Acute Anterior Circulation Stroke Research Articles

Insufficient Warfarin Therapy Is Associated With Higher Severity of Stroke Than No Anticoagulation in Patients With Atrial Fibrillation and Acute Anterior-Circulation Stroke.

Insufficient anticoagulant intensity on admission is common in stroke patients with atrial fibrillation (AF) on vitamin K antagonist (VKA) therapy. Nevertheless, the effects of VKA under-treatment on stroke severity or arterial occlusion are not well known. The aim of the present study was to investigate the relationship between insufficient VKA therapy and stroke severity, or the site of arterial occlusion in patients with acute ischemic stroke (AIS) and AF.Methods and Results:From March 2011 through July 2016, 446 consecutive patients with AF and AIS were recruited. Of the 446 patients, 364 (167 women; median age, 79 years; IQR, 71-86 years) with anterior-circulation stroke were assessed to investigate the effects of insufficient VKA. Of these, 281 were on no anticoagulant, 53 were undertreated with a VKA, and 30 were sufficiently treated with VKA on admission (PT-INR ≥2.0 for patients <70 years and PT-INR ≥1.6 for ≥70 years old). On multivariate analysis, insufficient VKA was independently associated with severe stroke (i.e., initial NIHSS score ≥10; OR, 2.70, P=0.022) and higher prevalence of proximal artery occlusion (OR, 1.91; P=0.039) compared with no anticoagulant therapy. Insufficient VKA therapy on admission was associated with higher severity of stroke and higher prevalence of proximal artery occlusion in patients with AF and acute anterior-circulation stroke compared with no anticoagulant medication.

Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

AbstractSuccessful revascularization is one of the main predictors of a favorable clinical outcome after mechanical thrombectomy. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome. This study aimed to investigate the clinical, imaging, and procedural factors that are predictive of poor clinical outcomes despite successful revascularization after mechanical thrombectomy in patients with acute anterior circulation stroke. The authors evaluated 69 consecutive patients (mean age, 74.6 years, 29 women) who presented with acute ischemic stroke due to internal cerebral artery or middle cerebral artery occlusions and who were successfully treated with mechanical thrombectomy between July 2014 and November 2016. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months after treatment. The associations between the clinical, imaging, and procedural factors and poor outcome were evaluated using logistic regression analyses. Using multivariate analyses, the authors found that the preoperative National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR], 1.152; 95% confidence interval [CI], 1.004–1.325; p = 0.028), the diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) (OR, 0.604; 95% CI, 0.412–0.882; p = 0.003), and a Thrombolysis in Cerebral Infarction (TICI) 2b classification (OR, 4.521; 95% CI, 1.140–17.885; p = 0.026) were independent predictors of poor outcome. Complete revascularization to reduce the infarct volume should be performed, especially in patients with a high DWI-ASPECTS, to increase the likelihood of a good outcome.

Clinical Effectiveness and Safety Outcomes of Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke in China

Backgrounds and Purpose: This study was aimed at investigating the outcomes and predictors for the poor functional outcome after endovascular treatment (EVT) in a large, mostly Asian population. Methods: Between January 2014 and June 2016, acute stroke patients with anterior circulation occlusion and EVT were retrospectively enrolled from 21 stroke centers in China. The main outcomes were modified Rankin Scale (0-2 as functional independence, 3-6 as poor) at 90 days, symptomatic intracranial hemorrhage (sICH) at 72 h, and death at 90 days. Logistic regression was used to identify predictors for poor functional outcome at 90 days. Results: Of the 698 patients, 304 (43.6%) patients had functional independence at 90 days. The sICH rate was 15.5% (108/698) and mortality rate at 90 days was 25.4% (177/698). Age (OR 1.04, 95% CI 1.02-1.07), National Institutes of Health Stroke Scale score at admission (11-20 vs. ≤10, OR 2.38, 95% CI 1.23-4.59; ≥21 vs. ≤10, OR 3.66, 95% CI 1.72-7.80), baseline glucose level (OR 1.09, 95% CI 1.01-1.18), onset to groin puncture >6 h (OR 1.88, 95% CI 1.06-3.31), sICH (OR 15.49, 95% CI 5.16-46.43), and pneumonia (OR 3.15, 95% CI 1.86-5.32) were independent predictors of poor functional outcomes, while good recanalization (OR 0.26, 95% CI 0.13-0.54), preoperative Alberta Stroke Program Early CT Score 8-10 (OR 0.48, 95% CI 0.28-0.83), and good collateral flow (OR 0.50, 95% CI 0.32-0.79) were protective factors. Conclusions: This study provides evidence in real world to support the performance of EVT in acute anterior circulation stroke patients in Chinese population. Patients with small infarct core, successful recanalization, good collateral status, and short treatment delay without sICH or pneumonia may benefit from EVT.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with Cervicocephalic Dolichoarteriopathy

