Ischemia Grade Research Articles

Outcome of mechanical thrombectomy with Solitaire stent as first-line intra-arterial treatment in intracranial internal carotid artery occlusion

Acute stroke from occlusion of the intracranial internal carotid artery (ICA) is associated with a poor clinical outcome despite a thrombolytic treatment. The purpose of this study was to evaluate the outcome of mechanical thrombectomy using the Solitaire stent for the treatment of acute stroke patients with intracranial ICA occlusion. A total of 104 consecutive patients with acute stroke were treated with mechanical thrombectomy using the Solitaire stent as a first-line intra-arterial treatment. We retrospectively reviewed data from 26 of these patients who presented with acute stroke attributable to intracranial ICA occlusion. Rescue treatments in cases of failed Solitaire thrombectomy included intra-arterial urokinase, angioplasty, and forced suction thrombectomy. Successful recanalization was defined as thrombolysis in cerebral ischemia grades 2b to 3. Outcome measure was the modified Rankin Scale (mRS) score of 0-2 at 3 months. Successful recanalization was achieved in 77% (20/26) of patients. Recanalization was achieved with the Solitaire stent alone in 69% (18/26) of patients. Ten patients (39%) had a good clinical outcome (mRS score of 0-2) at 3 months. There was a good outcome in 50% of patients (10/20) with recanalization and no good outcome in patients (0/6) without recanalization (P = 0.027). None of eight patients who received rescue treatments showed a good outcome. No symptomatic intracerebral hemorrhage occurred. Mortality was 8% (2/26) at 3 months. Mechanical thrombectomy using the Solitaire stent can achieve a high rate of successful recanalization and a very low rate of symptomatic hemorrhage and thus improve a clinical outcome in patients with acute intracranial ICA occlusion.

The Effects of Macular Ischemia on Visual Acuity in Diabetic Retinopathy

To investigate the impact of diabetic macular ischemia (DMI) on visual acuity (VA), through the analysis of novel fluorescein angiography (FA) parameters. Data were retrospectively collected over a 6-month period. DMI severity was graded using Early Treatment Diabetic Retinopathy Study (ETDRS) protocols. Custom software was used to quantify areas of the foveal avascular zone (FAZ), and of capillary nonperfusion over the papillo-macular nerve fiber layer bundle, and temporal macula, and associations tested with VA. A total of 488 patients with type 2 diabetes mellitus and FAs of sufficient quality to allow detailed quantitative analyses were included. ETDRS-DMI SEVerity was graded as: none, 39.7%; questionable, 18.4%; mild, 25.2%; moderate, 11.0%; and severe, 5.6%. Median FAZ areas were 0.19 mm(2) (interquartile range [IQR], 0.13-0.25); 0.25 mm(2) (IQR, 0.18-0.32); 0.27 mm(2) (IQR, 0.19-0.38); 0.32 mm(2) (IQR, 0.25-0.54); and 0.78 mm(2) (IQR, 0.60-1.32), respectively, and were significantly different between all grades (P < 0.002), apart from "questionable" versus "mild" grades. Significant association of VA to FAZ area was observed only in the moderate (β = 0.406, SE = 0.101, P = 0.001) and severe (β = 0.299, SE = 0.108, P = 0.006) subgroups, but not in milder ETDRS-DMI grades. A strong association with VA was observed in cases with papillomacular ischemia (β = 1.123, SE = 0.355, P = 0.005), independent of FAZ size or the presence of macular edema. Diabetic macular ischemia is associated with reduced VA in eyes with moderate to severe ETDRS-DMI grades of ischemia but preserved in milder grades. In addition, we describe the independent association of papillomacular nerve fiber bundle ischemia with reduced VA.

Mechanical thrombectomy with the Solitaire AB device in large intracerebral artery occlusions

