Incidence Of Symptomatic Intracerebral Hemorrhage Research Articles

Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size

BackgroundThe use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size has not been well studied.MethodsWe assigned, in a 1:1 ratio, patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging or computed tomography within 6.5 hours after symptom onset to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or to receive medical care alone (control group). The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage.ResultsA total of 333 patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); 9 were excluded from the analysis because of consent withdrawal or legal reasons. The trial was stopped early because results of similar trials favored thrombectomy. Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63; 95% confidence interval [CI], 1.29 to 2.06; P<0.001). Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and in 55.5% of those in the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68). Eleven procedure-related complications occurred in the thrombectomy group.ConclusionsIn patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage. (Funded by Montpellier University Hospital; LASTE ClinicalTrials.gov number, NCT03811769.)

Functional Outcomes Associated With Blood Pressure Decrease After Endovascular Thrombectomy

The associations between blood pressure (BP) decreases induced by medication and functional outcomes in patients with successful endovascular thrombectomy remain uncertain. To evaluate whether BP reductions induced by intravenous BP medications are associated with poor functional outcomes at 3 months. This cohort study was a post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control trial, a comparison of intensive and conventional BP management during the 24 hours after successful recanalization from June 18, 2020, to November 28, 2022. This study included 302 patients who underwent endovascular thrombectomy, achieved successful recanalization, and exhibited elevated BP within 2 hours of successful recanalization at 19 stroke centers in South Korea. A BP decrease was defined as at least 1 event of systolic BP less than 100 mm Hg. Patients were divided into medication-induced BP decrease (MIBD), spontaneous BP decrease (SpBD), and no BP decrease (NoBD) groups. The primary outcome was a modified Rankin scale score of 0 to 2 at 3 months, indicating functional independence. Primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and mortality due to index stroke within 3 months. Of the 302 patients (median [IQR] age, 75 [66-82] years; 180 [59.6%] men), 47 (15.6%)were in the MIBD group, 39 (12.9%) were in the SpBD group, and 216 (71.5%) were in the NoBD group. After adjustment for confounders, the MIBD group exhibited a significantly smaller proportion of patients with functional independence at 3 months compared with the NoBD group (adjusted odds ratio [AOR], 0.45; 95% CI, 0.20-0.98). There was no significant difference in functional independence between the SpBD and NoBD groups (AOR, 1.41; 95% CI, 0.58-3.49). Compared with the NoBD group, the MIBD group demonstrated higher odds of mortality within 3 months (AOR, 5.15; 95% CI, 1.42-19.4). The incidence of symptomatic intracerebral hemorrhage was not significantly different among the groups (MIBD vs NoBD: AOR, 1.89; 95% CI, 0.54-5.88; SpBD vs NoBD: AOR, 2.75; 95% CI, 0.76-9.46). In this cohort study of patients with successful endovascular thrombectomy after stroke, MIBD within 24 hours after successful recanalization was associated with poor outcomes at 3 months. These findings suggested lowering systolic BP to below 100 mm Hg using BP medication might be harmful.

Intracerebral hemorrhage after deep brain stimulation surgery guided with microelectrode recording: analysis of 297 procedures

ObjectivesReport the incidence of symptomatic and asymptomatic intracerebral hemorrhage (ICH) in patients submitted to deep brain stimulation (DBS) guided with microelectrode recording (MER) with further analysis of potential risk factors, both inherent to the patient and related to the pathology and surgical technique. MethodsWe performed a retrospective observational study. 297 DBS procedures were concluded in 277 patients in a single hospital centre between January 2010 and December 2020. All surgeries were guided with MER. We analysed the incidence of symptomatic and asymptomatic ICH and its correlation to age, sex, diagnosis, hypertension and perioperative hypertension, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, and number of MER trajectories. ResultsThere were a total of 585 electrodes implanted in 277 patients. 16 ICH were observed, of which 6 were symptomatic and 10 asymptomatic, none of which incurred in permanent neurological deficit. The location of the hemorrhage varied between cortical and subcortical plans, always in relation with the trajectory or the final position of the electrode. The incidence of symptomatic ICH per lead-implantation was 1%, and the CT-scan demonstrated asymptomatic ICH in 1.7% more patients. Male patients or with hypertension are 2.7 and 2.2 times more likely to develop ICH, respectively. However, none of these characteristics has been shown to have a statistically significant association with the occurrence of ICH, as well as age, diagnosis, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, number of MER trajectories and perioperative hypertension. ConclusionsMER-guided DBS is a safe technique, with low incidence of ICH and no permanent deficits in our study. Hypertension and male sex seem to be risk factors for the development of ICH in this surgery. Nevertheless, no statistically significant factors were found for the occurrence of this complication.

Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection

BackgroundThrombolytic agents, including tenecteplase, are generally used within 4.5 hours after the onset of stroke symptoms. Information on whether tenecteplase confers benefit beyond 4.5 hours is limited.MethodsWe conducted a multicenter, double-blind, randomized, placebo-controlled trial involving patients with ischemic stroke to compare tenecteplase (0.25 mg per kilogram of body weight, up to 25 mg) with placebo administered 4.5 to 24 hours after the time that the patient was last known to be well. Patients had to have evidence of occlusion of the middle cerebral artery or internal carotid artery and salvageable tissue as determined on perfusion imaging. The primary outcome was the ordinal score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability and a score of 6 indicating death) at day 90. Safety outcomes included death and symptomatic intracranial hemorrhage.ResultsThe trial enrolled 458 patients, 77.3% of whom subsequently underwent thrombectomy; 228 patients were assigned to receive tenecteplase, and 230 to receive placebo. The median time between the time the patient was last known to be well and randomization was approximately 12 hours in the tenecteplase group and approximately 13 hours in the placebo group. The median score on the modified Rankin scale at 90 days was 3 in each group. The adjusted common odds ratio for the distribution of scores on the modified Rankin scale at 90 days for tenecteplase as compared with placebo was 1.13 (95% confidence interval, 0.82 to 1.57; P=0.45). In the safety population, mortality at 90 days was 19.7% in the tenecteplase group and 18.2% in the placebo group, and the incidence of symptomatic intracranial hemorrhage was 3.2% and 2.3%, respectively.ConclusionsTenecteplase therapy that was initiated 4.5 to 24 hours after stroke onset in patients with occlusions of the middle cerebral artery or internal carotid artery, most of whom had undergone endovascular thrombectomy, did not result in better clinical outcomes than those with placebo. The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. (Funded by Genentech; TIMELESS ClinicalTrials.gov number, NCT03785678.)

Argatroban as an Add-On to rtPA in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Current treatment options for acute ischemic stroke, including intravenous thrombolysis (IVT) and mechanical thrombectomy, have undoubtedly revolutionized stroke care. The need for additional treatment options has brought into the light direct thrombin inhibitors (DTIs) and, specifically, argatroban as a promising candidate. However, there is uncertainty regarding the safety of adding argatroban to IVT, mainly due to the increased hemorrhagic risk. In this study, we performed a systematic review and meta-analysis examining the safety and efficacy of argatroban as an add-on treatment for IVT. The following databases were searched from inception until the 14th of May 2023: Pubmed/MEDLINE, ClinicalTrials.gov, the EU Clinical Trials Register, EMBASE/Scopus, and the Cochrane Library. Only randomized clinical trials (RCTs) enrolling patients with acute ischemic stroke who underwent IVT evaluating the add-on use of any DTIs were selected for the systematic review and further meta-analysis. The PRISMA guidelines were followed at all stages. Four studies with argatroban were included in the final analysis. Analysis of risk ratio and relative risk shows that the add-on therapy with argatroban seems to be effective and favors a good clinical outcome (mRS 0-2) at 90 days, similar to that of alteplase. All studies showed a low pooled incidence of symptomatic intracerebral hemorrhage (5%), parenchymal hematoma (3%), and other major bleeding (1%). Argatroban as an add-on treatment to IVT seems not to be associated with excessive bleeding risk; however, its efficacy remains unproven. According to this synopsis of the currently available evidence, it is premature to use argatroban as an add-on to IVT treatment outside the current clinical trial setting.