Cervicocephalic dolichoarteriopathy is not rare in patients with acute stroke. Results of intravenous (IV) tissue plasminogen activator (tPA) treatment have not been documented in this specific population. One hundred (58 females, age: 69 ± 13 years) consecutive patients treated with IV tPA for acute anterior circulation stroke were analyzed. Smoker's criteria were used to score basilar artery dolichoarteriopathy and combined criteria of Weibel-Fields and Metz for cervical carotid artery dolichoarteriopathy. Adjusted rates of effective response to tPA (defined as a decrease of the National Institutes of Health Stroke Scale [NIHSS] score to 1 or 0, or a total decrease ≥4 point by the end of the first 24 hours; in 51%); first-day dramatic response (≥8 NIHSS score decrease; seen in 27%); 3-month favorable (modified Rankin score ≤2; in 46%) and excellent (modified Rankin score ≤1; in 37%) functional prognosis, and hemorrhagic complications (any hemorrhage in 34%, significant Fiorelli's parenchymal hemorrhage type 2 in 8%) of IV tPA were not modified with presence and categories of the basilar and extracranial carotid artery dolichoarteriopathy. Univariate analysis documented that basilar artery dolichoarteriopathy was significantly more prevalent in patients with effective response to IV tPA (22% versus 6%, odds ratio: 4.22, P = .041). However, an exploratory multiple regression analysis disclosed that NIHSS (per 1 point, β = -.256, P = .009) and time to needle (per 15-minutes, β = -2.389, P = .019) were significant determiners of early favorable prognosis, whereas dolichoectasia was not (β = .141, P = .159). IV tPA is safe and effective in acute anterior circulation stroke coexistent with intracranial posterior circulation dolichoarteriopathy and cervical carotid artery kinking, tortuosity, or coiling.

Spotlight on the June 13 issue

#### Notable in Neurology This issue features an article detailing the ability of the Alberta Stroke Program Early Computed Tomography Score to detect infarction at different onset-to-CT time in acute anterior circulation stroke and another demonstrating that thalamic hubness can serve as a potential biomarker of surgical outcome in patients with temporal lobe epilepsy. A featured article describes a study that determined that CSF phosphorylated neurofilament heavy chain concentrations have added value as diagnostic biomarkers for amyotrophic lateral sclerosis. ### MR perfusion lesions after TIA or minor stroke are associated with new infarction at 7 days In this study, magnetic resonance perfusion-weighted imaging …

Correction to: Predictors of the Aspiration Component Success of a Direct Aspiration First Pass Technique (ADAPT) for the Endovascular Treatment of Stroke Reperfusion Strategy in Anterior Circulation Acute Stroke.

In the article by Blanc et al, “Predictors of the Aspiration Component Success of a Direct Aspiration First Pass Technique (ADAPT) for the Endovascular Treatment of Stroke Reperfusion Strategy in Anterior Circulation Acute Stroke,” which published online ahead of print on April 20, 2017, and appeared …

Internal Carotid Artery and the Proximal M1 Segment Are Optimal Targets for Mechanical Thrombectomy

