Intra-arterial Reperfusion Therapy Research Articles

Association between different acute stroke therapies and development of post stroke seizures

BackgroundEpilepsy is a major complication of stroke. We aimed to establish whether there is an association between intravenous thrombolysis, intra-arterial thrombolysis and post stroke seizure (PSS) development. Improved understanding of the relationship between reperfusion therapies and seizure development may improve post-stroke monitoring and follow-up.MethodsThis was a retrospective, multicentre cohort study conducted at the Royal Melbourne Hospital and Jingling Hospital Nanjing. We included patients with anterior circulation ischemic stroke admitted 2008–2015. Patients were divided into four treatment groups 1. IV-tPA only, 2. Intra-arterial therapies (IAT) only, 3. IAT + IV-tPA and 4. stroke unit care only (i.e. no IV-tPA or IAT). To assess the association between type of reperfusion treatment and seizure incidence we used multivariable logistic regression models adjusted for age, stroke severity, 3-month functional outcome and prognostic factors.ResultsThere were 1375 stroke unit care-only patients, of whom 28 (2%) developed PSS. There were 363 patients who received only IV-tPA, of whom 21 (5.8%) developed PSS. There were 93 patients who received IAT only, of whom 12 (12.9%) developed PSS and 112 that received both IV-tPA + IAT, of which 5 (4.5%) developed PSS. All reperfusion treatments were associated with seizure development compared to stroke unit care-only patients: IV-tPA only adjusted odds ratio (aOR) 3.7, 95%CI 1.8–7.4, p < 0.0001; IAT aOR 5.5, 95%CI 2.1–14.3, p < 0.0001, IAT + IV-tPA aOR 3.4, 95% CI 0.98–11.8, p = 0.05. These aORs did not differ significantly between treatment groups (IV-tPA + IAT versus IV-tPA p = 0.89, IV-tPA + IAT versus IAT, p = 0.44).ConclusionsPatients receiving thrombolytic or intra-arterial reperfusion therapies for acute ischemic stroke are at higher risk of epilepsy and may benefit from longer follow-up. No evidence for an additive or synergistic effect of treatment modality on seizure development was found.

Reconsidering Neuroprotection in the Reperfusion Era.

Neuroprotection to prevent infarct progression as a potential treatment for acute ischemic stroke carries a long and disappointing history. The failures of these prior neuroprotection trials have many potential explanations that encompass both problems with the preclinical assessment of these drugs and the design/implementation of clinical trials.1 Prior development of neuroprotection has focused primarily on its use as a monotherapy, and no clinical trial was designed to determine whether neuroprotection could extend the time window for successful reperfusion or ameliorate the consequences of reperfusion. Acute stroke therapy has now entered the era of highly effective reperfusion with the recent publication of 5 positive thrombectomy trials.2 Combining neuroprotection with intravenous or intra-arterial reperfusion therapy is now an important next step in the development of acute stroke therapies. One approach to neuroprotection would be to initiate therapy early after ischemic stroke onset, either in the ambulance or at a primary stroke center/community hospital to potentially extend the time window for intravenous or intra-arterial therapy. A second approach would be to use neuroprotection during or after partial or complete reperfusion to reduce the consequences of reperfusion injury. Both future neuroprotective approaches will require preclinical studies that anticipate novel clinical trial designs and trials that will be organized and evaluated differently than past monotherapy neuroprotection trials. Acute ischemic stroke therapy is designed to reduce infarction of hypoperfused brain tissue and limit the expansion of already irreversibly injured tissue when treatment is initiated, leading to smaller infarction and improved clinical outcomes.3,4 Severely hypoperfused but still potentially viable ischemic brain represents the ischemic penumbra, whereas irreversibly injured tissue is the ischemic core.5 Early after stroke onset, most patients with a large vessel occlusion (LVO) have an extensive ischemic penumbra that can be salvaged by timely reperfusion. This concept was proven …

Use of rivaroxaban in patients with stroke.