Intracerebral hemorrhage after deep brain stimulation surgery guided with microelectrode recording: analysis of 297 procedures

ObjectivesReport the incidence of symptomatic and asymptomatic intracerebral hemorrhage (ICH) in patients submitted to deep brain stimulation (DBS) guided with microelectrode recording (MER) with further analysis of potential risk factors, both inherent to the patient and related to the pathology and surgical technique. MethodsWe performed a retrospective observational study. 297 DBS procedures were concluded in 277 patients in a single hospital centre between January 2010 and December 2020. All surgeries were guided with MER. We analysed the incidence of symptomatic and asymptomatic ICH and its correlation to age, sex, diagnosis, hypertension and perioperative hypertension, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, and number of MER trajectories. ResultsThere were a total of 585 electrodes implanted in 277 patients. 16 ICH were observed, of which 6 were symptomatic and 10 asymptomatic, none of which incurred in permanent neurological deficit. The location of the hemorrhage varied between cortical and subcortical plans, always in relation with the trajectory or the final position of the electrode. The incidence of symptomatic ICH per lead-implantation was 1%, and the CT-scan demonstrated asymptomatic ICH in 1.7% more patients. Male patients or with hypertension are 2.7 and 2.2 times more likely to develop ICH, respectively. However, none of these characteristics has been shown to have a statistically significant association with the occurrence of ICH, as well as age, diagnosis, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, number of MER trajectories and perioperative hypertension. ConclusionsMER-guided DBS is a safe technique, with low incidence of ICH and no permanent deficits in our study. Hypertension and male sex seem to be risk factors for the development of ICH in this surgery. Nevertheless, no statistically significant factors were found for the occurrence of this complication.

Emergency Angioplasty or Stenting for Stroke Patients with Intracranial Atherosclerotic Large Vessel Occlusion.

Mechanical thrombectomy (MT) has become the gold standard for the treatment of large vessel occlusion (LVO) in acute ischemic stroke. However, it remains controversial whether emergency angioplasty or stenting in patients with intracranial atherosclerotic stenosis (ICAS) should be adopted. Thus, we performed a retrospective analysis of clinical data to determine whether emergency angioplasty or stenting is necessary. We retrospectively analyzed data from patients undergoing MT with ICAS-related LVO of the acute anterior circulation between 2017 and 2019. Eligible patients were divided into two treatment groups: those who received rescue angioplasty or stenting [Patients treated with rescue angioplasty or stenting (PTAS) group] and those who received thrombectomy alone (non-PTAS group). The primary outcomes were good prognosis at 90 days (mRS: 0-2). Mortality, symptomatic intracranial hemorrhage, and reocclusion rate were evaluated as secondary outcomes. A total of 184 patients with severe stenosis after MT were enrolled, including 64 patients receiving rescue angioplasty or stenting and 120 patients without rescue angioplasty or stenting. Compared with the non-PTAS group, a better functional outcome (mRS0-2) (51.6% vs. 35.0%, adjusted odds ratio: 2.11, 95% confidence interval [CI]: 1.22-4.29; P=0.02), lower 7-day National Institutes of Health Stroke Scale [6 (3-12.75) vs. 10 (4-16); P=0.04], lower 24-h neurological deterioration rate (7.8% vs. 21.7%, P=0.02), and lower 24-h reocclusion rate were observed in the PTAS group (6.3% vs. 17.5%, P=0.03). There were no significant differences in mortality or incidence of symptomatic intracerebral hemorrhage. Emergency angioplasty or stenting could be a safe and feasible therapeutic option with better outcomes for stroke patients with ICAS-related LVO.

Efficacy and safety of urgent carotid endarterectomy in patients with acute ischemic stroke.

