Acute Revascularization Therapy Research Articles

Ruyi Zhenbao Tablet and Baimai Ointment Therapy in Acute Ischemic Stroke: A Study Protocol for a Multi-Center, Randomized, Double-blinded, and Parallel-Controlled Trial.

Stroke is characterized by high incidence, recurrence rate, and mortality. Patients with acute ischemic stroke (AIS) who are ineligible for acute revascularization therapy require more effective medication treatments. A previous clinical study showed that Ruyi Zhenbao tablets and Baimai ointments might be effective against AIS; however, high-quality clinical evidence supporting their application in AIS is lacking. To explore the efficacy of the two classic Tibetan medicines in the treatment of AIS, a randomized clinical trial will be conducted in patients with AIS who are not eligible for thrombolytic treatment. A prospective, randomized, multiple-center, double-blinded, placebo-controlled, and parallel-group trial will be conducted. We shall randomize 480 eligible participants to either the intervention or the control group. The distribution ratio of each group will be 1:1:1:1, including 120 patients each in the dual-medication group, the Baimai ointment group, the Ruyi Zhenbao tablet group, and the placebo group. Participants will be treated with medication for 8 weeks, and they will receive three follow-up visits: at 4 weeks (D29), 8 weeks (D56), and 90 days (D90) after commencing treatment. The primary outcome will be D90 change in the simplified Fugl-Meyer score from baseline to posttreatment. The secondary outcomes are as follows: D29 change of simplified Fugl-Meyer score from baseline to posttreatment; proportion of participants whose D29 NIHSS scores decreased by four or more points from baseline D90 proportion of subjects with mRS score of 0-2 (inclusive); D90 proportion of subjects with Barthel index score ≥95; D90 incidence of cardiovascular and cerebrovascular events. Safety endpoint includes mortality within 90 days; proportion of subjects with adverse events/serious adverse events within 90 days. This research protocol lays a solid groundwork for its practical execution. This study is poised to serve as a reference for other Tibetan medicine researchers, contributing to the reduction of stroke-related expenditures globally and, in turn, benefiting a broader population of stroke patients.

Functional outcomes of ischemic stroke patients aged over 80 years treated with acute revascularization therapy according to pre-morbid disability: a PARADISE study.

Aging population leads to changes in the profile of patients with acute ischemic stroke (IS), and older adults were largely excluded from randomized clinical trials of acute revascularization therapy. This study aimed to assess functional outcomes of treated IS patients > 80 years old according to prior disability and identify associated factors. Consecutively older patients with acute IS treated with either IV thrombolysis and/or mechanical thrombectomy were enrolled between 2016 and 2019. Pre-morbid disability was assessed using the modified Rankin Scale (mRS) score, and patients were classified as being independent (mRS score, 0-2) or having pre-existing disability (mRS score, 3-5). A multivariable logistic regression analysis was performed to assess factors associated with a poor functional outcome (mRS score > 3) at 3 and 12 months in each group of patients. Among 300 included patients (mean age: 86.3 ± 4.6 years, 63% women, median NIHSS score: 14, IQR: 8-19), 100 had a pre-existing disability. In patients with a pre-morbid mRS score of 0-2, 51% had mRS >3 including 33% of deaths at 3 months. At 12 months, 50% had a poor outcome including 39% of deaths. In patients with a pre-morbid mRS score of 3-5, 71% had a poor outcome at 3 months including 43% of deaths, and at 12 months, 76% had mRS >3 including 52% of deaths. In multivariable models, the NIHSS score at 24 h was independently associated with poor outcomes at 3 and 12 months in both patients with (OR = 1.32; 95% CI: 1.16-1.51, p < 0.001 for 12 months outcome) or without (OR = 1.31; 95% CI: 1.19-1.44, p < 0.001 for 12 months outcome) pre-morbid disability. Although a large proportion of older patients with a pre-existing disability had a poor functional outcome, they did not differ from their non-impaired counterparts regarding prognostic factors. This means that there were no factors in our study that would help clinicians identify patients at risk of poor functional outcomes after revascularization therapy among those with prior disability. Further studies are needed to better understand the post-stroke trajectory of older IS patients with a pre-morbid disability.