Rivaroxaban, an inhibitor of Factor Xa, is a direct oral anti-coagulant that has been found to be non-inferior to warfarin in preventing cerebral ischemia in patients with non-valvular atrial fibrillation and in the subgroup of patients with a history of the previous stroke or transient ischemic attack. Vascular neurologists in daily clinical practice may encounter patients taking rivaroxaban or patients who may benefit from its use. In this paper, we review the current clinical indications, contraindications, and clinical management guidelines for rivaroxaban while providing a special focus on neurological aspects and expert opinions on rivaroxaban therapy management in various situations that a neurologist may encounter when treating patients with an ischemic stroke (including those requiring intravenous or intra-arterial reperfusion therapy) and patients with an intracerebral hemorrhage. Since data from clinical trials and real-life data are missing in some clinical situations, strong recommendations are not always available. Nevertheless, practical guidelines should be adopted to maximize benefits from this oral anti-coagulant.

High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

Background and Purpose: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD² scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD² scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD² scores. Results: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD² scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD² score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions: Higher ABCD² scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk' patients.

Endovascular Reperfusion Strategies for Acute Stroke.

Stroke is the most common cause of permanent disability, the second most common cause of dementia, and the third most common cause of death in the Western world. About 10% to 20% of strokes are due to large-artery occlusions causing severe disabling strokes. Recently, 5 randomized controlled trials established mechanical thrombectomy in stroke treatment in patients with large-vessel occlusions. The current intra-arterial reperfusion therapies allow high recanalization rates, high rates of favorable clinical outcome, and low complication rates. This review discusses the results of recent randomized trials and describes the current state-of-the-art endovascular treatment in acute ischemic stroke.

Value of utilizing both ASPECTS and CT angiography collateral score for outcome prediction in acute ischemic stroke.

Alberta Stroke Program Early CT Score (ASPECTS) represents the extent of irreversibly damaged tissue; while CT angiography collateral score (CTA-CS) denotes the degree of collaterals. We investigated whether there is cumulative value in using both ASPECTS and CTA-CS for outcome prediction and attempted to determine the specific subgroup of patients who could benefit from successful reperfusion using these scores. This is a retrospective observational study of stroke patients treated with intra-arterial reperfusion therapy for unilateral arterial occlusion in the anterior circulation. A favorable outcome was defined as modified Rankin Scale ≤ 2 at three-months. Receiver operating characteristic comparison analysis was performed to decide whether outcome predictability increases when ASPECTS and CTA-CS are used together. Classification and regression tree (CART) analysis was done to identify the variables that best predict outcome and define the specific subgroup of patients who could benefit from successful reperfusion. A total of 91 consecutive patients were included. Outcome predictability of ASPECTS with CTA-CS was better than that of ASPECTS (P = 0·088) or that of CTA-CS (P = 0·049). CART analysis revealed that ASPECTS > 5 was the primary determinant of favorable outcome, followed by CTA-CS > 1. Among 19 patients with ASPECTS ≤ 5, none had a favorable outcome. Successful reperfusion was associated significantly with favorable outcome in the 51 patients with ASPECTS > 5 and CTA-CS > 1, but not in the 21 patients with ASPECTS > 5 and CTA-CS ≤ 1. Outcome predictability improves when using ASPECTS and CTA-CS together.

E-005 Short-term Outcomes of Acute Ischemic Stroke Patients with MCA/ICA Occlusion Excluded for Intra-arterial Reperfusion Therapy

IntroductionLarge-vessel occlusions account for 45% of patients with acute ischemic stroke (AIS) presenting to the emergency departments in the United States. Many of these patients may not be eligible candidates...

Reperfusion Therapies for Wake-Up Stroke

Patients who present with stroke symptoms on awakening, often referred to as wake-up stroke (WUS), account for ≈25% of acute ischemic strokes.1 In this group, onset time is unknown and usually defined conservatively as time last seen well (LSW) before sleeping.2,3 Onset time is important because benefit from intravenous thrombolysis is time dependent until 4.5 hours after symptoms start.4 Patients with WUS are not treated routinely unless awake and symptom free within standard timescales. However, evidence suggests that clinical and imaging characteristics of patients with WUS do not differ significantly from those with stroke while awake (SWA) presenting within 0- to 3-hour thrombolysis time windows.1,5,6 Imaging findings for many patients with WUS are consistent with an onset immediately before waking.6 As patients with WUS may benefit from reperfusion treatment if promptly delivered, we systematically reviewed studies of patients with WUS treated with intravenous and intra-arterial reperfusion therapies to consider the strength of evidence and make future recommendations. ### Search Strategy/Selection Criteria An unlimited PubMed search (MEDLINE) was performed on April 16, 2013, using the terms: wake* OR awake* OR sleep* OR asleep OR unclear-onset OR unclear onset OR unwitness* OR witness* AND stroke. Further PubMed alerts were received until June 30, 2013. One author (D.B.) reviewed abstracts to identify potentially eligible studies. Because of the small number of publications anticipated, all study designs were included. Articles were included if they described additional analyses using data from previously identified cohorts. ### Data Extraction Two authors (D.B. and L.S.) independently extracted data. Discrepancies were resolved by discussion with C.P. as the final adjudicator. The data extracted were 1. inclusion criteria, 2. type(s) of data comparison/numbers of patients, 3. type(s) of intervention, drugs/doses, 4. time to treatment (TTT) from wake-up and LSW, 5. imaging findings, 6. stroke severity (baseline National Institute of Health Stroke Scale …