Background and Purpose: Mechanical thrombectomy (MT) is an established treatment of acute anterior circulation stroke caused by large vessel occlusion (LVO). We compared the clinical outcome (3-month modified Rankin Scale, mRS) in hyperacute (<3h from the onset of symptoms) ischemic stroke between an MT and an intravenous thrombolysis (IVT) cohort in proximal (ICA and the proximal M1 segment of the middle cerebral artery) and distal (the distal M1 and the M2 segment) LVOs. Methods: We prospectively reviewed 67 patients who underwent MT with newer-generation stent retrievers. The IVT cohort consisted of 98 patients who received IVT without MT. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome, and the clinical outcome. Differences between the groups were studied with theoretically appropriate statistical tests and binary logistic regression analysis. Results: The proportion of patients who had a proximal LVO and experienced good (mRS ≤2) or excellent (mRS ≤1) clinical outcome was significantly larger in the MT group (62 vs. 7%, p < 0.001; 47 vs. 3%, p < 0.001, respectively). In a regression model including relevant confounding variables, good clinical outcome was seen significantly more often among patients with proximal occlusions (OR = 6.0, CI 95% 1.9-18.3, p = 0.002). In a similar model, no statistically significant differences were observed in patients with more distal occlusions. Conclusions: MT is superior to IVT in achieving good clinical outcome in hyperacute anterior circulation stroke in the most proximal occlusions (ICA and proximal M1 segment). In the distal M1 and M2 segments neither of these therapies clearly outperforms the other.

Epilepsia partialis continua after an anterior circulation ischaemic stroke.

Although cerebrovascular disorders are the main cause of epilepsia partialis continua (EPC) in adulthood, the frequency of EPC after stroke is unknown. The aim was to prospectively ascertain its frequency 1 year after an ischaemic stroke. This was a prospective study of consecutive acute anterior circulation ischaemic stroke patients, previously independent, with an admission National Institutes of Health Stroke Scale score ≥4, an acute ischaemic lesion on imaging and no previous epileptic seizures. During admission patients received standardized diagnostic and medical care and were submitted to a neurophysiological evaluation protocol. One year after stroke, patients were re-evaluated by an epilepsy expert neurologist and performed a video-electroencephalogram with electromyography co-registration whenever myoclonus was observed during neurological examination for jerk-locked back averaging analysis (JLBA). EPC was defined as continuously repeated fragments of epileptic seizures, with preserved consciousness, lasting at least 1 h, and representing locally restricted epileptic activity. In all, 151 acute anterior circulation stroke patients were consecutively included and prospectively evaluated, but 23 died in the first year. One year after stroke, from 127 patients alive, 117 (92.1%) underwent clinical and neurophysiological evaluation. In two (1.7%) patients, EPC diagnosis was made both by clinical and electroencephalographic criteria, namely JLBA. Both patients had a history of remote symptomatic seizures and one of them acute symptomatic seizures and non-convulsive status epilepticus criteria during the first 7 days after stroke. Despite its low frequency, the high stroke incidence makes post-stroke EPC relevant. This study draws attention to this recognizable condition with therapeutic and eventually prognostic implications.

Predictors of the Aspiration Component Success of a Direct Aspiration First Pass Technique (ADAPT) for the Endovascular Treatment of Stroke Reperfusion Strategy in Anterior Circulation Acute Stroke.

A direct aspiration first pass technique (ADAPT) has been reported to be fast, safe, and effective for the treatment of acute ischemic stroke. The aim of this study is to determine the preoperative factors that affect success of the aspiration component of the technique in ischemic stroke patients with large vessel occlusion in the anterior circulation. We enrolled all 347 consecutive patients with anterior circulation acute ischemic stroke admitted for mechanical thrombectomy at our institution from August 2013 to October 2015 and treated by ADAPT for the endovascular treatment of stroke. Baseline and procedural characteristics, modified thrombolysis in cerebral infarction scores, and 3-month modified Rankin Scale were captured and analyzed. Among the 347 patients (occlusion sites: middle cerebral artery=200, 58%; internal carotid artery Siphon=89, 25%; Tandem=58, 17%), aspiration component led to successful reperfusion (modified thrombolysis in cerebral infarction 2b/3 scores) in 55.6% (193/347 patients), stent retrievers were required in 40%, and a total successful final reperfusion rate of 83% (288/347) was achieved. Overall, procedural complications occurred in 13.3% of patients (48/347). Modified Rankin Scale score of 0 to 2 at 90 days was reported in 45% (144/323). Only 2 factors positively influenced the success of the aspiration component: an isolated middle cerebral artery occlusion (P<0.001) and a shorter time from stroke onset to clot contact (P=0.018). In this large retrospective study, ADAPT was shown to be safe and effective for anterior circulation acute ischemic stroke with a final successful reperfusion achieved in 83%. The site of arterial occlusion and delay of the procedure were predictors for reperfusion. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02523261, NCT02678169, and NCT02466893.