Plasma growth differentiation factor − 8 / Myostatin level as prognostic biomarker of patients with ischemic stroke and acute revascularization therapy. PARADISE study

BackgroundIdentifying biological markers of ischemic stroke (IS) is an important research approach to develop innovative therapeutic strategies. This study aimed to assess the association between plasma Growth Differentiation Factor-8 (GDF-8)/Myostatin levels and outcome of IS patients. MethodsConsecutive patients with acute IS treated with either intravenous thrombolysis and/or mechanical thrombectomy at Dijon University Hospital, France were prospectively included. Clinical variables were recorded, and plasma GDF-8 was collected just after the revascularization procedure. Primary endpoint was functional outcome at 3 months assessed by the modified Rankin Scale (mRS) score. Secondary endpoints included mRS scores at 6 and 12 months, and overall mortality over 1-year of follow-up. ResultsAmong the 173 included patients (median age: 76 years, Interquartile range (IQR): 66–85; 49% women), median plasma GDF-8 levels at admission were significantly lower in those with a poor outcome at 3 months defined as a mRS score > 2 (2073 (IQR: 1564-2757) pg/mL versus 1471 (1192-2241) pg/mL, p < 0.001). Lower GDF-8 levels at admission were associated with higher 3-months mRS score in multivariable ordinal logistic regression analysis (OR = 0.9995; 95% CI: 0.9991–0.9999, p = 0.011). The association was also observed with 6- and 12-month mRS scores. Although mortality was higher in patients with lower GDF-8 levels, the association was not significant in multivariable Cox analysis. ConclusionLower plasma GDF-8 levels were associated with a poorer functional outcome in IS patients treated with acute revascularization therapy. Underlying pathophysiological mechanisms involving GDF-8 in post-stroke outcome remain to be elucidated.

Quality of Life in the First Year after Ischemic Stroke Treated with Acute Revascularization Therapy.

(1) Background: we aimed to describe the disease-specific quality of life (QoL) of ischemic stroke patients treated with acute revascularization therapy, its evolution from 6 months to 12 months, and associated factors. (2) Methods: QoL was assessed with the SS-QoL in consecutive patients treated with either intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT). Variables associated with QoL scores and its evolution were studied using multivariate mixed models, and interaction with time. Analyses were performed in four domains of SS-QoL: self-care, mobility, mood, and social roles. (3) Results: Among the 501 included patients (mean (sd) age 68.9 (14.5), 49% women), lower post-stroke QoL was independently related to lower level of school education, prestroke mRS > 2, and 24 h NIHSS score > 4. Independent predictors of unfavorable evolution of QoL over time were age <75 years (Mobility p = 0.0194 and Mood p = 0.0015), NIHSS score ≤ 4, (Self-care p = 0.0053 and Mood p = 0.0048), and modified Rankin Scale score ≤ 2 (Social roles, p = 0.0006). Revascularization therapy had no significant effect on the QoL scores, but patients treated with MT (alone or as bridging therapy) had significantly greater improvement in mobility score between 6 and 12 months than patients treated with IVT alone (p = 0.0072). (4) Conclusion: QoL evolution over one year had only slight variation and was associated with the modalities of acute treatment, age, and stroke severity.

Primary mechanical thrombectomy for anterior circulation stroke in children: Report of two cases and literature review.

Introduction and importancePediatric acute ischemic stroke is a rare but devastating condition with substantial rates of morbidity and mortality. Endovascular treatment is standard acute revascularization therapy for stroke in adults, but it is not well-studied in pediatrics. We report the successful treatment of two pediatric cases of anterior circulation stroke with primary mechanical thrombectomy.Case presentationTwo Asian children, aged 13 and 8 years, presented to Dr. Soetomo General Academic Hospital in September 2020 and April 2021, respectively, with hemiplegia and significant Pediatric National Institutes of Health Stroke Scale (Ped NIHSS) scores. Head CT scans demonstrated hyperdense middle cerebral artery signs, suggesting large-vessel occlusion stroke. Both patients underwent emergent thrombectomy within 5 and 10 h after initial onset, and successful recanalization was achieved within an hour. Both demonstrated good neurological recovery and there was no recurrent stroke during follow-up.Clinical discussionThrombectomy has appeal for childhood acute ischemic stroke (AIS) due to a longer post-stroke time window for intervention. As the short-term outcome, a significantly reduced Ped NIHSS score is achieved. Long-term outcomes are measured by modified Rankin Scale (mRS) scores. A literature review from 2016 to 2021 yielded 21 pediatric case reports of primary mechanical thrombectomy for anterior circulation stroke (including the present cases). We compare our cases with the published literature to discuss the short-term and long-term outcomes.ConclusionMechanical thrombectomy holds promise as a treatment modality in pediatric AIS. These case reports described successful primary mechanical thrombectomy for AIS treatment in children.

