous tPA for acute ischemic stroke in the OSF Stroke Network.
Methods—Fifty-seven consecutive patients treated with tPA were examined from June 1996 through December 1998. Admission and discharge National Institute of Health Stroke Scales (NIHSS), modified Rankin Scales (MRS), and discharge disposition, as well as intracerebral hemorrhage and mortality rates, were compared.
Results—Of 20 network hospitals, 12 had the experience of administering tPA. No statistically significant differences in the variables recorded were observed for patients treated at the community hospitals versus those who received tPA at the tertiary medical center. In 35% of patients, tPA was initiated by an emergency room or primary care physician in consultation with an OSF neurologist. At discharge, 47% of the patients had minimal or no disability (MRS, 0 to 1), 44% had an NIHSS score of 0 or 1, 54% went home, 25% were transferred to in-patient rehabilitation, 12% went to a nursing or skilled-care facility, and 9% died. Intracerebral hemorrhage rate was 9%; 5% were symptomatic.
Conclusions—tPA can be administered safely with good outcome at community and rural hospitals. The OSF Stroke Network can serve as a model to assist small community hospitals to set up stroke programs and deliver up-to-date, acute stroke therapies.
Key Words: stroke, ischemic • thrombolysis • tissue plasminogen activator
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
In June 1996, the FDA approved intravenous tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within 3 hours of onset. This approval was granted in light of the favorable results obtained in the pivotal National Institutes of Neurological Disorders and Stroke (NINDS) tPA trial.1 Since its approval, it has been estimated that between 1% and 6% of ischemic stroke patients have been treated with tPA, resulting in part from the strict 3-hour time window2 3 and reluctance by many treating physicians. Reports on the use of tPA since its approval are scarce.4 5 6
Chiu and colleagues2 published safety and feasibility data of tPA therapy in 30 patients in an urban practice in treatment of ischemic stroke in Houston, Tex. Their outcomes were consistent with the NINDS trial, suggesting that tPA was safe and effective. Although these data confirmed the success of acute thrombolytic therapy in urban hospitals where neurologists are readily available, questions still exist as to the applicability and safety of tPA administration for acute ischemic stroke in community and rural hospitals.
OSF (Sisters of the Third Order of Saint Francis) Saint Francis Medical Center (SFMC) took the initiative to organize a regional OSF Stroke Network (SN) in February 1997. The experience of treating 57 acute ischemic stroke patients among the OSF SN hospitals is presented.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
The OSF SN consists of 20 hospitals (range, 45 to 730 beds) located in 23 central Illinois counties. This network was established for the purpose of assisting community hospitals in the development of comprehensive stroke prevention and treatment programs for an estimated 1.5 million people in central Illinois. Fourteen (70%) of the 20 hospitals are located in towns with populations <20 000. OSF SFMC is a 730-bed tertiary care center with a dedicated stroke unit offering the full spectrum of stroke diagnosis and therapies. OSF SFMC resources also include 2 medical transport helicopters and 2 full-time Life Flight transport teams. OSF SFMC provides 24-hour telephone consultation service for all 20 SN hospitals, and some sites use telemedicine. Each network site has received physician education by a fellowship-trained stroke neurologist, and all sites have several individuals certified on the NIHSS score. NIHSS scores on admission and discharge are being obtained for all patients admitted with strokelike symptoms.
When a participating hospital receives an acute stroke patient, the local emergency physician, primary care physician, and/or neurologist have the option of consulting 1 of the OSF neurologists on call. If appropriate, the patient was treated with tPA according to the guidelines published by the American Heart Association.7 Most patients who received tPA among SN hospitals are transferred to OSF SFMC. Subsequent transfer of the patient to OSF SFMC is not required. However, transfer is an option if concerns exist about neurosurgery/neurological backup or if access to blood products is needed. The decision to treat with tPA and/or to transfer the patient was made jointly between the local physician and the consulting OSF SFMC neurologist.