Mechanical thrombectomy has the potential to revolutionise the treatment of acute stroke. The Solitaire AB device is used for clot retrieval with unprecedented revascularisation rates being reported. Our aim is to report our experiences of the safety and efficacy of the Solitaire AB device in acute ischaemic stroke. A retrospective dual-centre study of 21 patients with acute ischaemic stroke who underwent mechanical thrombectomy with the Solitaire AB device between 1 October 2010 and 1 December 2011 was carried out. Using clinical data recovered from patients' case notes, we identified time intervals from groin puncture to recanalisation, revascularisation rates, procedural complications and neurological status before and after treatment (using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) respectively). Successful revascularisation, defined as Thrombosis in Cerebral Ischemia Grade 2 or 3, was achieved in 81% of cases. The mean NIHSS score at presentation was 18.5. The mean number of passes required to achieve recanalisation was 1.95 and the median duration of the procedure from groin puncture to recanalisation was 65 min. Procedural events included distal emboli (n = 2), arterial dissection (n = 1) and arterial perforation (n = 1).There were three cases of asymptomatic intracranial haemorrhage. Forty-eight per cent of patients achieved a good functional outcome at 3 months (mRS score ≤2). The mortality rate at 3 months was 19% (n = 4). There was no procedure-related mortality. Mechanical thrombectomy with the Solitaire AB device is safe and achieves high rates of revascularisation in acute stroke with good clinical outcomes.

Circadian Rhythms in the Efficacy of Intravenous Alteplase in Patients With Acute Ischemic Stroke and Middle Cerebral Artery Occlusion

Circadian rhythm interactions of hemostatic factors can modify tissue plasminogen activator (tPA) effects. We assess the relationship of the time frame of intravenous tPA administration with the outcome of patients with acute ischemic stroke (AIS). We studied 135 consecutive patients with AIS and transcranial duplex documented middle cerebral artery (MCA) occlusion treated with intravenous tPA. Complete recanalization was defined as total improvement on thrombolysis in brain ischemia (TIBI) grades 2 h after tPA infusion. Clinical response was evaluated by the modified Rankin scale at 90 days. We determined plasminogen activator inhibitor-1 (PAI-1) levels in 33 patients with available plasma samples before treatment. Our results are follows: 92 (68.1%) patients were treated in the diurnal (9:00–21:00) and 43 (31.8%) in the nocturnal period (21:00–9:00). Complete recanalization was recorded in 52/135 (38.5%) patients. Both the rate of complete recanalization (45.6% vs. 23.2%; p = .01) and good clinical outcome (64.1% vs. 44.2%; p = .02) were significantly higher in the group of diurnal tPA administration compared with those treated in the nocturnal period. The adjusted odds ratio (OR) of diurnal tPA treatment for complete MCA recanalization was 2.37 (95% confidence interval [CI], 1.02–5.52; p = .045). Diurnal tPA infusion significantly improved the overall distribution of scores on the modified Rankin scale, as compared with nocturnal treatment (OR, 2.07; 95% CI, 1.16–4.64 by ordinal regression analysis). Low PAI-1 levels were associated with complete recanalization but did not significantly differ between the two time frames. In conclusion, diurnal administration of tPA is associated with complete MCA recanalization and better functional outcome at 90 days in patients with AIS. (Author correspondence: mgomis.germanstrias@gencat.cat, meritxellgomis@gmail.com)

Effect of anesthesia and cerebral blood flow on neuronal injury in a rat middle cerebral artery occlusion (MCAO) model

Middle cerebral artery occlusion (MCAO) models have become well established as the most suitable way to simulate stroke in experimental studies. The high variability in the size of the resulting infarct due to filament composition, rodent strain and vessel anatomy makes the setup of such models very complex. Beside controllable variables of homeostasis, the choice of anesthetics and the grade of ischemia and reperfusion played a major role for extent of neurological injury. Transient MCAO was induced during either isoflurane or ketamine/xylazine (ket/xyl) anesthesia with simultaneously measurement of cerebral blood flow (CBF) in 60 male Wistar rats (380-420g). Neurological injury was quantified after 24h. Isoflurane compared with ket/xyl improved mortality 24h after MCAO (10 vs. 50%, p=0.037) and predominantly led to striatal infarcts (78 vs. 18%, p=0.009) without involvement of the neocortex and medial caudoputamen. Independent of anesthesia type, cortical infarcts could be predicted with a sensitivity of 67% and a specificity of 100% if CBF did not exceed 35% of the baseline value during ischemia. In all other cases, cortical infarcts developed if the reperfusion values remained below 50%. Hyperemia during reperfusion significantly increased infarct and edema volumes. The cause of frequent striatal infarcts after isoflurane anesthesia might be attributed to an improved CBF during ischemia (46±15% vs. 35±19%, p=0.04). S-100β release, edema volume and upregulation of IL-6 and IL-1β expression were impeded by isoflurane. Thus, anesthetic management as well as the grade of ischemia and reperfusion after transient MCAO demonstrated important effects on neurological injury.