Acute symptomatic occlusion of the internal carotid artery (ICA) is associated with unfavorable prognosis. However, no clear definition of its optimal treatment exists. The aim of this study was to evaluate the efficacy and risks of urgent carotid endarterectomy (CEA) in patients with ischemic stroke due to acute extracranial ICA occlusion. A retrospective analysis was performed of all consecutive patients undergoing urgent CEA for acute extracranial ICA occlusion during the period from July 2014 to June 2021. The primary outcome was functional independence at three months defined as modified Rankin Scale (mRS) score 2. Secondary outcomes included the severity of the neurological deficit at the time of discharge and its comparison with the preoperative condition as assessed using the National Institutes of Health Stroke Scale (NIHSS), the incidence of symptomatic intracerebral hemorrhage (ICH), and 30-day periprocedural mortality. During the study period, a total of 42 urgent CEAs were performed for acute extracranial ICA occlusions. The median preoperative NIHSS score was 7 (interquartile range [IQR] 5-13). The median time interval between the onset of symptoms and surgery was 290 minutes (IQR 235-340). Technical success rate of urgent CEA was 97.6% (41 patients). The median NIHSS at the time of hospital discharge was 2 (IQR 3-7; p.

Effect of mechanical thrombectomy with vs. without intravenous thrombolysis in acute ischemic stroke.

The results of mechanical thrombectomy (MT), wi-thout or with intravenous thrombolysis, were evaluated and compared in 178 patients with acute ischemic stroke (AIS) due to large vessel occlusions (LVO) at Bach Mai Hospital. A total of 178 patients with AIS due to LVO were assigned to undergo MT alone (MT-alone group) or MT preceded by intravenous alteplase (the combined group), at a dose of 0.9 mg per kilogram, administered within 4.5 hours after symptom onset (combined group). The successful recanalization rate (assessed as thrombolysis in cerebral infarction [TICI] classification of 2b-3) and the incidence of good clinical recovery outcomes (modified Rankin Scale [mRS] ≤2) after 3 months were analyzed in both groups and compared. A total of 178 patients were enrolled (median age, 65 years; 55% men; median National Institutes of Health Stroke Scale [NIHSS]: 14.3). Favorable outcomes were reported in 76 patients (66.7%) in the MT-alone group and 42 patients (65.6%) in the com-bined group, with no significant between-group difference (P = 0.31 for noninferiority). However, MT alone was associated with a lower percentage of patients with successful reperfusion after MT compared with the combined group (87.7% vs. 90.6%). Mortality at 90 days was 12.2% (14 patients) in the MT-alone group and 17.2% (11 patients) in the combined group. The incidence of symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.3%] vs. 1 [1.6%]; P = 0.42). Among patients with AIS due to LVO in our study, MT alone was noninferior in terms of functional outcomes compared with MT preceded by the administration of intravenous alteplase within 4.5 hours after symptom onset.

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke

BackgroundThe value of administering intravenous alteplase before endovascular treatment (EVT) for acute ischemic stroke has not been studied extensively, particularly in non-Asian populations.MethodsWe performed an open-label, multicenter, randomized trial in Europe involving patients with stroke who presented directly to a hospital that was capable of providing EVT and who were eligible for intravenous alteplase and EVT. Patients were randomly assigned in a 1:1 ratio to receive EVT alone or intravenous alteplase followed by EVT (the standard of care). The primary end point was functional outcome on the modified Rankin scale (range, 0 [no disability] to 6 [death]) at 90 days. We assessed the superiority of EVT alone over alteplase plus EVT, as well as noninferiority by a margin of 0.8 for the lower boundary of the 95% confidence interval for the odds ratio of the two trial groups. Death from any cause and symptomatic intracerebral hemorrhage were the main safety end points.ResultsThe analysis included 539 patients. The median score on the modified Rankin scale at 90 days was 3 (interquartile range, 2 to 5) with EVT alone and 2 (interquartile range, 2 to 5) with alteplase plus EVT. The adjusted common odds ratio was 0.84 (95% confidence interval [CI], 0.62 to 1.15; P=0.28), which showed neither superiority nor noninferiority of EVT alone. Mortality was 20.5% with EVT alone and 15.8% with alteplase plus EVT (adjusted odds ratio, 1.39; 95% CI, 0.84 to 2.30). Symptomatic intracerebral hemorrhage occurred in 5.9% and 5.3% of the patients in the respective groups (adjusted odds ratio, 1.30; 95% CI, 0.60 to 2.81).ConclusionsIn a randomized trial involving European patients, EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. (Funded by the Collaboration for New Treatments of Acute Stroke consortium and others; MR CLEAN–NO IV ISRCTN number, ISRCTN80619088.)