Data were collected on 57 consecutive patients treated with intravenous tPA and cared for at OSF SFMC between June 1996 and December 1998. NINDS guidelines for tPA administration for acute ischemic stroke were followed closely. Patients were grouped into 2 categories: those who received tPA at a community hospital and transferred to OSF SFMC and those who were given tPA at OSF SFMC and remained there throughout the course of their acute hospitalization. An OSF neurologist at a non–OSF SN hospital managed 5 patients, and 5 patients were transferred to OSF SFMC from a non–OSF SN hospital. Patients were given 0.9 mg/kg IV tPA (maximum, 90 mg). Ten percent of the total dose was given as bolus; the rest was infused over 60 minutes. Blood pressure was controlled with antihypertensives such as labetalol. In most cases, systolic blood pressure was maintained at <185 mm Hg, with a diastolic blood pressure <110 mm Hg.
Demographic information, including age, sex, and pertinent medical history, was obtained from medical records. Variables collected included onset of symptom time, emergency room arrival time, laboratory draw time, time of CT, time of tPA bolus administration, mortality, and adverse events. Stroke subtype was determined by use of Treatment of Acute Stroke Trial (TOAST) criteria.8 Outcome was evaluated by comparison of baseline and discharge NIH Stroke Scales (NIHSS),9 modified Rankin Scale (MRS), discharge disposition, mortality, and length of immediate hospitalization. NIHSS scores were done by a certified staff member. Descriptive and frequency statistical analyses were obtained and comparisons were made by use of SPSS for Windows, version 8.0 (SPSS Inc).
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
Demographics
Fifty-seven patients were treated with intravenous tPA at 12 SN hospitals and 2 non-SN hospitals between June 1996 and December 1998 (Table 1
). During
this same period, 
900 ischemic stroke patients were treated
at the OSF Comprehensive Stroke Center. Of these 900 patients, 57
(6.3%) were treated with tPA. Most patients (60%) treated with tPA
were male (n=34), and the average age was 71±14 years
(mean±SD; range, 41 to 91 years; Table 2). Pertinent medical history revealed
that 46% had a history of hypertension, 14% had diabetes, 19%
presented with carotid artery disease, 28% had a history of
atrial fibrillation, 14% had a history of previous stroke, and 4% had
transient ischemic attacks. With the TOAST criteria, 26 (46%)
probably had cardioembolic strokes, 16 (28%) presented with
large-vessel occlusion, 13 (23%) had signs of small-vessel disease,
and 2 (3%) had undetermined origin. An emergency room or primary care
physician initiated tPA treatment in 20 of 57 patients (35%) with
prior consultation with an OSF SN neurologist.
|
|
Admission
The average NIHSS score at admission was 14 (range, 4 to 25;
median, 15) (Table 2
). Thirty patients (53%) were admitted with
an MRS of 4 or 5; 24 (42%) had an MRS of 2 or 3; and 3 (5%) had
relatively mild symptoms as reflected by an MRS of 1. The mean time
from door to CT was 33±20 minutes (range, 10 to 87 minutes), and the
average time from door to laboratory was 28±21 minutes (range, 10 to
115 minutes). The mean time from onset to tPA treatment was 148±52
minutes (range, 57 to 360 minutes). Six patients (11%) were treated
with tPA within 90 minutes of the onset of stroke symptoms, and 5 (9%)
were given tPA beyond the maximum FDA recommended time of 180 minutes
(183, 185, 250, 293, and 360 minutes).
Discharge
The average length of the hospital stay was 6.2 days (range, 1 to
23 days). Thirty-one patients (54%) were discharged to home, 14 (25%)
to in-patient rehabilitation services, and 7 (12%) to a nursing home
or skilled-care facility; 5 patients (9%) died.
Symptomatic intracranial hemorrhage occurred in 3
patients (5%), and 2 (4%) had CT confirmation of
asymptomatic intracerebral
hemorrhage. In addition, 3 patients (5%) experienced
hematuria, and 1 patient died of pericardial hemorrhagic effusion.