Elevated Glycated Albumin in Serum Is Associated with Adverse Cardiac Outcomes in Patients with Acute Coronary Syndrome Who Underwent Revascularization Therapy.

Aims: The associations between increased glycated albumin (GA) in the serum and diabetic complications and mortality have been revealed in the general population. However, less is known regarding the prognostic value of GA in patients diagnosed with acute coronary syndrome (ACS). Methods: In this study, all patients admitted for ACS who underwent a successful percutaneous coronary intervention (PCI) at our center from January 2018 to February 2019 were retrospectively examined. Clinical characteristics, laboratory results (e.g., serum GA levels), and procedural details were collected. The primary outcome included a composite of major adverse cardio-cerebral events (MACCE), such as death, myocardial infarction, stroke, and unplanned revascularization. The association between serum GA levels and clinical outcomes was tested in three multivariable models using Cox proportional hazard analysis. Subgroup analysis was performed in patients who were diagnosed with diabetes versus patients without diabetes. Results: A total of 1,806 ACS patients (mean age of 59.4 years; 77.8% were men; 44.9% were diagnosed with diabetes) were enrolled in this study, where the majority exhibited unstable angina (81.6%) and showed preserved left ventricular systolic function. Patients in the high GA level group were commonly female and were more likely to have metabolic disorders and to exhibit severe CAD (all p ＜0.05). MACCE occurred in 126 patients (7.0%) during a mean follow-up time of 17.2 months. The cumulative risk of MACCE at the 18-month follow-up visit significantly increased in a stepwise fashion along with increased GA levels (log-rank p =0.018) in the serum. The association between serum GA levels and MACCE was further determined after adjusting traditional risk factors and hemoglobin A1c (HbA1c) (GA, per 1% increase: hazard ratio [HR] 1.09, 95% confidence interval [CI] 1.06–1.13; GA, higher vs. lower tertial: HR 1.92, 95% CI 1.01–3.67). In a subgroup analysis, the prognostic role of serum GA only existed in diabetic patients, even when adjusting for traditional risk factors and HbA1c levels. Conclusions: Elevated GA levels in the serum were associated with poor intermediate-term outcomes in low-risk ACS patients who underwent PCI, especially in patients with preexisting diabetes.

A Qualitative Inquiry Into Patient Reported Factors That Influence Time From Stroke Symptom Onset to Hospitalization.

BACKGROUND: Approximately 50% of Danish stroke patients did not arrive within the 4.5-hour revascularization window in 2018, and only 20% received acute revascularization therapy. Delay in seeking help was a major factor for missing the time window. This study explored patient-reported factors influencing the timing of a decision to seek help. METHODS: We performed a qualitative interview study to explore prehospital help-seeking behavior. Inclusion was guided by a purposive sampling of stroke and transient ischemic attack patients and, if necessary, bystanders. Semistructured explorative interviews with 8 patients and 2 bystanders were audio-recorded, transcribed verbatim, and analyzed via thematic analysis. RESULTS: Analysis yielded 3 main themes: (1) symptom interpretation, (2) barriers and enablers to response, and (3) participant suggested optimization of acute stroke response and awareness. DISCUSSION: Factors associated with prompt action to seek help were either a perception that the symptom indicated a serious illness or a strong emotional response. Patients with recurrent stroke failed to associate symptoms with a new stroke. Having a stroke in unfamiliar surroundings prompted delay in seeking help. Suggestions for optimization included targeted stroke campaigns. CONCLUSION: Response to stroke onset may be driven by perceptions of symptom severity and emotional response rather than the ability to correctly identify symptoms. Stroke education should include the information that new stroke symptoms may be different from the old ones because different parts of the brain may be affected.

Stroke chameleons: acute central pain mimicking acute coronary syndrome.