The association between collateral status, recanalization and long term outcome in stroke patients treated with stent retrievers – Are there indications not to perform thrombectomy based on CT angiography?

Background and purposeTo investigate the association between baseline pial collateral status on computed tomography angiography (CTA) with recanalization and functional outcome in patients with acute anterior circulation stroke treated with stent retriever thrombectomy. Material and methodsRetrospective analysis of 87 patients from a prospective thrombectomy registry. Collateral status on CTA source images was categorized into good, moderate, and poor with the Tan and Miteff scores by two-blinded readers. Association between CTA collateral status and successful recanalization was investigated with univariate regression analysis. Multivariate logistic regression was used to analyse the association between collateral score and favourable clinical outcome (mRS 0-2) and death at follow-up. ResultsMean age was 72.5 years and baseline median NIHSS score was 15. Patients with poor collaterals on Tan score had a significant higher mortality compared with moderate or good collaterals during a mean follow-up period of 5.2 months (85.7% vs. 30.6% vs. 25.7%, P<0.001). Univariate logistic regression analysis did not show a significant association between Tan score (OR 1.681, 95% CI 0.683–4.140) and successful recanalization. Higher age (OR 1.067, 95% CI 1.013–1.124; P=0.015) and lower Tan score (OR 0.421, 95% CI 0.192–0.922; P=0.031) were independent predictors of death at follow-up on multivariate analysis. The Miteff collateral score could be assessed only in 65 of the 87 patients and the Tan collateral score had a higher interrater reliability. ConclusionsPoor collaterals on CTA were associated with a very high rate of fatal outcome in anterior circulation stroke patients despite a high rate of successful recanalization with stent retrievers.

Severe carotid stenosis and delay of reperfusion in endovascular stroke treatment: an Interventional Management of Stroke-III study

OBJECTIVE The impact of extracranial carotid stenosis on interventional revascularization of acute anterior circulation stroke is unknown. The authors examined the effects of high-grade carotid stenosis on the results of endovascular treatment of patients in the Interventional Management of Stroke (IMS)-III trial. METHODS The 278 patients in the endovascular arm of the IMS-III trial were categorized according to the degree of carotid stenosis as determined by angiography. In comparing patients with severe stenosis or occlusion (≥ 70%) to those without severe stenosis (< 70%), the authors evaluated the time to endovascular reperfusion, modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores, 24-hour mean infarct volumes, symptomatic intracerebral hemorrhage rates, and modified Rankin Scale (mRS) scores at 90 days. RESULTS Compared with the 249 patients with less than 70% stenosis, patients with severe stenosis (n = 29) were found to have a significantly longer mean time to reperfusion (105.7 vs 77.7 minutes, p = 0.004); differences in mTICI scores, infarct volumes, hemorrhage rates, and mRS scores at 90 days did not reach statistical significance. Multiple regression analysis revealed that severe carotid stenosis (p < 0.0001) and higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.004) were associated with an increase in time to reperfusion. Older age (p < 0.0001), higher NIHSS score (p < 0.0001), and the absence of reperfusion (p = 0.001) were associated with worse clinical outcomes. CONCLUSIONS Severe ipsilateral ICA stenosis was associated with a significantly longer time to reperfusion in the IMS-III trial. Although these findings may not translate directly to modern devices, this 28-minute delay in reperfusion has significant implications, raising concern over the treatment of tandem ICA stenosis and downstream large-vessel occlusion.

Abstract 38: Brain CT Perfusion is Superior to Non-contrast CT Aspects in the Evaluation of Hyperacute Infarct Volume