Of the patients treated with tPA, 47% were discharged with no or
minimal disability as defined by an MRS of 0 or 1, and 44% had an
NIHSS score of 0 or 1 at discharge. Sixty-eight percent had >4 points
of improvement on NIHSS at discharge compared with admission scores
(Figures 1 and 2). The average discharge NIHSS score was
6.3 (range, 0 to 28); the median was 2.
|
|
OSF SFMC Versus Other Hospitals
Demographic and outcome data were compared for patients treated
with tPA at a community hospital and transferred to OSF SFMC and those
who were given tPA at OSF SFMC and remained there throughout the course
of their hospitalization. No statistically significant difference in
age, time from door to CT or laboratory, or length of stay was observed
between the groups (Table 3). NIHSS
scores and MRS at admission and discharge were higher for patients
given tPA at OSF SFMC, but these differences were not statistically
significant. The time from onset of symptoms to tPA administration was
shorter at the community hospitals compared with OSF SFMC (mean, 141
versus 155 minutes).
|
Other than the treatment with tPA beyond the 180-minute window in 5 patients, no other patients were found to have deviated from the protocol. Complication rates for hemorrhage, death, and myocardial infarction (MI) did not appear to differ between patients given tPA at outlying hospitals and those treated at OSF SFMC.
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
Between June 1996 and December 1998,
900 ischemic
stroke patients were treated at the OSF Comprehensive Stroke Center. Of
these 900 patients, 57 (6.3%) were treated with tPA. The OSF SN data
suggest that nearly half of the 57 patients who received tPA had
complete recovery and that tPA appeared to be effective regardless of
stroke subtype or severity. Most patients treated with tPA were
discharged home (54%). The length of stay in this series was 6.2 days.
In general, patients who had a longer length of stay typically
presented with multiple complications or compounding factors,
such as intracerebral hemorrhage, MI, and
carotid endarterectomy. The NINDS trial excluded patients with acute MI; therefore, no correlation between mortality after tPA for acute stroke and MI has been established. In this study, 3 of the 5 patients who died had symptoms consistent with acute MI. One patient developed Dressler’s syndrome (confirmed by echocardiogram) and worsened after tPA treatment. Chiu et al2 did not exclude these patients and found 2 patients in whom hemopericardium occurred after tPA administration. Taken together, intravenous tPA should be cautiously or perhaps not considered for patients presenting with concomitant stroke and acute or recent MI.
Of the 57 patients, 5 were treated outside the 180-minute window. Inaccurate initial reporting of symptom onset time occurred in 3 of the 5 patients. The other 2 patients were treated at 183 and 185 minutes, and delays occurred in drug administration. Although 5 patients were treated outside the window, no significant complications occurred in any. Of importance, however, is that the degree of clinical improvement was not as pronounced in these patients compared with the other 52.
Complication rates were collected through hospital discharge. The rates of symptomatic (5%) and nonsymptomatic (4%) intracerebral hemorrhage were similar to the results of the NINDS trial (10%), although those data were collected through 3 months.1 Twenty-one patients (37%) had repeated CT scans within 72 hours of tPA treatment. The decision to repeat CT scans was based on the patient’s clinical presentation and the need to consider anticoagulation for secondary stroke prevention. It is important to note that a CT scan was not repeated in every patient, so the rate of nonsymptomatic intracerebral hemorrhage may be underestimated. One patient who died as a result of intraventricular and intracerebral hemorrhage also suffered an acute MI. In another patient, death caused by intracerebral hemorrhage was likely related to prolonged hypertension (systolic blood pressure >190) that persisted for >6 hours. In addition to intracerebral hemorrhages, other hemorrhages likely related to tPA treatment observed in this study included hematuria (5 patients) and mild to moderate bruising of the skin. Complication rates were not significantly different between patients treated at outlying hospitals and those treated at OSF SFMC. This finding should be cautiously interpreted because of the relatively low number of patients in this series.
One of the primary goals of establishing the OSF SN was to provide access to neurological expertise in rural and community hospitals. This need has been more urgent since the approval of tPA for acute ischemic stroke. Twenty of 57 patients were treated with tPA at facilities without on-site neurological expertise, and either an emergency room or primary care physician initiated the treatment. Most of these patients were given tPA after telephone consultation with an OSF SN neurologist. Once tPA was initiated, these patients were transported by helicopter to OSF SFMC. Transfer, in most cases, was requested because of a lack of neurosurgical backup and/or 24-hour availability of blood products at the outlying community hospitals.
