Transcranial Doppler Ultrasound Timing Critical for Beneficial Outcomes Following Stroke Thrombolysis

The use of hyperacute transcranial Doppler ultrasound (TCD) in patients who undergo stroke thrombolysis is safe and may be associated with better outcomes when performed prior to or during intravenous thrombolysis (IVT) in order to avoid treatment delays, according to analysis of data from the Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register (SITS-ISTR) collected between December 2002 and December 2011. Findings from the study were published in Stroke.

The primary objective of the analysis was to evaluate the hypothesis that TCD examination prior to IVT increases door-to-needle time (DNT) and assess the extent of any increase. Secondary objectives included the following evaluations of hypotheses: (1) that outcomes among patients examined with TCD prior to IVT differ from outcomes among patients who are not; (2) that outcomes among patients examined with TCD during IVT differ from outcomes among patients who are not; and (3) that TCD examination during IVT is superior to TCD prior to IVT with respect to DNT and clinical outcomes. Study outcomes included DNT, symptomatic intracerebral hemorrhage, functional outcome per modified Rankin scale, and mortality at 3 months.

Among 31,596 patients registered in SITS-ISTR during the study period, 11,265 received treatment at 124 hospitals (in 20 countries), which reported at least 1 pre-IVT TCD examination. The database also contained records from 9044 patients at 107 hospitals (in 19 countries), which reported at least 1 TCD examination conducted during IVT. Overall, 15.1% (1701 of 11,265) of patients were examined with TCD prior to IVT infusion, and 8.3% (747 of 9044) of patients were examined with TCD during IVT infusion.

DNT was significantly higher among patients who underwent pre-IVT TCD compared with those examined with TCD during IVT (74 minutes vs 60 minutes, respectively; P <.001). Moreover, onset-to-needle time was also higher among patients who received pre-IVT TCD compared with those examined with TCD during IVT (150 minutes vs 140 minutes, respectively; P <.001).

After multivariate adjustment, TCD during IVT was independently associated with modestly increased excellent functional outcomes at 3 months (modified Rankin scale, 0 to 1; adjusted odds ratio [aOR], 1.28; 95% CI, 1.06-1.55; P =.012) and lower mortality (aOR, 0.73; 95% CI, 0.55-0.95; P =.022).

The researchers concluded that although the association of hyperacute TCD with beneficial outcomes suggests a potential impact on the management of patients with acute stroke, further investigation is warranted.

Reference

Mazya MV, Ahmed N, Azevedo E, et al; on behalf of the SITS Investigators. Impact of transcranial Doppler ultrasound on logistics and outcomes in stroke thrombolysis: results from the SITS-ISTR. Stroke. 2018;49(7):1695-1700.