Relative filling time delay based on CT perfusion source imaging: a simple method to predict outcome in acute ischemic stroke.

Collateral vessel status is strongly associated with clinical outcome in ischemic stroke but can be challenging to assess. The aim of this study was to develop a tomography perfusion source imaging-based assessment of collateral vessel status. Consecutive patients with ischemic stroke who received intravenous thrombolysis or intra-arterial reperfusion therapy after CTP were retrospectively analyzed. In those with middle cerebral artery or internal carotid artery occlusion, CT perfusion source imaging was used to identify the relative filling time delay between the normal MCA Sylvian branches and those in the affected hemisphere. Receiver operating characteristic analysis and logistic regression were used to assess the association of the relative filling time delay with the 24-hour Alberta Stroke Program Early CT Score based on noncontrast CT and the 90-day modified Rankin Scale score. There were 217 patients treated in 2009-2011 who had CTP data, of whom 60 had MCA or ICA occlusion and 55 had 90-day mRS data. The intraclass correlation coefficient for relative filling time delay was 0.95. Relative filling time delay was correlated with 24-hour ASPECTS (Spearman ρ=-0.674; P<.001) and 90-day mRS score (ρ=0.516, P<.01). Increased relative filling time delay was associated with poor radiologic outcome (ASPECTS, 0-7) (area under the curve=0.79, P<.001) and poor functional outcome (mRS score, 3-6) (area under the curve=0.77, P=.001). In multivariate logistic regression, the association of longer relative filling time delay with poor outcome remained significant, independent of age, sex, and baseline National Institutes of Health Stroke Scale score. Relative filling time delay is a useful independent predictor of clinical outcome after ischemic stroke.

Delayed-phase CT angiography is superior to arterial-phase CT angiography at localizing occlusion sites in acute stroke patients eligible for intra-arterial reperfusion therapy

We compared the accuracy for localizing arterial occlusion sites between delayed-phase computed tomography angiography (CTA) and arterial-phase CTA in acute stroke patients with large vessel occlusion. Institutional Review Board approval was obtained, and informed consent was waived. For patients treated with intra-arterial thrombolysis within a 6hour window between January 2009 and November 2011, we retrospectively assessed the arterial occlusion sites of pre-treatment, delayed-phase and arterial-phase CTA and compared these with digital subtraction angiography (DSA) findings. The positive predictive value for detection of vessel occlusion for both CTA methods was derived using DSA as a reference standard. The outcomes were compared using the McNemar test. Inter-observer disagreement within each modality was assessed using the Kendall W test. Among 73 patients treated with intra-arterial thrombolysis, 24 (32.9%) underwent both arterial-phase and delayed-phase CTA, and 66 (90.4%) underwent arterial-phase CTA only. For 24 patients undergoing both arterial-phase and delayed-phase CTA, the delayed-phase CTA detected concordant occlusion sites with DSA in 21 patients, yielding a positive predictive value of 87.5%, whereas the arterial-phase CTA detected this in 14 patients, for a positive predictive value of 58.3% (p=0.013). When discordant with DSA, arterial-phase or delayed-phase CTA indicated occlusions in more proximal sites than DSA. Delayed-phase CTA more precisely localized the occlusion site than arterial-phase CTA in acute stroke patients with large vessel occlusion. Thus, delayed-phase CTA findings could guide neurointerventionists in selecting intra-arterial thrombolysis modalities.