Even with the growing evidence supporting the use of thrombolytics for acute ischemic stroke, many physicians, including some neurologists, are still skeptical and will rarely or never use tPA. This study demonstrated that tPA can be safely given to acute ischemic stroke patients in rural and community hospitals with or without on-site neurology. In addition, patients receiving tPA at smaller community hospitals will have a fairly high potential for a good outcome. The present findings suggest that in smaller rural hospitals, the times from the door to CT and the door to the laboratory can be within or shorter than the NINDS consensus guideline for stroke workups.10 11 12 This fact is quite impressive and suggests that regardless of hospital size, a system to do expedited stroke workups can be set up and successfully implemented by a stroke team. Another important factor to successfully administer tPA is strict adherence to the NINDS protocol and AHA treatment guidelines.7 10 11 12 13
tPA can be safely and effectively given with good outcome in patients with acute ischemic stroke who present at rural community hospitals. In such facilities, it is very likely that these patients will be under the direct care of emergency and/or primary care physicians. To assist physicians in these cases, community hospitals and its physicians must have access to 24-hour neuroscience support. Such neuroscience backup will come only from larger regional medical centers. These regional centers should also assist with or provide community hospitals with physician education and address their concerns regarding thrombolytic therapy. Ultimately, such programs will provide the opportunity for patients to receive stroke therapies previously unavailable to patients in those rural areas.
|
Appendix |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
The OSF stroke team participants were Angela Benavides, MD; Chester R. Dela Cruz, MD; André Durocher, MD; Edward Hui, MD, PhD; Maria Karbowska-Jankowska, MD; Jorge C. Kattah, MD; Jai Kumar, MD; John McLean, MD; Richard Miller, MD; Michelle Roda, DO; and Pamela J. Tolson, BSN.
|
Acknowledgments |
|---|
We would like to thank the participating stroke teams of the OSF SN: Community Hospital of Ottawa, Graham Hospital, Illinois Valley Community Hospital, Kewanee Hospital, Mendota Community Hospital, OSF Saint Francis Medical Center, OSF Saint James Hospital, OSF St Mary Medical Center, Pekin Hospital, Perry Memorial Hospital, St Margaret’s Hospital, and St Mary’s Hospital.
Received July 26, 1999; revision received October 1, 1999; accepted October 14, 1999.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendixReferences |
|---|
1. National Institute of Neurological Diseases and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–1587.
2.
Chiu D, Krieger D, Villa-Cordova C, Kasner SE,
Morgenstern LB, Bratina PL, Yatsu FM, Grotta JC.
Intravenous tissue plasminogen
activator for acute ischemic stroke: feasibility,
safety, and efficacy in the first year of clinical practice.
Stroke. 1998;29:18–22.
3. Hickenbottom SL, Morgenstern LB. Physician response to rt-PA two years after approval: attitudes, barriers to adoption, and potential solutions. Stroke Intervent. 1998;1:3–5.
4. Anderson A, Smith DB, Hughes RL. The Colorado Acute Stroke Network experience with intravenous rt-PA in acute ischemic stroke. Neurology. 1998;50:A157. Abstract.
5. Dafer RM, Tiejen GE, Korsnack A. Experience with rt-PA at a small medical center. Neurology. 1998;50:A115. Abstract.
6. Cruz-Flores S, Thompson DW, Banet G, Burch CM, Parks BJ, Selhorst JB, Shulman S. Intravenous thrombolysis in acute ischemic stroke: preliminary experience with tissue plasminogen activator. Neurology. 1998;50:A113–A114. Abstract.
7.
Adams HP, Brott TG, Furland AJ, Gomez CR,
Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, Feinberg W,
Mayberg M, Thies W. Guidelines for thrombolytic
therapy for acute stroke: a supplement to the guidelines for the
management of patients with acute ischemic stroke: a statement
for healthcare professionals from a special writing group of the Stroke
Council, American Heart Association. Circulation. 1996;94:1167–1174.
8.
Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB,
Gordon DL, March EE, for the TOAST Investigators. Classification of
subtype of acute ischemic stroke: definitions for use in a
multicenter clinical trial. Stroke. 1993;24:35–41.
9. Lyden P, Brott T, Tilley BC, Welch KMA, Mascha EJ, Levine SR, Haley EC, Grotta J, Marler J, for the NINDS rt-PA Stroke Study Investigators. Improved reliability of the NIH Stroke Scale using video training. Stroke. 1994;25:2220–2226.[Abstract]
10.