Clinical and Electroencephalographic Assessment of the State of Premature Children Treated with Cytoflavin during the First Year of Life

The aim of the present work was to perform clinical and neurophysiological assessment of the rates of neuromental development during the first year of life in preterm neonates with cerebral ischemia grade II–III, allowing for the effects of treatment with Cytoflavin and resuscitation measures. A total of 120 children with gestational ages of 28–36 weeks and body weights of 1060–3150 g were studied. The study group included 61 children whose complex treatment included Cytoflavin at a dose of 2 ml/kg/day i.v. for five days. The control group consisted of 59 patients who received basal treatment without Cytoflavin. Follow-up to a corrected age (CA) of one year included assessment of overall condition and neurological status (using a quantitative assessment of postural muscle tone on the INFANIB scale, psychomotor development on the BSID-II scale, and the functional state of the CNS by computerized electroencephalography by monitoring of physiological sleep). The results demonstrated faster normalization of all study measures of development in children receiving Cytoflavin in their complex treatment as compared with the control group.

Bilateral atherosclerotic internal carotid artery occlusion causing acute bihemispheric infarctions

Multiple acute brain infarctions in both cerebral hemispheres involving the anterior circulation are uncommon (affecting less 1.0–6.0 % of acute stroke patients) and usually suggest an embolic mechanism, particularly one of aortic or cardiac origin [1–4]. Unilateral internal carotid artery (ICA) atherosclerotic lesions may rarely cause acute bihemispheric infarctions through crossflow in the anterior communicating artery with the contralateral anterior cerebral artery (ACA) territory being invariably involved in all described cases [4]. To the best of our knowledge there has been no report of bilateral extracranial atherothrombotic ICA occlusion causing acute bihemispheric infarctions involving both middle cerebral artery territories. A 73-year-old man with a history of hypertension, hypercholesterolemia and smoking presented with an acute right upper arm weakness that he noticed on awakening. Admission brain CT and electrocardiogram were normal. Neurological examination disclosed a mild left hemipareris and left-side visual neglect with an NIH Stroke Scale score (NIHSS-score) of 5 points. The patient underwent emergent carotid duplex evaluation showing multiple hyperechoic plaques in both common carotid arteries (CCA) and acute bilateral ICA occlusion (Fig. 1a, b). Transcranial Doppler examination showed (1) acute bilateral middle cerebral artery (MCA) occlusion with minimal flow (thrombolysis in brain ischemia grade I) in right and blunted flow (thrombolysis in brain ischemia grade II) in left MCA, (2) present collateral flow through reversed ophthalmic artery (OA) bilaterally and (3) absent collateral flow through posterior communicating arteries. The patient also underwent 30-min bilateral transcranial doppler monitoring that documented the presence of microembolic signals in both MCAs (Fig. 2). Acute reperfusion therapies including intravenous or intra-arterial thrombolysis as well as mechanical thrombectomy were withheld because of unknown time of stroke onset. Emergent echocardiography excluded the presence of cardiac thrombus and other source of cardiogenic embolism (including aortic arch dissection). He was treated with aspirin (325 mg) and enoxeparin (40 mg). Fourteen hours later, he became quadriplegic and lethargic (NIHSS-score 26 points). Repeat brain CT (performed after 12 h from the baseline CT) showed bilateral cortical infarctions (Fig. 1c, d) in both MCA territories (arrowheads). The patient expired the following day. Simultaneous occurrence of multiple infarcts in different arterial territories is a characteristic feature of cardioembolic stroke according to the findings of recent studies G. Tsivgoulis (&) I. Heliopoulos K. Vadikolias M. Flamouridou S. Tsakaldimi C. Piperidou Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, Kapodistriou 3, Nea Xili, Alexandroupolis 68100, Greece e-mail: tsivgoulisgiorg@yahoo.gr

Infarction Volume Predicts Recovery from Prolonged Disability in Subarachnoid Hemorrhage (P06.253)