O-021 Evaluation of Baseline CT ASPECTS in Perfusion-guided Selected Patients for Intra-arterial Reperfusion Therapy

Background and PurposeAppropriate patient selection in acute ischaemic stroke (AIS) is central for improving patient outcomes following intra-arterial (IA) reperfusion therapy (thrombolysis/mechanical thrombectomy). Perfusion imaging with CTP/MR DWI-PWI has been...

Early Anticipation of Candidacy for Intra-Arterial Reperfusion Therapy Based on Baseline Clinical Stroke Subtypes: Comparison with Multiparametric MRI Taken within 4.5 Hours from Stroke Onset

Background: The decision to proceed with intra-arterial (IA) reperfusion therapy is typically made late in the course of in-hospital treatment for acute ischemic stroke. Early anticipation of candidacy for IA reperfusion therapy based on clinical stroke subtypes would be useful for guiding stroke management. The aim of this study was to investigate the relationship between the clinical Oxfordshire Community Stroke Project (OCSP) classification and MRI results taken within a 4.5-hour time window from stroke onset, with the hypothesis that the persistence of major arterial occlusion and extended ischemic penumbra, key criteria for proceeding with IA reperfusion therapy, would be distinctive between the clinical stroke subtypes. Methods: A total of 161 patients with acute ischemic stroke in the anterior circulation were included in this study. All patients were treated with intravenous alteplase, and MRI scans were performed following alteplase initiation. Prior to treatment, the patients were categorized, based on the OCSP classification scheme, as having total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), or lacunar infarcts (LACI). The relationship between OCSP subtypes, MRI parameters, and clinical variables was analyzed. Results: Overall, 40/161 patients (24.8%) were candidates for IA rescue reperfusion. With respect to the classification, 30/69 TACI (43.5%), 6/33 PACI (18.2%), and 4/59 LACI patients (6.8%) were candidates (p < 0.001). Major arterial occlusion was found in 56/161 patients (34.8%), and 46/69 TACI (66.7%), 6/33 PACI (18.2%), and 4/59 LACI patients (6.8%) had a major arterial occlusion (p < 0.001). A perfusion-diffusion mismatch greater than 20% was found in 85/161 patients (52.8%). More specifically, 40/69 TACI (58.0%), 25/33 PACI (75.8%), and 20/59 LACI patients (33.9%) had a perfusion-diffusion mismatch (p < 0.001). However, in terms of the total area of mismatch, 66.0% of patients with ASPECTS_DWI-PWI ≥2 (Alberta Stroke Program Early CT Score) were classified as TACI patients (p < 0.001) and of the patients with ASPECTS_DWI-PWI ≥3, 74.3% were classified as TACI patients (p < 0.001). Relative to candidates for IA rescue reperfusion, the clinical TACI group showed 75.0% sensitivity, 67.8% specificity, a positive predictive value of 43.5%, and a negative predictive value of 89.1%. Conclusions: In this study, patients classified as having clinical TACI were significantly more likely to be candidates for IA rescue reperfusion. Additionally, they incurred a higher incidence of persistent major arterial occlusion and had a penumbra area that was significantly larger than normal. Therefore, clinical OCSP can be used as an ‘early warning system' for IA reperfusion candidacy, which can allow for advanced preparation of IA therapy and theoretically shorten treatment time and reduce infarction.

Abstracts from the 3rd Annual Therapeutic Hypothermia and Temperature Management ConferenceMarch 4–5, 2013Miami, FL

Abstracts from the 3rd Annual Therapeutic Hypothermia and Temperature Management ConferenceMarch 4–5, 2013Miami, FL

Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I)

BackgroundThe efficacy of hypothermia as a neuroprotectant has yet to be demonstrated in acute ischemic stroke. We conducted a phase I pilot study to assess the feasibility and safety of...

Abstract WP336: Telestroke To Bring Tertiary Center Acute Stroke Practice To Rural Minnesota Residents; Percent Treated With Interventional Procedures, Timing, And Clinical Results.