Tilley BD, Lyden PD, Brott TG, Lu M, Levine SR, Welch
KMA, for the NINDS rt-PA Stroke Group. Total quality improvement method
for reduction of delays between emergency department admission and
treatment of acute ischemic stroke. Arch Neurol. 1997;54:1466–1474.
11. NSA Stroke Center Network recommendations. J Stroke Cerebrovasc Dis. 1997;6:299–303.
12.
The NINDS rt-PA Stroke Study Group. A systems approach
to immediate evaluation and management of hyperacute stroke: experience
at 8 centers and implications for community practice and patient care.
Stroke. 1997;28:1530–1540.
13. Marler JR, Winter Jones P, Emr M, eds. Proceedings of National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, Md: National Institute of Neurological Disorders and Stroke, National Institutes of Health; August 1997. NIH publication 97–4239.
This article has been cited by other articles:
 |
|
 |
|
  L. H. Schwamm, R. G. Holloway, P. Amarenco, H. J. Audebert, T. Bakas, N. R. Chumbler, R. Handschu, E. C. Jauch, W. A. Knight IV, S. R. Levine, et al. A Review of the Evidence for the Use of Telemedicine Within Stroke Systems of Care: A Scientific Statement From the American Heart Association/American Stroke Association Stroke, July 1, 2009; 40(7): 2616 - 2634. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Reeves, A. Bhatt, P. Jajou, M. Brown, and L. Lisabeth Sex Differences in the Use of Intravenous rt-PA Thrombolysis Treatment for Acute Ischemic Stroke: A Meta-Analysis Stroke, May 1, 2009; 40(5): 1743 - 1749. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. C. Leira, A. Ahmed, D. L. Lamb, H. M. Olalde, R. C. Callison, J. C. Torner, H. P. Adams Jr, and for the AIRDOC study Investigators Extending Acute Trials to Remote Populations: A Pilot Study During Interhospital Helicopter Transfer Stroke, March 1, 2009; 40(3): 895 - 901. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. T. Laskowitz, S. E. Kasner, J. Saver, K. S. Remmel, E. C. Jauch, and BRAIN Study Group Clinical Usefulness of a Biomarker-Based Diagnostic Test for Acute Stroke: The Biomarker Rapid Assessment in Ischemic Injury (BRAIN) Study Stroke, January 1, 2009; 40(1): 77 - 85. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. J. Alberts, R. A. Felberg, L. R. Guterman, S. R. Levine, and for Writing Group 4 Atherosclerotic Peripheral Vascular Disease Symposium II: Stroke Intervention: State of the Art Circulation, December 16, 2008; 118(25): 2845 - 2851. [Full Text] [PDF]
|
|
|
|
 |
|
 E. C. Leira, D. C. Hess, J. C. Torner, and H. P. Adams Jr Rural-Urban Differences in Acute Stroke Management Practices: A Modifiable Disparity Arch Neurol, July 1, 2008; 65(7): 887 - 891. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Acker III, A. M. Pancioli, T. J. Crocco, M. K. Eckstein, E. C. Jauch, H. Larrabee, N. M. Meltzer, W. C. Mergendahl, J. W. Munn, S. M. Prentiss, et al. Implementation Strategies for Emergency Medical Services Within Stroke Systems of Care: A Policy Statement From the American Heart Association/ American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council Stroke, November 1, 2007; 38(11): 3097 - 3115. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Schwab, B. Vatankhah, C. Kukla, M. Hauchwitz, U. Bogdahn, A. Furst, H. J. Audebert, M. Horn, and On behalf of the TEMPiS Group Long-term outcome after thrombolysis in telemedical stroke care Neurology, August 28, 2007; 69(9): 898 - 903. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Kent, H. P. Selker, R. Ruthazer, E. Bluhmki, and W. Hacke The Stroke-Thrombolytic Predictive Instrument: A Predictive Instrument for Intravenous Thrombolysis in Acute Ischemic Stroke Stroke, December 1, 2006; 37(12): 2957 - 2962. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. J. Audebert, C. Kukla, B. Vatankhah, B. Gotzler, J. Schenkel, S. Hofer, A. Furst, and R. L. Haberl Comparison of Tissue Plasminogen Activator Administration Management Between Telestroke Network Hospitals and Academic Stroke Centers: The Telemedical Pilot Project for Integrative Stroke Care in Bavaria/Germany Stroke, July 1, 2006; 37(7): 1822 - 1827. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Yamaguchi, E. Mori, K. Minematsu, J. Nakagawara, K. Hashi, I. Saito, Y. Shinohara, and for the Japan Alteplase Clinical Trial (J-ACT) Gro Alteplase at 0.6 mg/kg for Acute Ischemic Stroke Within 3 Hours of Onset: Japan Alteplase Clinical Trial (J-ACT) * Supplemental Appendix 2 Stroke, July 1, 2006; 37(7): 1810 - 1815. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Z. Bambauer, S. C. Johnston, D. E. Bambauer, and J. A. Zivin Reasons why few patients with acute stroke receive tissue plasminogen activator. Arch Neurol, May 1, 2006; 63(5): 661 - 664. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Bandera, M. Botteri, C. Minelli, A. Sutton, K. R. Abrams, and N. Latronico Cerebral Blood Flow Threshold of Ischemic Penumbra and Infarct Core in Acute Ischemic Stroke: A Systematic Review Stroke, May 1, 2006; 37(5): 1334 - 1339. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R.G. Gonzalez Imaging-guided acute ischemic stroke therapy: From "time is brain" to "physiology is brain". AJNR Am. J. Neuroradiol., April 1, 2006; 27(4): 728 - 735. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Z. Deng, M. J. Reeves, B. S. Jacobs, G. L. Birbeck, R. U. Kothari, S. L. Hickenbottom, A. J. Mullard, S. Wehner, K. Maddox, A. Majid, et al. IV tissue plasminogen activator use in acute stroke: Experience from a statewide registry Neurology, February 14, 2006; 66(3): 306 - 312. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. T. Bateman, H. C. Schumacher, B. Boden-Albala, M. F. Berman, J.P. Mohr, R. L. Sacco, and J. Pile-Spellman Factors Associated With In-Hospital Mortality After Administration of Thrombolysis in Acute Ischemic Stroke Patients: An Analysis of the Nationwide Inpatient Sample 1999 to 2002 Stroke, February 1, 2006; 37(2): 440 - 446. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. C. Hess, S. Wang, W. Hamilton, S. Lee, C. Pardue, J. L. Waller, H. Gross, F. Nichols, C. Hall, and R. J. Adams REACH: Clinical Feasibility of a Rural Telestroke Network Stroke, September 1, 2005; 36(9): 2018 - 2020. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Alberts, R. E. Latchaw, W. R. Selman, T. Shephard, M. N. Hadley, L. M. Brass, W. Koroshetz, J. R. Marler, J. Booss, R. D. Zorowitz, et al. Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition Stroke, July 1, 2005; 36(7): 1597 - 1616. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. I. Qureshi, J. F. Kirmani, M. A. Sayed, A. Safdar, S. Ahmed, R. Ferguson, L. A. Hershey, K. J. Qazi, and for the Buffalo Metropolitan Area and Erie County Time to hospital arrival, use of thrombolytics, and in-hospital outcomes in ischemic stroke Neurology, June 28, 2005; 64(12): 2115 - 2120. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. S. Jacobs, P. L. Baker, C. Roychoudhury, R. H. Mehta, and S. R. Levine Improved Quality of Stroke Care for Hospitalized Medicare Beneficiaries in Michigan Stroke, June 1, 2005; 36(6): 1227 - 1231. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
The Paul Coverdell Prototype Registries Writing Gr Acute Stroke Care in the US: Results from 4 Pilot Prototypes of the Paul Coverdell National Acute Stroke Registry Stroke, June 1, 2005; 36(6): 1232 - 1240. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. D. Hill, A. M. Buchan, and for The Canadian Alteplase for Stroke Effectivenes Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study Can. Med. Assoc. J., May 10, 2005; 172(10): 1307 - 1312. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Task Force Members, L. H. Schwamm, A. Pancioli, J. E. Acker III, L. B. Goldstein, R. D. Zorowitz, T. J. Shephard, P. Moyer, M. Gorman, S. C. Johnston, et al. Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems Stroke, March 1, 2005; 36(3): 690 - 703. [Full Text] [PDF]