Objective: To compare the predictive capacity to detect established infarct in acute anterior circulation stroke between the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on non-contrast computed tomography (CT) and CT perfusion. Methods: Fifty-nine acute anterior circulation ischemic stroke patients received brain non-contrast CT, CT perfusion and hyperacute magnetic resonance imaging (MRI) within 100 minutes from CT imaging. ASPECTS scores were calculated by 4 independent vascular neurologists, blinded from CT perfusion and MRI data. CT perfusion infarct core volumes were calculated by MIStar software. The accuracy of commonly used ASPECTS cut-off scores and a CT perfusion core volume of ≥ 70 mL to detect a hyperacute MRI diffusion lesion of ≥ 70 ml was evaluated. Results: Median ASPECTS score was 9 (IQR 7-10). Median CT perfusion core volume was 22 ml (IQR 10.4-71.9). Median MRI diffusion lesion volume was 24,5 ml (IQR 10-63.9). ASPECTS score of &lt; 6 had a sensitivity of 0.37, specificity of 0.95 and c-statistic of 0.66 to predict an acute MRI lesion ≥ 70 ml. In comparison, a CT perfusion core lesion of ≥ 70 ml had a sensitivity of 0.76, specificity of 0.98 and c-statistic of 0.92. The CT perfusion core lesion covered a median of 100% of the acute MRI lesion volume (IQR 86-100%). Conclusions: CT perfusion is superior to ASPECTS to predict hyperacute MRI lesion volume in ischemic stroke.

Abstract 129: Clinical-imaging Mismatch versus Perfusion Imaging Mismatch Selection for Stroke Patients Undergoing Mechanical Thrombectomy

Background and Purpose: The best approach to select patients for reperfusion therapy in acute ischemic stroke remains to be established. Different methodologies have been proposed using different clinical, vascular, and parenchymal imaging parameters. Our aim is to compare Perfusion-imaging Mismatch (PIM) and Clinical-Core Mismatch (CCM) patient selection and assess their ability to predict outcomes. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution for patients with acute anterior circulation strokes, adequate CT perfusion imaging maps and a National Institute of health Stroke Scale (NIHSS) ≥10 from September 2010 to March 2015. Patients were categorized according to the PIM and CCM definitions. PIM was defined as follows: Core Lesion ≤50cc; Tmax &gt;10sec &lt;100cc; Mismatch (Tmax&gt; 6s lesion - core lesion) ≥15cc and ratio &gt;1.8. CCM was defined as: NIHSS ≥ 10 and core infarct &lt;31 cc (and age &lt; 80) or NIHSS ≥ 20 and core infarct &lt;51 cc (and age &lt; 80) or NIHSS ≥ 10 and core infarct &lt;21 cc (and age ≥ 80). The ability of PIM and CCM to predict good outcomes (modified Rankin scale 0-2) was evaluated using the area under the receiver operating characteristic curves (AUC), Akaike information criterion (AIC) and Bayesian information criterion (BIC). Results: A total of 368 patients qualified for the study. PIM had a lower number of qualifying patients compared to CCM (n=231, 62.8% vs n=303, 82.3%). The two groups were statistically different (p&lt;0.001) with the following disagreement: 12 PIM+/CCM- and 84 PIM-/CCM+. There were no differences in good outcomes between PIM+ and PIM- patients (52% vs 48%, p=0.5). CCM+ patients had higher rates of good outcomes than CCM- (53% vs. 35%, p=0.015). There were no differences between PIM and CCM in predicting good outcomes as assessed by the AUC, AIC and BIC (0.82, 323.64 and 330.61 vs 0.82, 323.56 and 330.53 respectively) Conclusion: We were unable to demonstrate a difference between the PIM and CCM in predicting clinical outcomes. However, PIM seems to unjustifiably disqualify a significant proportion of patients that still benefit from reperfusion. In contrast with CCM, PIM does not seem to be a good discriminator of good outcomes. Future prospective studies are warranted.

Abstract WMP21: The Delayed Vessel Sign in Multiphase CT Angiography: Facilitating the Rapid On-table Confirmation of Acute Ischaemic Stroke