Objective: To evaluate predictors of 3-month outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH) who are severely disabled at 14 days. Background Validated predictors of outcome after SAH include delayed cerebral ischemia, age, and admission neurologic grade. Less is known about recovery in those who remain severely neurologically injured at 14 days. Since delayed ischemia varies in severity between patients, its consequences should also vary. Thus, we hypothesized that volume of cerebral infarction is associated with recovery in these patients. Design/Methods: We prospectively identified consecutive SAH patients and recorded clinical data, including cerebral infarction on routinely obtained CT scans. We defined severe neurological injury at 14 days as modified Rankin Scale (mRS) 4 or 5 and NIH Stroke Scale ≥ 8. The mRS was prospectively recorded at three months (mRS 0-3, functional independence, and mRS 4-6, dependence or death). Infarction volume was calculated (AnalyzeDirect, Mayo Clinic) from the diagnostic CT. We explored outcome determinants with logistic and ordinal regression. Results: At 14 days, 87 patients (mean age 58.0 ± 14.7 years, 37.5% male) had severe neurologic injury and 63 (71.6%) had infarctions. Three-month outcomes were known in 79 (89.8%), 27 (30.7%) of whom were independent. Fourteen (16%) patients died, 7 from withdrawal of support. Age and infarct volume were associated with outcome, but transcranial Doppler velocity above 120 cm/s, symptomatic vasospasm, WFNS grade, and modified Fisher grade were not. In multivariate logistic regression, age (1.07 per year, 95%CI 1.02-1.1, P=0.002) and infarct volume (1.05 per mL, 95%CI 1.01-1.08, P=0.01) were associated with increased odds of 3-month dependence or death. Results were similar for ordinal regression. Conclusions: In patients with aSAH who remain severely neurologically injured at 14 days, recovery is possible and is associated with age and infarction volume. These data may aid in planning care. Disclosure: Dr. Rosenberg has nothing to disclose. Dr. Liebling has nothing to disclose. Dr. Maas has nothing to disclose. Dr. Naidech has received research support from Gaymar Inc.

Abstract 3290: Timing Of Recanalization After Intravenous Thrombolysis Determines The Functional Outcomes In Acute Ischemic Stroke

Background and Purpose: Intravenously administered tissue plasminogen activator (IV-TPA) is the only approved therapeutic agent for arterial recanalization in acute ischemic stroke (AIS). Wide variations in rates and timing of neurological recovery are observed in thrombolyzed patients. Although, recanalization of acutely occluded intracranial artery remains the major aim IV-TPA, timing and impact of this phenomenon on functional outcomes has not been evaluated properly. We evaluated the relationship between the arterial patency and timing of recanalization with functional outcomes at 3-months in AIS. Methods: Data for consecutive AIS patients treated with IV-TPA within 4.5 hours of symptom-onset during 2007-2010 were prospectively entered in the thrombolysis registry maintained at our tertiary care center. Data were collected for demographic characteristics, vascular risk factors, stroke subtypes and blood pressure before IV-TPA bolus. National Institute of Health Stroke Scale (NIHSS) scores were obtained before IV-TPA, at 2-hours and at 24-hours. Patients were continuously monitored with 2-MHz pulsed wave diagnostic transcranial Doppler (TCD) for 2-hours after IV-TPA bolus for early recanalization (ER). ER was assessed using the Thrombolysis in Brain Ischemia grading TCD system. Arterial patency was assessed on day 2 in patients who underwent CT angiography or magnetic resonance angiography, labeled as delayed recanalization (DR). Absence of recanalization on early TCD or imaging on day 2 was called persistent arterial occlusion (PAO). Favorable functional outcomes at 3 months were determined by modified Rankin scale (mRS) of 0-1. Results: Of the 2238 AIS patients admitted during the study period, 240 (11%) received IV-TPA within 4.5-hours of symptom-onset. Median age was 65yrs (range 19-92), 63% males, median NIHSS 17points (range 3-35) and median onset-to-treatment time 149 minutes. Overall, 122 (50.8%) patients achieved favorable functional outcome at 3-months. Information about ER, DR and PAO was available for 160 patients- ER in 55(34.4%), DR in 44(27.5%) and PAO in 61(38.1%) patients. Timing of recanalization was associated with favorable outcome (ER 72.7%, DR 63.6% and PAO 31.1%; p&lt;0.005). Factors associated with favorable outcome at 3-months on univariable analysis were younger age, female gender, atrial fibrillation, baseline NIHSS, onset-to-treatment time and timing of recanalization. However, on multivariable analysis, NIHSS at onset (OR per 1-point increase 0.907, 95%CI 0.848-0.969), ER (OR 3.32, 95%CI 1.295-9.474) and DR (OR 3.021 95%CI 1.197-7.634) were found as independent predictors of favorable outcome at 3-months. Conclusions: Timing of arterial recanalization induced by IV-TPA in acute ischemic stroke is a strong predictor of favorable outcome at 3-months.