|
|
|
|
|
|
L. H. Schwamm, A. Pancioli, J. E. Acker III, L. B. Goldstein, R. D. Zorowitz, T. J. Shephard, P. Moyer, M. Gorman, S. C. Johnston, P. W. Duncan, et al. Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems Circulation, March 1, 2005; 111(8): 1078 - 1091. [Full Text] [PDF]
|
|
|
|
|
|
M. Kaste Thrombolysis: What More Does It Take? Stroke, February 1, 2005; 36(2): 200 - 202. [Full Text] [PDF]
|
|
|
|
|
|
J. L. Frey, H. K. Jahnke, P. W. Goslar, S. Partovi, and M. S. Flaster tPA by telephone: Extending the benefits of a comprehensive stroke center Neurology, January 11, 2005; 64(1): 154 - 156. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. U. Heuschmann, P. L. Kolominsky-Rabas, J. Roether, B. Misselwitz, K. Lowitzsch, J. Heidrich, P. Hermanek, C. Leffmann, M. Sitzer, M. Biegler, et al. Predictors of In-Hospital Mortality in Patients With Acute Ischemic Stroke Treated With Thrombolytic Therapy JAMA, October 20, 2004; 292(15): 1831 - 1838. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Ingall, W. M. O'Fallon, K. Asplund, L. R. Goldfrank, V. S. Hertzberg, T. A. Louis, and T. J. H. Christianson Findings From the Reanalysis of the NINDS Tissue Plasminogen Activator for Acute Ischemic Stroke Treatment Trial Stroke, October 1, 2004; 35(10): 2418 - 2424. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. W. Albers, P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 483S - 512S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Wang, H. Gross, S. B. Lee, C. Pardue, J. Waller, F. T. Nichols III, R. J. Adams, and D. C. Hess Remote Evaluation of Acute Ischemic Stroke in Rural Community Hospitals in Georgia Stroke, July 1, 2004; 35(7): 1763 - 1768. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. D. Graham Tissue Plasminogen Activator for Acute Ischemic Stroke in Clinical Practice: A Meta-Analysis of Safety Data Stroke, December 1, 2003; 34(12): 2847 - 2850. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Handschu, R. Littmann, U. Reulbach, C. Gaul, J. G. Heckmann, B. Neundorfer, and M. Scibor Telemedicine in Emergency Evaluation of Acute Stroke: Interrater Agreement in Remote Video Examination With a Novel Multimedia System Stroke, December 1, 2003; 34(12): 2842 - 2846. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Wiborg and B. Widder Teleneurology to Improve Stroke Care in Rural Areas: The Telemedicine in Stroke in Swabia (TESS) Project Stroke, December 1, 2003; 34(12): 2951 - 2956. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Crome and M. Bahr Editorial Comment--Remote Evaluation of Acute Ischemic Stroke: A Reliable Tool to Extend Tissue Plasminogen Activator Use to Community and Rural Stroke Patients? Stroke, October 1, 2003; 34 (10): e191 - e192. [Full Text] [PDF]
|
|
|
|
|
|
M. M. Rymer, D. Thurtchley, and D. Summers Expanded Modes of Tissue Plasminogen Activator Delivery in a Comprehensive Stroke Center Increases Regional Acute Stroke Interventions Stroke, June 1, 2003; 34 (6): e58 - e60. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. U. Heuschmann, K. Berger, B. Misselwitz, P. Hermanek, C. Leffmann, M. Adelmann, H.-J. Buecker-Nott, J. Rother, B. Neundoerfer, and P. L. Kolominsky-Rabas Frequency of Thrombolytic Therapy in Patients With Acute Ischemic Stroke and the Risk of In-Hospital Mortality: The German Stroke Registers Study Group Stroke, May 1, 2003; 34(5): 1106 - 1112. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Nighoghossian Editorial Comment--tPA in Daily Clinical Practice Stroke, May 1, 2003; 34(5): 1112 - 1113. [Full Text] [PDF]
|
|
|
|
|
|