'Stroke chameleons' refer to a group of syndromes that initially are not diagnosed as cerebrovascular events but are then found to represent stroke. The objective of this study was to report on acute ischaemic stroke (AIS) patients with chest or epigastric pain of central origin, clinically resembling an acute coronary syndrome (ACS). A prospective list was kept of AIS patients admitted to our institution between 2002 and 2014 with stroke symptoms appearing as an ACS on first clinical evaluation. For each identified patient, clinical and radiological features, delay to correct diagnosis, stroke etiology and 3-month functional outcome were reviewed. Data were mainly extracted from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL). Five AIS patients presenting mainly with chest or epigastric pain leading to a wrong diagnosis of ACS were identified. Cardiac evaluation showed minor electrocardiogram changes in two patients and isolated troponin elevation in one, subsequently shown to be of non-coronary origin. The correct diagnosis of AIS was made only between 1h and 72h after hospital arrival. Four patients presented a vertebrobasilar stroke. None of the patients received acute stroke revascularization therapy despite two of them being in the time window for such treatment. Acute ischaemic stroke presentation can infrequently resemble an ACS. In cases of negative cardiac work-up, a central origin of chest pain should be considered, especially in the presence of subtle other neurological symptoms or signs. Appropriate diagnosis of stroke could avoid treatment delays and improve outcomes.

Troubleshooting Intraprocedural Arterial Perforation during Acute Revascularization Therapy by Transarterial Embolization with NBCA

Troubleshooting Intraprocedural Arterial Perforation during Acute Revascularization Therapy by Transarterial Embolization with NBCA

Association Between Fatigue and Cognitive Impairment at 6 Months in Patients With Ischemic Stroke Treated With Acute Revascularization Therapy.

Background: Fatigue is a frequent symptom after stroke. We aimed to determine the association between fatigue and cognitive performance in patients with ischemic stroke who received acute revascularization therapy (IV thrombolysis and/or mechanical thrombectomy).Methods: Seventy patients were prospectively included in the stroke unit of the University Hospital of Dijon, France. A follow-up was performed at 6 months with clinical examination, fatigue assessment by the Fatigue Severity Scale (FSS), and a comprehensive neuropsychological evaluation. Patients with fatigue (FSS score >4) were compared with patients without fatigue. Neuropsychological factors associated with fatigue at 6 months were analyzed using multivariable logistic regression models.Results: Fatigue was reported by 34.3% of patients. Patients with fatigue were older, had more frequent residual handicap, depressive symptoms, and impaired quality of life. They had more frequently low score (<26) on the MoCA scale (79.2 vs. 47.8%, OR = 4.15; 95% CI: 1.32–13, p = 0.015), memory impairment (60 vs. 30.6%, OR = 3.41; 95% CI: 1.09–10.7, p = 0.035), and executive dysfunction (65 vs. 30.8%, OR = 4.18; 95% CI: 1.33–13.1, p = 0.014). In multivariable logistic regression analysis, only memory impairment was independently associated with fatigue (OR = 5.70; 95% CI: 1.09–29.6, p = 0.039). Further analyses restricted to non-depressed patients (n = 58, 84.1%) showed in multivariable models that a score < 26 on MoCA scale (OR 5.12; 95% CI: 1.00–26.2, p = 0.05), and a memory impairment (OR = 6.17; 95% CI: 1.06–35.9, p = 0.043) were associated with fatigue. There was also a non-significant trend toward an association between divided attention deficit and fatigue (OR = 6.79; 95% CI: 0.80–57.6, p = 0.079).Conclusion: The association between fatigue and subtle cognitive impairment including memory or attention deficits could be of interest in elaborating future interventional studies to evaluate the impact of therapeutic strategies, including cognitive rehabilitation, on fatigue.

Growth Differentiation Factor-15 (GDF-15) Is Associated With Mortality in Ischemic Stroke Patients Treated With Acute Revascularization Therapy.