Abstract 2219: Trevo System: Single Center Experience With A Novel Mechanical Thrombectomy Device

Background and Purpose: Recent reports have indicated that mechanical thrombectomy may have potential as a treatment for acute ischemic stroke. This study aims to describe the safety and effectiveness of Trevo RetrieverTM (Concentric Medical Inc, Mountain View, California) using StentrieverTM technology, in revascularization of patients with acute ischemic stroke. Methods: Prospective study evaluating the clinical, radiological and functional outcome of 13 patients with an angiographically verified occlusion of the anterior cerebral circulation. All patients underwent thrombectomy with TR as monotherapy or in combination with intra-arterial thrombolysis, within the first 8 hours from symptoms onset. Successful revascularization was defined as thrombolysis in cerebral ischemia grade 2a to 3. Good outcome was defined as modified Rankin Scale score ≤ 2. Results: Median baseline NIHSS score was 19 (16-22). The occlusion site was MCA in 8 patients and ICA in 5 patients. Five patients received IV tPA before endovascular procedure. Revascularization was achieved in 10 of 13 patients (77%). The median number of passes for maximal recanalization was 2 (1-3) and the mean time from groin puncture to recanalization was 95±31 minutes. No significant intra-procedural complications occurred. Four patients (30%) died during the 90-day follow-up period and 4 patients (30%) achieved functional independence at 3 months. Conclusions: Early clinical experience suggests that the TR can allow safe and effective revascularization in certain subjects with acute ischemic stroke.

Trevo System: Single‐Center Experience with a Novel Mechanical Thrombectomy Device

Recent reports have indicated that mechanical thrombectomy may have the potential to treat acute ischemic stroke. This study aims to describe the safety and effectiveness of Trevo Retriever, using Stentriever technology, in revascularization of patients with acute ischemic stroke. Prospective study evaluating the clinical, radiological, and functional outcome of 13 patients with an angiographically verified occlusion of the anterior cerebral circulation. All patients underwent thrombectomy with TR as monotherapy or in combination with intra-arterial thrombolysis, within the first 8 hours from the onset of symptoms. Successful revascularization was defined as thrombolysis in cerebral ischemia grade 2a to 3. Good outcome was defined as modified Rankin Scale score ≤ 2. Median baseline National Institutes of Health Stroke Scale score was 19(16-22). The occlusion site was middle cerebral artery in 8 patients and internal carotid artery in 5 patients. Revascularization was achieved in 10 of 13 patients (77%). The mean time from groin puncture to recanalization was 95 ± 31 minutes. No significant intra-procedural complications occurred. Four patients (30%) died during the 90-day follow-up period and 4 patients (30%) achieved functional independence. Early clinical experience suggests that the TR can allow safe and effective revascularization in certain subjects with acute ischemic stroke.

Endovascular Management in Patients with Acute Basilar Artery Obstruction: Low-Dose Intra-Arterial Urokinase and Mechanical Clot Disruption

Mechanical clot disruption for the treatment of acute basilar artery occlusion (BAO) is known to provide a benefit. We aimed to determine the safety, recanalization rate and time-to-flow restoration of mechanical clot disruption and low dose urokinase (UK) infusions for the treatment of patients with acute BAO. Between June 2006 and June 2010, 21 patients with acute BAO underwent endovascular treatment that included angioplasty or stent placement. The time to treatment, duration of the procedure, dose of urokinase (UK), recanalization rates and symptomatic hemorrhages were analyzed. Clinical outcome measures were assessed at admission and at the time of discharge using the National Institutes of Health Stroke Scale (NIHSS) score and at three months after treatment using the modified Rankin Score (mRS). On admission, the median NIHSS score was 13.2. Median time from symptom onset to arrival at hospital was 356 minutes, and median time from symptom onset to intraarterial thrombolysis (IAT) was 49 minutes. We used the following interventional treatment regimens: Intra-arterial (IA) UK and a minimal mechanical procedure (n=14), IA UK with angioplasty (n=1), IA UK with angioplasty and stent placement (n=3) and IA UK with HyperForm (n=3). The recanalization (thrombolysis in cerebral ischemia grade II or III) rate was 90.5% (19/21). There was symptomatic hemorrhage in one patient (4.8%). The median NIHSS score at discharge was 6.3. The three-month outcome was favorable (mRS: 0-2) for 14 patients (66.7%) and poor (mRS: 3-6) for seven patients (33.3%). The overall mortality at three months was 14.3% (three patients died). Low-dose IAT with mechanical clot disruption is a safe and effective treatment for treatment for acute BAO.