Objective: The “delayed vessel sign” refers to the presence of relative unilateral delayed enhancement of a vessel or vessels in the anterior circulation on delayed phases of a multiphase CTA (MPCTA) distal to the point of vessel occlusion. We aimed to determine if educating radiologists on the “delayed vessel sign” would improve sensitivity, confidence and speed in the detection of distal anterior circulation vessel occlusions in the suspected stroke patient. Methods: Non-contrast CT (NCCT) and MPCTA studies of 53 individual patients, who presented with signs/symptoms of acute anterior circulation stroke, were retrospectively selected by an independent radiologist. 15 cases without a vessel occlusion, 15 cases with a M1 occlusion and 23 cases with a distal anterior circulation (A2/M2/M3) occlusion were included. Initially, NCCT and single phase CTA (SPCTA) studies were independently interpreted by four observers (two neuroradiologists, two radiology trainees) and observers’ confidence (scale 1-5), speed and sensitivity of detection were recorded. Observers were then educated on the “delayed vessel sign” and each study was re-examined after an interval of at least 14 days. Results: There was a significant improvement in the sensitivity of detection of distal anterior circulation vessel occlusions on MPCTA compared to SPCTA (p=0.0003) and this was also true for M1 occlusions (p=0.045). Overall confidence was 4.0 for SPCTA and 4.88 with MPCTA (p&lt;0.0001). Average time taken to interpret each case on SPCTA was 85.5s and decreased to 40.1s with MPCTA (p&lt;0.0001). Conclusion: The “delayed vessel sign” is a reliable indicator of ipsilateral vessel occlusion, and is particularly useful in cases involving distal MCA branches where the occlusion is not easily identified on the initial angiographic phase. We have found this sign facilitates the rapid on-table confirmation of acute ischemic stroke, even when small vessels are involved and the clinical diagnosis is uncertain.

Predictive Factors for Good Outcome and Mortality After Stent-Retriever Thrombectomy in Patients With Acute Anterior Circulation Stroke.

Background and Purpose Predictive factors associated with stent-retriever thrombectomy for patients with acute anterior circulation stroke remain to be elucidated. This study aimed to investigate clinical and procedural factors predictive of good outcome and mortality after stent-retriever thrombectomy in a large cohort of patients with acute anterior circulation stroke.Methods We analyzed clinical and procedural data in 335 patients with acute anterior circulation stroke treated with stent-retriever thrombectomy. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months. The associations between clinical, imaging, and procedural factors and good outcome and mortality, respectively, were evaluated using logistic regression analysis.Results Using multivariate analysis, age (odds ratio [OR], 0.965; 95% confidence interval [CI], 0.944-0.986; P=0.001), successful revascularization (OR, 4.658; 95% CI, 2.240-9.689; P<0.001), parenchymal hemorrhage (OR, 0.150; 95% CI, 0.049-0.460; P=0.001), and baseline NIHSS score (OR, 0.908; 95% CI, 0.855-0.965; P=0.002) were independent predictors of good outcome. Independent predictors of mortality were age (OR, 1.043; 95% CI, 1.002-1.086; P=0.041), successful revascularization (OR, 0.171; 95% CI, 0.079-0.370; P<0.001), parenchymal hemorrhage (OR, 2.961; 95% CI, 1.059-8.276; P=0.038), and a history of previous stroke/TIA (OR, 3.124; 95% CI, 1.340-7.281; P=0.008).Conclusions Age, revascularization status, and parenchymal hemorrhage are independent predictors of both good outcome and mortality after stent retriever thrombectomy for acute anterior circulation stroke. In addition, NIHSS score on admission is independently associated with good outcome, whereas a history of previous stroke is independently associated with mortality.

Elevated mean platelet volume is associated with poor outcome after mechanical thrombectomy

BackgroundElevated mean platelet volume (MPV), indicating higher platelet activity, could be a predictor of prognosis in patients with acute ischemic stroke receiving medical therapy.ObjectiveTo investigate the relationship between MPV and...

Safety and Tolerability of SonoVue® in Patients with Large Artery Anterior Circulation Acute Stroke.

Ultrasound contrast agents (UCAs) are routinely used to improve the visualization of intracranial arteries. Since a higher rate of intracranial hemorrhage (ICH) has been observed in patients undergoing sonothrombolysis in combination with UCAs, we conducted this study with the aim of assessing safety and tolerability of SonoVue® in patients with acute ischemic stroke due to anterior circulation large artery occlusion (LAO) and eligible to intravenous thrombolysis and/or mechanical thrombectomy. Among 474 patients consecutively admitted to our Stroke Unit with anterior circulation ischemic stroke, SonoVue® was administered during transcranial ultrasound evaluation to 48 patients with suspected LAO for diagnostic confirmation (group I) and to 44 patients with inadequate temporal bone window. Forty-eight stroke patients with LAO diagnosed only by computed tomography (CT) angiography /magnetic resonance (MR) angiography and matched for age, gender, and National Institutes of Health Stroke Scale score with group I represented the control group (group II). Thrombolysis, thrombectomy, or combined treatment were offered to all eligible patients. Brain MR imaging/CT was performed in both groups in case of neurological deterioration or after 1 week to check for ICH. SonoVue® did not cause any serious adverse event; only mild and transient side effects were reported in six cases (6.5%). Among patients in groups I and II, there were 31 (32.3%) secondary cerebral bleedings with no statistically significant difference between the groups, but only 2 (2.1%) were symptomatic. According to our study, SonoVue® can be safely administered to acute ischemic stroke patients with suspected anterior circulation LAO and/or inadequate temporal bone window.