Background and Aims: Growth differentiation factor-15 (GDF-15) has been identified as a robust marker of developing cardiovascular disease, however, little is currently known about its prognostic value in stroke patients. In a context of growing interest to discover new biomarkers in stroke, we aimed to assess the association between circulating GDF-15 levels and three-month mortality in ischemic stroke patients treated with acute revascularization therapy.Methods: 173 patients hospitalized for acute ischemic stroke and treated with either intravenous thrombolysis (n = 99, 57.2%), mechanical thrombectomy (n = 41, 23.4%) or combined therapy (n = 33, 19.1%) were prospectively included. Baseline clinical and biological characteristics were recorded. Plasma GDF-15 levels were measured at admission (D0), and at 24 h, 3 and 7 days. Clinical severity was assessed with the National Institutes of Health Stroke Scale (NIHSS) score, and vital status was obtained 3 months after the stroke.Results: At 3 months post-stroke, 32 patients (18.5%) had died. The deceased patients had higher D0 plasma GDF-15 levels (median [IQR]: 2,777 [1,769–5,446] vs. 1,460 [965–2,079] pg/mL, P < 0.001). In multivariable logistic regression analysis, D0 GDF-15 levels in the third tertile of the distribution were independently associated with mortality at 3 months (OR = 3.71; 95% CI: 1.09–12.6, P = 0.036), even after adjustment for confounding variables including clinical severity.Conclusions: Our data show for the first time that GDF-15 plasma concentration at admission is independently associated with 3-month mortality in ischemic stroke patients treated with acute revascularization therapy. The pathophysiological mechanisms that could explain this association warrant further study.

P2724Inhospital mortality in patients with infarct-relaled cardiogenic shock undergoing coronary angiography treated with and without acute revascularization therapy

P2724Inhospital mortality in patients with infarct-relaled cardiogenic shock undergoing coronary angiography treated with and without acute revascularization therapy

O2-2-7 - Different diagnosis with Dual energy CT imaging between hemorrhage and contrast agents for acute revascularization therapy patients

O2-2-7 - Different diagnosis with Dual energy CT imaging between hemorrhage and contrast agents for acute revascularization therapy patients

Efficiency of the Penumbra 5MAX ACE Reperfusion Catheter in Acute Ischemic Stroke Patients

This study was performed to investigate whether the Penumbra 5MAX ACE is superior to other Penumbra systems. We performed a retrospective, single center analysis of patients with acute ischemic stroke with occlusion of the internal carotid artery or middle cerebral artery (M1 segment) who underwent endovascular therapy using a Penumbra system. The reperfusion success rate, puncture-to-revascularization time, and number of passes were assessed. Multivariate regression analysis was conducted to evaluate independent factors related to revascularization within 60 minutes. Successful revascularization was defined by a thrombolysis in cerebral infarction score ≥2b. The Penumbra 5MAX ACE was used in 24 of the 40 patients (60%). Although the revascularization success rate was similar between patient groups (P = .229), the number of passes was significantly lower (1.5 ± .8 versus 2.6 ± 1.3, P = .006) and the puncture-to-revascularization time was shorter (50 ± 26 minutes versus 116 ± 69 minutes, P = .002) in patients treated with the Penumbra 5MAX ACE. The Penumbra 5MAX ACE was identified as an independent factor for early revascularization (odds ratio, 5.80; P = .041). Among patients with a premorbid modified Rankin Scale score of 0-1, a modified Rankin Scale score of 0-2 at 3 months was observed in 15 of the 19 patients (79%) treated with the Penumbra 5MAX ACE and in 8 of the 16 (50%) who were not (P = .072). Acute revascularization therapy using the Penumbra 5MAX ACE can achieve rapid successful recanalization and tend to improve clinical outcomes.

Abstract TP78: When Non-revascularized Transfer Patients Come A-Knocking at a Stroke Center