Predictors and outcome of grade 3 ischemia in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Purpose Grade 3 ischemia (G3I: distortion of the terminal portion of the QRS complex) is a predictor of serious complications after acute myocardial infarction. However, less is known about which patients are more prone to present with G3I. Methods Patients who were enrolled in the Ongoing Tirofiban In Myocardial infarction Evaluation trial 2 were included. These patients were divided in 2 groups based on the enrolment electrocardiogram: grade 2 ischemia (G2I) or G3I. Results Between June 2004 and November 2007, 1308 patients with interpretable electrocardiograms were enrolled. Grade 3 ischemia was found in 426 (32.6%) patients. Patients with G3I were older, more often male, more often had diabetes, had a Thrombolysis In Myocardial Infarction (TIMI) risk score of greater than 3, had 3 vessel disease, had an anterior infarction, more often presented in Killip class greater than 1, less often had a preprocedural TIMI 3 flow, and less often had a myocardial blush grade 3 post-PCI. One hour post-PCI, residual ST deviation was higher in patients with G3I compared with patients with G2I. Furthermore, G3I was associated with more major cardiac events (including death, myocardial infarction, urgent target vessel revascularization). After multivariate adjustment, G3I was an independent predictor of failure of ST-segment resolution 1 hour post-PCI (odds ratio, 1.4; 95% confidence interval, 1.1-1.9) and 30-day mortality (odds ratio, 3.2; 95% confidence interval, 1.2-8.7). Conclusion Grade 3 ischemia was associated with high-risk patient criteria (older age, diabetes, TIMI risk score >3, Killip class >1, and anterior myocardial infarction) and represents a subgroup of high-risk patients who seems to be associated with poor myocardial reperfusion and worse outcome.

The kinetics of C–reactive protein concentration in patients operated for atheromatous arterial obliteration of the lower limbs

The aim of the study was to assess the kinetics of CRP (C–reactive protein) concentration in patients treated operatively due to atheromatous arterial obliteration of the lower limbs. The obtained results indicate decisively that there is no point in determining CRP as far as the diagnosis of the grade of lower limb ischaemia is concerned. The obtained and statistically processed data were the sufficient basis to give the equation of regression curve of the third grade for the postoperative period, which proceeded without complications. The highest CRP concentration occurred on the third day after the operation. Then a slow reduction in the concentration of the examined protein and its gradual return to the baseline values were observed. The postoperative complications may be indicated by CRP concentration whose values were different from those presented below. Therefore determination of CRP concentration is a very useful examination after grafting the aortal-bifurcated prosthesis.

Routine early coronary angioplasty after thrombolysis in acute ST-elevation myocardial infarction: lysis is not the final step

This editorial refers to ‘Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis’, by S. P. D'Souza et al. doi:10.1093/eurheartj/ehq398 Primary coronary intervention (PCI) is the preferred reperfusion therapy in patients with acute ST-elevation myocardial infarction (STEMI). However, many hospitals lack PCI facilities and few provide around-the-clock staffing for these procedures. Therefore, thrombolysis is administered to eligible patients if primary PCI cannot be performed in a timely fashion. Traditionally, the standard approach for a patient who had received thrombolytics and presented signs of reperfusion injury was to assess the risk of future cardiac adverse events before discharge. The two most important parameters used to evaluate short-term and long-term risk following myocardial infarction were left ventricular function and the extent and grade of myocardial ischaemia. Patients with spontaneous or induced severe ischaemia or left ventricular dysfunction were candidates for angiography and revascularization. Outside these circumstances, coronary arteriography was not recommended, as there was no evidence of any benefit to the patient if residual ischaemia or left ventricular dysfunction was not observed. In the late 1980s, before stents and glycoprotein IIb/IIIa inhibitors or thienopyridines began to be used, the results of routine cardiac catheterization and systematized PCI were disappointing.1 However, current interventional practice, which uses stents, thienopyridines, and IIb/IIIa inhibitors, has generated studies that again highlight the role of early routine angioplasty in the management of patients with STEMI receiving thrombolysis. The results of those studies have recently been analysed in two meta-analyses,2,3 one of which has led to this editorial.3 Adjunctive or early elective PCI is used in patients who are initially successfully reperfused with thrombolysis and who undergo early (i.e. <24 h), routine (i.e. not rescue), and, if appropriate, planned (i.e. not urgent) catheterization. This approach combines the …