Experiences With Intravenous Thrombolysis in Acute Ischemic Stroke by Elderly Patients-A "Real World Scenario".

Objectives: This retrospective single-center study aimed to investigate the risk factors, outcomes and complication rates in patients older vs. younger than 80 years treated with intravenous alteplase.Methods: Data of 1,253 thrombolysed patients were analyzed between January 1, 2004 and August 31, 2016. Vascular risk factors, stroke severity based on the NIHSS score, functional outcome using modified Rankin Scale (mRS), mortality and symptomatic intracerebral hemorrhage (SICH) were compared between two subgroups (<80 and ≥80 years).Results: 1,125 patients were included, 199 (17.6%) among them were aged over 80 years, majority (63.3%) were female (p < 0.00001). Mean age was 68.2 ± 12.4 years, i.e., 64.7 ± 10.8 years and 84.3 ± 3.4 years in the younger and the older groups, respectively (p < 0.001). Atrial fibrillation and pre-stroke anticoagulation among patients over 80 years was more likely (p < 0.0005 and p = 0.02, respectively). NIHSS scores on admission and at 24 h were higher in elderly patients (p < 0.0001). ASPECT score at 24 h was less favorable in elderly patients (p = 0.007) and was associated with worse outcome. At 3 months, 59.8% of the patients from the older group had an unfavorable outcome (p < 0.0001), however 34.7% had independent outcome. The one-year- survival was significantly worse in the older group (p < 0.0001). The incidence of SICH was lower among older patients. In a logistic regression model, atrial fibrillation, heart failure, diabetes mellitus and smoking were proven as a significant independent risk factors for worse outcome.Conclusion: Although, the outcomes were less favorable in patients over 80 years of age, our results support the feasibility of using intravenous thrombolysis among patients over 80 years of age.

Is the weekend effect true in acute stroke patients at tertiary stroke center?

BackgroundThere is contradicting evidence on the outcome of emergency patients treated during weekends versus weekdays. We studied if outcome of ischemic stroke patients receiving intravenous thrombolysis (IVT) differs according to the treatment time. MethodsOur retrospective study included consecutive patients receiving IVT within 4.5 h of stroke onset between June 1995 and December 2018 at the Helsinki University Hospital. The patients were compared based on the treatment initiation either during weekdays (Monday to Friday) or weekend (Saturday and Sunday). The primary outcome was 3-month mortality and secondary outcomes comprised 3-month modified Rankin Scale (mRS) and incidence of symptomatic intracerebral hemorrhage (sICH). Additional analyses studied the effect of IVT treatment according to non-office hours, time of day, and season. ResultsOf the 3980 IVT-treated patients, 28.0% received treatment during weekends. Mortality was similar after weekend (10.0%) and weekday (10.6%) admissions in the multivariable regression analysis (OR 0.78; 95% CI 0.59–1.03). Neither 3-month mRS (OR 0.98; 95% CI 0.86–1.12), nor the occurrence of sICH (4.2% vs 4.6%; OR 0.87; 95% CI 0.60–1.26) differed between the groups. No outcome difference was observed between the office vs non-office hours or by the time of day. However, odds for worse outcome were higher during autumn (OR 1.19; 95% CI 1.04–1.35) and winter (OR 1.15; 95% CI 1.01–1.30). ConclusionWe did not discover any weekend effect for IVT-treated stroke patients. This confirms that with standardized procedures, an equal quality of care can be provided to patients requiring urgent treatment irrespective of time.