Hypointense Vessels Detected by Susceptibility-Weighted Imaging Identifies Tissue at Risk of Infarction in Anterior Circulation Stroke.

The diagnostic value of susceptibility-weighted magnetic resonance imaging of acute stroke patients has shown potential as a surrogate marker of impaired hemodynamics. We investigate the value of asymmetrical hypointense cerebral vessels (HV) for the identification of vessel status and tissue at risk of infarction (TaR). Symmetry of HV was visually rated on SWI data from a well-defined population of acute anterior circulation stroke with onset <24 hours. MRI perfusion data was analyzed and volumes of tissue at risk segmented using a delay threshold of Tmax> 6 seconds. Status of the extra- and intracranial arteries was assessed by ultrasound and MR angiography. 35 patients were included (12 women; median age 69 years, IQR 61-77; median NIHSS at admission 10, IQR 6-20). Asymmetrically distributed HV were detected at the stroke hemisphere in 25 patients (71%). Of those, 12 patients displayed occlusion of the middle cerebral artery, whereas occlusion of the extracranial ICA was detected in 6 patients. TaR was larger, yet not significantly different in patients with asymmetrically HV (mean volume 38.9 ml, SD 52.9 ml) compared to patients showing symmetrical HV (4.2 ml; SD 10.7 ml, p-value 0.081). Significant differences where, however, found after excluding patients with extracranial ICA occlusions (42.9 ml; SD 50.4 ml vs. 4.2 ml, SD 10.8 ml, p-value 0.025). Visual analysis of HV in SWI identifies tissue at risk in patients with anterior circulation stroke. Potentially pre-existing extracranial ICA occlusions leading to prominent HV have to be considered as a confounding factor.

Imaging Predictors for Atherosclerosis-Related Intracranial Large Artery Occlusions in Acute Anterior Circulation Stroke.

Imaging Predictors for Atherosclerosis-Related Intracranial Large Artery Occlusions in Acute Anterior Circulation Stroke.

Treatment in patients who are not eligible for intravenous alteplase: MR CLEAN subgroup analysis.

Patients with acute ischemic stroke due to intracranial large vessel occlusion benefit from intra-arterial therapy. Uncertainty exists about the effect of intra-arterial therapy in patients with contraindications for treatment with intravenous alteplase treatment. Our aim was to describe the clinical characteristics of this subgroup of patients and whether intra-arterial therapy is as safe and effective as it is after intravenous alteplase treatment. All 500 MR CLEAN patients were included and we distinguished between patients who were and were not treated with intravenous alteplase treatment. We estimated the effect of intra-arterial therapy on the shift on the modified Rankin Scale score with ordinal logistic regression analysis and tested for interaction of intravenous alteplase treatment with intra-arterial therapy on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Fifty-five patients (11%) were not treated with intravenous alteplase treatment, mostly because of prolonged coagulation time tests or recent surgery. These patients were older and more often had atrial fibrillation or other vascular comorbidity. There was no interaction between intravenous alteplase treatment and intervention effect (p = 0.927). Intra-arterial therapy effect size in patients without intravenous alteplase treatment was 2.06 [95% CI: 0.69-6.13] and in patients with intravenous alteplase treatment 1.71 [95% CI: 1.22-2.40]. There were no safety issues. For patients with acute ischemic anterior circulation stroke caused by intracranial large vessel occlusion, who have contraindications for intravenous alteplase, intra-arterial treatment is not less effective or less safe than in patients who receive the treatment after intravenous alteplase. Clinical trial registration-URL: http://www.trialregister.nl. Unique identifier: (NTR)1804.Clinical trial registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN10888758.