Mechanical Thrombectomy With the Solitaire AB Device in Large Artery Occlusions of the Anterior Circulation

To describe the safety and effectiveness of a self-expanding and fully retrievable stent (Solitaire AB; ev3 Inc, Plymouth, MN) in revascularization of patients with acute ischemic stroke. Prospective, single-center study of 20 patients with an acute ischemic stroke attributable to a large artery occlusion of the anterior circulation within the first 8 hours from symptoms onset (median National Institutes of Health Stroke Scale, 19 [interquartile range, 15-23]). The occlusion site was middle cerebral artery in 12 patients, proximal internal carotid artery/middle cerebral artery tandem occlusion in 3 patients, and terminus internal carotid artery in 5 patients. Thrombectomy was used as rescue therapy in 2 patients who were refractory to intra-arterial plasminogen activator, and in 3 patients in whom successful recanalization with the MERCI retriever was not achieved. Successful revascularization defined as thrombosis in cerebral ischemia grade 2b or 3 was achieved in 18 of 20 (90%) treated vessels, and 16 patients showed immediate restoration of flow after stent deployment. The mean number of passes for maximal recanalization was 1.4, and the median (quartiles) time from groin puncture to recanalization was 50 (38-71) minutes. No case required adjuvant therapy after deployment of the embolectomy device. No significant procedural events occurred. Symptomatic intracranial hemorrhage was found in 2 (10%) patients, 4 (20%) patients died during the 90-day follow-up period, and 45% of patients showed good functional outcome at 3 months (modified Rankin Scale score <or=2). These results suggest that the Solitaire AB device can rapidly, safely, and effectively retrieve clots from the middle cerebral artery and terminus internal carotid artery within 8 hours from symptoms onset.

W1650 Grade of Ischemia on Lower Endoscopy is the Reliable Predictor of Need for Operative Intervention for Ischemic Colon in Critically Ill Patients

W1650 Grade of Ischemia on Lower Endoscopy is the Reliable Predictor of Need for Operative Intervention for Ischemic Colon in Critically Ill Patients

End-Diastolic Velocity Increase Predicts Recanalization and Neurological Improvement in Patients With Ischemic Stroke With Proximal Arterial Occlusions Receiving Reperfusion Therapies

It is unknown how little flow velocity improvement is necessary to achieve recanalization and clinical recovery. We sought to investigate which flow velocity parameter was associated with complete recanalization/reperfusion and neurological improvement in patients receiving reperfusion therapies. Patients with proximal intracranial occlusions were treated with systemic or intra-arterial tissue plasminogen activator within 6 hours from symptom onset. Consecutive peak systolic and end-diastolic (EDV) velocities were measured during continuous transcranial Doppler monitoring. Recanalization was graded with Thrombolysis in Brain Ischemia grades. Neurological and functional outcomes were assessed by the National Institutes of Health Stroke Scale and modified Rankin Scale scores. Of 36 patients (mean age 57 + or - 19 years, median National Institutes of Health Stroke Scale 15 points, interquartile range 9), 13 (36%) achieved complete recanalization and those had greater EDV increase during transcranial Doppler monitoring (15 + or - 11 cm/s versus 6 + or - 10 cm/s; P=0.001). Peak systolic velocity increase with complete recanalization was 25 + or - 11 cm/s (versus 20 + or - 25 cm/s with partial recanalization/persisting occlusion; P=0.123). Neurological improvement at 24 hours positively correlated to EDV increase (Spearman r=0.337, P=0.044) but not to peak systolic velocity (r=0.197, P=0.250). EDV increase at the end of monitoring was higher in patients with favorable functional outcome at 3 months (13 + or - 13 cm/s versus 4 + or - 8 cm/s; P=0.021). After adjustment for potential confounders, including age, stroke risk factors, and baseline stroke severity, a 10-cm/s increase in EDV was independently associated with a 3-point decline in the National Institutes of Health Stroke Scale score at 24 hours from baseline (95% CI: 0 to 5; P=0.045). A modest increase in the EDV as opposed to peak systolic velocity is associated with complete recanalization/reperfusion, early neurological improvement, and favorable functional outcome. Diastolic flow augmentation may represent a novel target for development of reperfusion therapies.