Abstract 44: DEVT: Endovascular Treatment Alone versus Intravenous Alteplase Plus Endovascular Treatment in Stroke

Background: In large vessel occlusion strokes, it is unknown whether the potential risks and added costs associated with intravenous alteplase before mechanical thrombectomy remain justifiable. Methods: In 33 stroke centers in China, patients presenting with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from onset and eligible for intravenous thrombolysis underwent 1:1 randomization mechanical thrombectomy alone (primary-thrombectomy group) or standard dose of intravenous alteplase followed by mechanical thrombectomy (bridging-therapy group). The primary endpoint was non-inferiority of functional independence at 90 days (defined as score 0-2 on the modified Rankin scale). Non-inferiority was established with a margin of -0.1. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. Results: The trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization (116 to the primary-thrombectomy and 118 to the bridging-therapy group). The primary endpoint of functional independence at 90 days was achieved by 63(54.3%) patients in the primary-thrombectomy versus 55(46.6%) in the bridging-therapy group (incidence difference, 7.7%; 95% confidence interval, -5.1% to 20.5%), indicating that primary-thrombectomy was non-inferior to bridging-therapy (Z=2.7157, P non-inferiority =0.00330). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% versus 6.8%) and 90-day mortality (17.2% versus 17.8%). Conclusions: In stroke patients with proximal anterior circulation occlusions within 4.5 hours from onset, mechanical thrombectomy alone was non-inferior to intravenous alteplase followed by mechanical thrombectomy in terms of 90-day functional independence. (Funded by the Natural Science Foundation of China and others; DEVT chictr.org.cn number, ChiCTR-IOR-17013568.)

Abstract P30: Safety and Efficacy of Intravenous Tirofiban in Acute Ischemic Stroke With Extended Window Period

Introduction: Intravenous Thrombolysis is approved upto 4½ hrs and Endovascular Therapy upto 24 hrs in eligible Acute Ischemic Stroke (AIS) patients with Large Vessel Occlusion. There are still substantial number of AIS patients where there is no effective treatment available. In this Study we aim to test the safety and Efficacy of the reversible gp IIb/IIIa receptor inhibitor antagonist Tirofiban in AIS beyond 4 ½ hrs and within 24 hrs. Methodology: Among a total of 750 AIS patients admitted in our Stroke Unit, from July 2019 to March 2020, 100 Consecutive patients were included in this study and received Intravenous tirofiban as an initial bolus followed by infusion. Inclusion criteria were Age 18-80yrs, Window Period 4 ½ to 24 hrs. National Institute of health Stroke Scale score (NIHSS) between 5-20, No contraindication for lytic drugs. CT Brain excluding Hemorrhage or &gt; 1/3 rd infarct. Cardioembolic strokes were excluded. Efficacy Assessments: NIHSS and modified Rankin scale (mRS) performed at baseline, within 48hrs, Day-7 and Day-90. The good outcome was defined as mRS 0-1 at 3 months. The safety outcomes were assessed by the incidence of Symptomatic Intracerebral hemorrhage (SICH), Systemic Bleeding and any mortality. Results: There were 74 males, 26 females with median Age of 56 yrs (range from 18 to 80yrs). The Median NIHSS is 10 (range from 5-20), Majority (87%) had anterior circulation strokes and 13% were in Posterior circulation. One patient (1%) developed symptomatic parenchymal Hemorrhage, 4 patients (4%) had mild haemorrhagic transformation within infarct, 8 patients (8%) had nonfatal systemic bleed in the form of Hematuria. Total Mortality - 2 patients (2%), one patient died in the hospital due to cardiac arrest and another patient died at home after discharge. At 3 months, 62 patients (62%) had good outcome (mRS 0-1) and 33 patients (33%) had favourable outcome (mRS 2-3). Conclusion: In this Observational Study we found that Intravenous Tirofiban is not only safe, but effective in AIS patients with extended window period. However, Randomized Clinical Trials are needed to further clarify our observation.

Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers

ObjectiveThe “weekend effect” has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. MethodsWe performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. ResultsTwo hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). ConclusionsDespite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.

Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke

<h3>Importance</h3> For patients with large vessel occlusion strokes, it is unknown whether endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment (standard treatment) can achieve similar functional outcomes. <h3>Objective</h3> To investigate whether endovascular thrombectomy alone is noninferior to intravenous alteplase followed by endovascular thrombectomy for achieving functional independence at 90 days among patients with large vessel occlusion stroke. <h3>Design, Setting, and Participants</h3> Multicenter, randomized, noninferiority trial conducted at 33 stroke centers in China. Patients (n = 234) were 18 years or older with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from symptoms onset and eligible for intravenous thrombolysis. Enrollment took place from May 20, 2018, to May 2, 2020. Patients were enrolled and followed up for 90 days (final follow-up was July 22, 2020). <h3>Interventions</h3> A total of 116 patients were randomized to the endovascular thrombectomy alone group and 118 patients to combined intravenous thrombolysis and endovascular thrombectomy group. <h3>Main Outcomes and Measures</h3> The primary end point was the proportion of patients achieving functional independence at 90 days (defined as score 0-2 on the modified Rankin Scale; range, 0 [no symptoms] to 6 [death]). The noninferiority margin was −10%. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. <h3>Results</h3> The trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization. All 234 patients who were randomized (mean age, 68 years; 102 women [43.6%]) completed the trial. At the 90-day follow-up, 63 patients (54.3%) in the endovascular thrombectomy alone group vs 55 (46.6%) in the combined treatment group achieved functional independence at the 90-day follow-up (difference, 7.7%, 1-sided 97.5% CI, −5.1% to ∞)<i>P</i>for noninferiority = .003). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% vs 6.8%; difference, −0.8%; 95% CI, −7.1% to 5.6%) and 90-day mortality (17.2% vs 17.8%; difference, −0.5%; 95% CI, −10.3% to 9.2%). <h3>Conclusions and Relevance</h3> Among patients with ischemic stroke due to proximal anterior circulation occlusion within 4.5 hours from onset, endovascular treatment alone, compared with intravenous alteplase plus endovascular treatment, met the prespecified statistical threshold for noninferiority for the outcome of 90-day functional independence. These findings should be interpreted in the context of the clinical acceptability of the selected noninferiority threshold. <h3>Trial Registration</h3> Chinese Clinical Trial Registry:ChiCTR-IOR-17013568

The Safety and Efficiency of Tirofiban in Acute Ischemic Stroke Patients Treated with Mechanical Thrombectomy: A Multicenter Retrospective Cohort Study.

Introduction Limited comparative studies have reported the safety and efficacy of tirofiban in acute ischemic stroke (AIS) patients after mechanical thrombectomy (MT). Additionally, the available studies are inconsistent with each other, which makes application of tirofiban unclear in neuro-intervention. Here, we performed a comparative retrospective study to investigate whether tirofiban combined with MT improves short- and long-term prognosis in AIS patients and whether its use is associated with complications. Method Retrospective data were collected for AIS patients admitted between January 2013 and January 2019 at three stroke centers. According to whether tirofiban was used during the operation, patients were divided into tirofiban group and control group. Multivariate and COX regression analyses were performed to determine the association of tirofiban treatment with safety and efficiency in subjects treated with MT. Result A total of 174 patients were analyzed, of whom 89 (51.1%) were treated with tirofiban. There were no differences in the incidence of symptomatic intracerebral hemorrhage (10.2% vs. 10.6%, p=0.918), parenchymal hemorrhage type 2 (18.0% vs. 16.5%, p=0.793), and reocclusion at 24 h (3.4% vs. 10.6%, p=0.060) between the tirofiban group and control group. Multivariate regression showed that tirofiban was not associated with intracerebral hemorrhage, early neurological deterioration, neurological improvement at 7 days, functional independence at 3-month and 9-month follow-up, or death at 9-month follow-up (adjusted p > 0.05 for all). However, AIS patients treated with MT + tirofiban showed a trend towards acquiring faster functional independence, with a median time to acquire functional independence of 4.0 months compared with 6.5 months in the control group (risk ratio = 1.49, 95% confidence interval 0.98–2.27; long rank p=0.066). Conclusion Tirofiban may help AIS patients given MT to gain functional independence faster, without increasing the risk of complications.