Background: Guidelines recommend acute ischemic stroke (AIS) patients be transported rapidly to the closest certified stroke center (SC). The impact of SC care on transfer patients who do not receive acute revascularization therapy is not well understood. We sought to compare patient characteristics, adverse events (AEs), and short term functional outcomes in patients directly presenting to and transferred into a comprehensive stroke center (CSC). Methods: We conducted a retrospective review of consecutive AIS patients transferred to our CSC from March 2014-April 2015. We excluded patients who received tPA or endovascular therapy. Demographic and clinical data were collected. We compared AEs (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia) and poor short term functional outcome, as defined by modified Rankin scale (mRS) score 3-6, among patients directly admitted to our CSC and patients transferred to our CSC. Results: Of 589 patients who did not receive revascularization therapy, 24.4% were transfers. Transfers were disproportionately white (76.4 vs 57.8%, p&lt;0.001), had higher median NIHSS (5 vs 4, p=0.028), were less often privately insured (40.1 vs 46.4%), and had less desirable ASPECTS scores on initial head CT (8-10; 22.9 vs 44.0, p&lt;0.001). Transfers had higher odds of having AEs (crude OR 2.134, 95% 1.353-3.365). This association remained after adjusting for age, stroke severity, and admission glucose (OR 2.103, 95% CI 1.276-3.466.004). Transfers more frequently developed HT on repeat imaging (17.5 vs 7.0%, p&lt;0.001), clinical seizure during inpatient stay (4.9 vs 1.6%, p=0.024), and PNA (7.6 vs 3.8%, p=0.061). However, transfer status was not associated with poor short-term functional outcome (crude OR 1.453, 95% CI 0.986-2.141; adjusted OR 1.200, 95% CI 0.703-2.046). Conclusion: Despite having more severe strokes and higher frequency of adverse events, patients transferred into our CSC for a higher level of care did not have worse short term functional outcomes. This highlights the importance of specialized inpatient care provided in NICUs and stroke units by experienced multidisciplinary teams.

Identification of High-Risk Patients with Non-ST Segment Elevation Myocardial Infarction using Strain Doppler Echocardiography: Correlation with Cardiac Magnetic Resonance Imaging.

Assessment of left ventricular (LV) function is important for decision-making and risk stratification in patients with acute coronary syndrome. Many patients with non-ST segment elevation myocardial infarction (NSTEMI) have substantial infarction, but these patients often do not reveal clinical signs of instability, and they rarely fulfill criteria for acute revascularization therapy.AIMThis study evaluated the potential of strain Doppler echocardiography analysis for the assessment of LV infarct size when compared with standard two-dimensional echo and cardiac magnetic resonance (CMR) data.METHODSThirty patients with NSTEMI were examined using echocardiography after hospitalization for 1.8 ± 1.1 days for the assessment of left ventricular ejection fraction, wall motion score index (WMSI), and LV global longitudinal strain (GLS). Infarct size was assessed using delayed enhancement CMR 6.97 ± 3.2 days after admission as a percentage of total myocardial volume.RESULTSGLS was performed in 30 patients, and 82.9% of the LV segments were accepted for GLS analysis. Comparisons between patients with a complete set of GLS and standard echo, GLS and CMR were performed. The linear relationship demonstrated moderately strong and significant associations between GLS and ejection fraction (EF) as determined using standard echo (r = 0.452, P = 0.012), WMSI (r = 0.462, P = 0.010), and the gold standard CMR-determined EF (r = 0.57, P < 0.001). Receiver operating characteristic curves were used to analyze the ability of GLS to evaluate infarct size. GLS was the best predictor of infarct size in a multivariate linear regression analysis (β = 1.51, P = 0.027). WMSI >1.125 and a GLS cutoff value of −11.29% identified patients with substantial infarction (≥12% of total myocardial volume measured using CMR) with accuracies of 76.7% and 80%, respectively. However, GLS remained the only independent predictor in a multivariate logistic regression analysis to identify an infarct size ≥12%.CONCLUSIONGLS is a good predictor of infarct size in NSTEMI, and it may serve as a tool in conjunction with risk stratification scores for the selection of high-risk NSTEMI patients.

International survey of acute stroke imaging used to make revascularization treatment decisions.

To assess the differences across continental regions in terms of stroke imaging obtained for making acute revascularization therapy decisions, and to identify obstacles to participating in randomized trials involving multimodal imaging. STroke Imaging Repository (STIR) and Virtual International Stroke Trials Archive (VISTA)-Imaging circulated an online survey through its website, through the websites of national professional societies from multiple countries as well as through email distribution lists from STIR and the above mentioned societies. We received responses from 223 centers (2 from Africa, 38 from Asia, 10 from Australia, 101 from Europe, 4 from Middle East, 55 from North America, 13 from South America). In combination, the sites surveyed administered acute revascularization therapy to a total of 25,326 acute stroke patients in 2012. Seventy-three percent of these patients received intravenous (i.v.) tissue plasminogen activator (tPA), and 27%, endovascular therapy. Vascular imaging was routinely obtained in 79% (152/193) of sites for endovascular therapy decisions, and also as part of standard IV tPA treatment decisions at 46% (92/198) of sites. Modality, availability and use of acute vascular and perfusion imaging before revascularization varied substantially between geographical areas. The main obstacles to participate in randomized trials involving multimodal imaging included: mainly insufficient research support and staff (50%, 79/158) and infrequent use of multimodal imaging (27%, 43/158) . There were significant variations among sites and geographical areas in terms of stroke imaging work-up used tomake decisions both for intravenous and endovascular revascularization. Clinical trials using advanced imaging as a selection tool for acute revascularization therapy should address the need for additional resources and technical support, and take into consideration the lack of routine use of such techniques in trial planning.