343 Does grade 3 ischemia on admission electrocardiogram predicts failure of myocardial reperfusion after coronary angioplasty for acute myocardial infarction?

Failure of myocardial perfusion after coronary angioplasty for acute myocardial infarction (AMI) is associated with a poor prognosis. Grade 3 ischemia (G3I) was shown to be associated with failure of myocardial perfusion. Evaluate the prognosis impact of G3i, recorded on the admission electrocardiogram, after percutaneous coronary intervention (PCI) for AMI. One hundred eight patients had PCI in the setting of AMI. G3I was defined as: Absence of S wave below the TP-PR isoelectric line in > 2 leads. Patients meeting the ST-elevation criteria but not the G3I criteria were classified as grade 2 ischemia (G2I). Myocardial perfusion was evaluated on ST-segment resolution and angiographyally on the flow of infarct-related artery graded according to the TIMI scale. Occurrence of no-reflow, no ST-segment resolution and hospital mortality were evaluated. Patients were divided in 2 groups: G3I (51 patients) and G2I. (57 patients). Clinical and angiographic characteristics were similar, absence of ST-segment resolution; the no-reflow phenomena and hospital mortality were more common in the G3I group respectively: 47% vs 20% (p= 0.002), 27% vs 10% (p = 0,024) and 21,.6% Vs 8.8% (p = 0.062). IG3, female gender, diabetes and delay to consultation > 2 hours were associated with the occurrence of no-reflow, persistence of ST- segment elevation and hospital death. In multivariate analysis, IG3 was an independent factor of no-reflow and absence of ST- segment resolution: OR 3.45 (CI 95% [1.15 to10.31]) p=0.027 and OR 3.47 (CI 95% [1.37 to9.01]) p=0.011, respectively. Female gender, no-reflow and persistence of ST-segment elevation were the only independent predictive factors of hospital mortality, respectively : OR 10,59 (CI 95% [1,68 to66,8]) p=0,012 ; OR 7,39 (CI 95% [1,52 to35,8]) p=0,013 ; OR 50 (CI 95% [4,69 to532]) p=0,001 but not the grade 3 ischemia. Grade 3 ischemia on the admission electrocardiogram of acute myocardial infarction is a strong independent predictors of failure of tissular reperfusion.

Low-Dose Intra-Arterial Urokinase and Aggressive Mechanical Clot Disruption for Acute Ischemic Stroke after Failure of Intravenous Thrombolysis

Intravenous (IV) thrombolysis often fails to achieve recanalization of occluded cerebral arteries, especially in patients with proximal large arterial occlusions. The goal of this study was to assess the feasibility, safety, and efficacy of low-dose intra-arterial (IA) urokinase and aggressive mechanical clot disruption (AMCD) after failure of IV thrombolysis for acute ischemic stroke. We prospectively enrolled 12 patients with acute ischemic stroke who initially received IV recombinant tissue plasminogen activator (rtPA) and were subsequently treated with combined low-dose IA urokinase and AMCD. Time to treatment, urokinase dose, duration of the procedure, recanalization rates, and symptomatic hemorrhage were analyzed. Clinical outcome measures were assessed on admission and at discharge (National Institutes of Health Stroke Scale [NIHSS]), and at 3 months after treatment (modified Rankin Scale [mRS]). Median NIHSS score on admission was 17. Median time from symptom onset to IV rtPA was 120 minutes, and median time from symptom onset to IA therapy was 230 minutes. The median duration of IA therapy was 55 minutes. Median dose of urokinase was 300,000 U. Recanalization (thrombolysis in cerebral ischemia grade II or III) was achieved in all patients. No procedure-related complications were observed. There was no symptomatic hemorrhage. At discharge, median NIHSS score was 3. The 3-month outcome was excellent (mRS, 0-1) in 8 patients, good (mRS, 2) in 1 patient, and poor (mRS, 3-5) in 3 patients. There was no hospital or 3-month mortality. In this study, combination therapy with low-dose IA urokinase and AMCD is safe and effective after failed IV thrombolysis in patients with acute ischemic stroke. A high rate of recanalization, low rate of symptomatic hemorrhage, and excellent functional outcome can be achieved.