S. L. Silliman, B. Quinn, V. Huggett, and J. G. Merino Use of a Field-to-Stroke Center Helicopter Transport Program to Extend Thrombolytic Therapy to Rural Residents Stroke, March 1, 2003; 34(3): 729 - 733. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Niessen, T. Hilger, M. Hoehn, and K.-A. Hossmann Thrombolytic Treatment of Clot Embolism in Rat: Comparison of Intra-arterial and Intravenous Application of Recombinant Tissue Plasminogen Activator Stroke, December 1, 2002; 33(12): 2999 - 3005. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Ruland, P. B. Gorelick, M. Schneck, D. Kim, C. G. Moore, S. Leurgans, and A. Bhardwaj Acute Stroke Care in Illinois: A Statewide Assessment of Diagnostic and Treatment Capabilities * Editorial Comment: A Statewide Assessment of Diagnostic and Treatment Capabilities Stroke, May 1, 2002; 33(5): 1334 - 1340. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. A. Taylor, G. D. Hughes, and R. J. Garrison Cardiovascular Disease Among Women Residing in Rural America: Epidemiology, Explanations, and Challenges Am J Public Health, April 1, 2002; 92(4): 548 - 551. [Abstract] [Full Text]
|
|
|
|
|
|
J. N. Fink, M. H. Selim, S. Kumar, B. Silver, I. Linfante, L. R. Caplan, and G. Schlaug Is the Association of National Institutes of Health Stroke Scale Scores and Acute Magnetic Resonance Imaging Stroke Volume Equal for Patients With Right- and Left-Hemisphere Ischemic Stroke? Stroke, April 1, 2002; 33(4): 954 - 958. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. G. Merino, B. Silver, E. Wong, B. Foell, B. Demaerschalk, A. Tamayo, F. Poncha, and V. Hachinski Extending Tissue Plasminogen Activator Use to Community and Rural Stroke Patients Stroke, January 1, 2002; 33(1): 141 - 146. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. M. Demchuk, D. Tanne, M. D. Hill, S. E. Kasner, S. Hanson, M. Grond, and S. R. Levine Predictors of good outcome after intravenous tPA for acute ischemic stroke Neurology, August 14, 2001; 57(3): 474 - 480. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. J. Gladstone and S. E. Black Update on intravenous tissue plasminogen activator for acute stroke: from clinical trials to clinical practice Can. Med. Assoc. J., August 1, 2001; 165(3): 311 - 317. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. D. Reed, S. C. Cramer, D. K. Blough, K. Meyer, J. G. Jarvik, and D. Z. Wang Treatment With Tissue Plasminogen Activator and Inpatient Mortality Rates for Patients With Ischemic Stroke Treated in Community Hospitals Editorial Comment Stroke, August 1, 2001; 32(8): 1832 - 1840. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H.-C. Koennecke, R. Nohr, S. Leistner, and P. Marx Intravenous tPA for Ischemic Stroke Team Performance Over Time, Safety, and Efficacy in a Single-Center, 2-Year Experience Stroke, May 1, 2001; 32(5): 1074 - 1078. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P.T. Akins, C. Delemos, D. Wentworth, J. Byer, S.J. Schorer, and a. R.P. Atkinson Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke? Neurology, December 26, 2000; 55(12): 1801 - 1805. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. M. Chapman, A. R. Woolfenden, D. Graeb, D. C. C. Johnston, J. Beckman, M. Schulzer, and P. A. Teal Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke : A Canadian Hospital's Experience Stroke, December 1, 2000; 31(12): 2920 - 2924. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Brott and J. Bogousslavsky Treatment of Acute Ischemic Stroke N. Engl. J. Med., September 7, 2000; 343(10): 710 - 722. [Full Text] [PDF]
|
|
|
|
|
|
S. Schmulling, M. Grond, J. Rudolf, and W.-D. Heiss One-Year Follow-Up in Acute Stroke Patients Treated With rtPA in Clinical Routine Stroke, July 1, 2000; 31(7): 1552 - 1554. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Albers, V. E. Bates, W. M. Clark, R. Bell, P. Verro, and S. A. Hamilton Intravenous Tissue-Type Plasminogen Activator for Treatment of Acute Stroke: The Standard Treatment with Alteplase to Reverse Stroke (STARS) Study JAMA, March 1, 2000; 283(9): 1145 - 1150. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||