Hesperidin reduces adverse symptomatic intracerebral hemorrhage by promoting TGF-β1 for treating ischemic stroke using tissue plasminogen activator.

Treatment with recombinant tissue plasminogen activator (rt-PA) is the most effective therapeutic option against brain ischemic stroke at the present time. However, elevated incidence of symptomatic intracerebral hemorrhage (SIH) greatly hinders ideal treatment outcome of rt-PA. We sought to assess the impacts of hesperidin on SIH following rt-PA therapies. Patients with ischemic stroke were assigned into two groups in a random fashion, to receive either rt-PA + placebo (Pc) or rt-PA + hesperidin. Treatment outcome was evaluated 24h after the initial reperfusion using the transcranial Doppler ultrasonography (TCD) and the NIH Stroke Scale (NIHSS). Further, serum concentrations of transforming growth factor (TGF)-β1, matrix metalloproteinase (MMP)-2, and MMP-9 were examined. Following the initial administration, stroke patients continued to receive either daily Pc or daily hesperidin, and the treatment outcome after 7days was examined using the TCD, NIHSS, Glasgow Outcome Scale (GOS), and the Modified Rankin Scale (MRS). Combined treatment of rt-PA with hesperidin yielded significant improvement of outcomes, as revealed by better TCD and NIHSS scores as well as decreased SIH incidences, which could be attributable to elevation of TGF-β1 and reduction in serum levels of both MMP-2 and MMP-9 caused by hesperidin. Follow-up hesperidin treatment for 7 consecutive days also markedly enhanced the recovery of stroke patients, as indicated by TCD, MRS, GOS, and NIHSS. Findings of the present study strongly suggested potential clinical application of hesperidin supplement in rt-PA therapies to reduce SIH and thereby improve the treatment outcomes of rt-PA in patients with ischemic stroke.

Abstract TMP8: High Flow Normobaric Oxygen (NBO) Therapy Provides Effective Neuroprotection After Endovascular Recanalization in Acute Ischemic Stroke

Introduction: Recent advancements in endovascular thrombectomy for large vessel acute ischemic stroke (AIS) have achieved longer intervention time windows (16-24 h) and higher rates of revascularization (71%). Despite improvements, 40% of patients still have severe disability [modified Rankin scale (mRS): 3-5] with 15% mortality. Thus, adjuncts to improve clinical outcomes after endovascular recanalization need to be explored. NBO has long been recognized as a potential adjuvant therapy in AIS. Previous clinical trials have failed to demonstrate efficacy, while vessel recanalization was not assessed in the trials. The present study was performed to determine whether administration of NBO after endovascular recanalization conveys a clinical benefit. Methods: In this single-center prospective study (ChiCTR-INR-17013685), all AIS patients with large vessel occlusion who underwent endovascular recanalization (TICI≥1) were recruited between January 2016 to June 2018. Patients received NBO therapy by Venturi mask (FiO2 50%, 15 L/min) or routine low-dose oxygen supplementation (3 L/min) for 6 h, immediately after vessel recanalization. Clinical outcome measures, including NIIHSS scores, mRS scores, and mortality, as well as the incidence of symptomatic intracerebral hemorrhage (ICH) were recorded. Results: 138 AIS subjects (69 randomized to NBO) were analyzed. Average NIHSS score at stroke onset were similar (17.7±5.1 in NBO;17.8±5.1 with control, p=0.89). There were no significant differences in other baseline characteristics either. Mild disability (mRS 0-3) in patients in the NBO group (78%) was significantly higher (p=0.04) than in control (61%) at 90 days. Severe disability (mRS 3-5) was equal in both groups (30 v. 26%, p=0.706), while mortality in the NBO group (9%) was largely decreased (p=0.016) compared to control (25%). Additionally, 61% (n=42) of patients in the NBO group were functionally independent (mRS 0-2) compared to 49% (n=34) in control, although this difference did not reach a significant level (p=0.231). ICH was low in both groups (3 vs 7%, p=0.44). Conclusion: The utilization of NBO following endovascular revascularization appears to be safe and may enhance the therapeutic effect of endovascular thrombectomy in AIS.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage.

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.