Abstract W P228: Results Of A Turkish Comprehensive Stroke Center Quality Program. A median Of Door To Needle Time Of 60 Minutes Is Achievable With MRI Based Diagnostic Paradigm

BACKGROUND: Quality measures provide the basis for evaluating and improving treatment of stroke patients based on scientific evidence. In this study, the first year results of a quality program of acute ischemic stroke patients who were admitted within the first 24 hours after the onset in a Turkish comprehensive stroke center were reviewed. METHODS: Between September 2012 and August 2013, 161 patients were consecutively admitted to Memorial Stroke Center; they were mainly diagnosed with MRI. Institutional quality program, which include Joint Commission International primary and comprehensive stroke center quality indicators, is maintained prospectively and the threshold values of performance were defined as 80% and above. RESULTS: Fifty three percent of the cases were male and the mean age was 68. Median onset to door time was 233 minutes. Median door to imaging time for the patients admitted within 4.5 hours was 15 minutes. Median imaging duration was 25 minutes. Median and mean door to end of imaging was 40 and 43 minutes respectively. Forty patients underwent acute revascularization therapy; 23 only IV r-TPA, 10 bridging, 7 only endovascular therapy. From eligible patients, 88,9% received IV thrombolysis and 78.9% received endovascular treatment within appropriate time window. The median door to needle time was 65 minutes both for patients in the 4,5 and 6 hours from onset. Only 25% percent of patients receiving IV r-TPA were treated within 40 minutes after arrival. The median door to the groin puncture and groin puncture to recanalization time were 84 and 105 min respectively. There was no symptomatic bleeding in revascularized patients. The percent of good prognosis (mRS 0-2) and mortality was 62,5% and 8,8% respectively. DISCUSSION: Results of our quality data are in line with the literature despite use of an MR-based diagnostic paradigm. Only 1 of 4 patients received thrombolysis within 40 minutes, but this is mainly due to treatment decisional and starting process after the end of imaging, which should and can be shortened.

急性期血行再建療法と画像診断

要旨 脳梗塞急性期血行再建療法の適応判断に画像診断は必須である．発症4.5 時間以内であればASPECTS/ASPECTS+W で早期虚血変化を評価し，rt-PA 静注の適応を決定する．MRI 拡散強調画像はCT より虚血感度が高いが，表示条件を標準化しCT との検出特性の違いを念頭におく．同時に脳血管情報を収集し，適応を満たせば遅滞なく脳血管内治療を実施する．MR CLEAN 以降のステント型血栓回収デバイスを用いた脳血管内治療のランダム化比較試験は，治療ターゲットである閉塞血管があり，虚血コアが小さい例を対象とし，その上で良好な側副血行あるいは灌流画像で救済可能組織を確認したことが成功の一因となった．MRI first の迅速診断体制の強化か，CT first （CTA/multiphase CTA/CT perfusion）への転換か，我々の立ち位置が問われている．

Acute Revascularization Therapy in Pregnant Patients

Ischemic stroke is uncommon during pregnancy, but decision making for acute revascularization therapy including intravenous recombinant tissue plasminogen activator (rt-PA) is difficult. The use of rt-PA remains controversial, but a systematic review of 16 patients (mean age 31.7 years) showed good results for both maternal (77.8%) and fetal (56.3%) outcomes. Pregnancy alone is not a solid contraindication for acute revascularization therapy including rt-PA. An endovascular approach might be beneficial for reducing the hemorrhagic complication; however, the treatment strategy should be considered based on the available treatment facility. Close cooperation with obstetrics is essential for the successful management of saving the lives of both the mother and the fetus.