The utility of telemedicine to increase the use of IV tPA for acute ischemic stroke (AIS) patients in the rural setting is well established. The availability of intraarterial (IA) reperfusion therapy is restricted to larger stroke centers in metropolitan areas so the process for evaluation and transfer within a stroke system of care will be critical to its rapid delivery to rural patients. In 2012, we conducted a review of the use of IA therapy in our stroke system; studying efficiency of the team approach, timing of treatment, and patient outcomes to evaluate the hypothesis that telemedicine can facilitate IA treatment for the AIS patient presenting in a rural setting. METHODS: All patients presenting to the spoke hospitals (SHs) and the hub hospitals (HH) with AIS and subsequently receiving IA therapy were reviewed for the months of March 2011 through February 2012. This review followed institution of a stroke code improvement process for SHs which included an aggressive 30 minute door-to-drug goal, addition of CTA imaging, and early mobilization of helicopter transport. FINDINGS: Of the HH patients receiving reperfusion therapy 26 of 68 patients (38%) received IA treatment and 62% received IV tPA treatment alone. In contrast, only 5 of 31 treated cases from SHs (16%) received IA treatment. In IA treated cases, mean door-to-case-start time from the SHs (143 min) was comparable to that of cases presenting directly to the HH (117 min) despite the helicopter travel required prior to case start for SHs. Reperfusion success (TICI2b/3) was similar whether the patients presented to HH or the SHs (69% and 60%) and discharge MRS≥3 was achieved in 46% and 40% respectively. CONCLUSION: With a telemedicine supported system, IA treatment options can be initiated in a time efficient fashion with similar outcomes whether the patient presents to a rural spoke hospital site or the hub hospital with IA capability. Differences in the rate of use of IA treatment may be related to EMS referral patterns of patients with severe stroke to a tertiary stroke center.

Neuroimaging markers of hemorrhagic risk with stroke reperfusion therapy

We sought to identify pretreatment neuroimaging markers associated with intracerebral hemorrhage (ICH) after reperfusion therapy for acute ischemic stroke. A literature review using available online medical literature databases was performed to identify noninvasive imaging markers correlated with ICH after reperfusion therapy. Key words, including different neuroimaging modalities such as noncontrast CT, multimodal CT, and MRI techniques, were queried. The review included randomized, controlled trials, post hoc studies, and institutional registries. Studies of IV as well as intra-arterial reperfusion therapies were considered. Articles were organized on the basis of imaging modality and type of treatment. Each imaging modality was given 1 of 3 grades for consideration of use in clinical practice (grade 1: a modality whose use for hemorrhage prediction is supported by randomized controlled trials or post hoc studies from prospective trials; grade 2: a modality that is largely available but requires further prospective validation; and grade 3: a modality which is rarely used and has limited clinical utility). Grade 1 imaging modalities included the size of infarction as seen on noncontrast CT or diffusion MRI. Higher hemorrhagic risk has been seen with larger infarctions, suggesting that these imaging modalities may be effective screening tests to exclude specific patients. Perfusion imaging using CT or MRI was considered to have a grade 2 recommendation, pending further validation. The use of xenon CT, radionuclide imaging, voxel-based MRI analysis, and blood-brain barrier disruption imaging still require further design improvements (grade 3). Future reperfusion trials require clearly defined protocols for imaging and determination of symptomatic ICH. Future trials may consider the use of perfusion imaging and the inclusion of patients without large territorial infarctions to accurately predict those at risk for ICH with reperfusion therapy.

Preferential Effect of Premorbid Statins on Atherothrombotic Strokes through Collateral Circulation Enhancement

Background/Aims: Endovascular recanalization therapies are an increasingly used strategy for acute cerebral ischemia with heterogeneous clinical outcomes. We aimed to determine the impact of previous medication on ischemic stroke following intra-arterial revascularization therapy. Methods: Consecutive patients receiving intra-arterial reperfusion therapy after an acute intracranial occlusion were analyzed. Premorbid use of antiplatelets, statins, oral antidiabetic drugs, antihypertensive drugs and oral anticoagulants were recorded. Collateral pial circulation (CPC) was scored on initial angiogram. Results: 118 patients were included (mean age 70.4 ± 11 years, 45% female). 66 patients (56%) were cardioembolic, 30 (25%) atherothrombotic, and 22 (19%) other/unknown etiologies. No significant impact of medication was detected in all the series or cardioembolic strokes. However, relevant differences were found among atherothrombotic strokes. The previous use of antiplatelets was associated with smaller infarct volume (64 vs. 170 ml; p = 0.043) whereas premorbid statin predicted reduced infarct volume (64 vs. 215 ml; p = 0.019), clinical improvement (79 vs. 29%; p = 0.016) and good CPC (100 vs. 20%; p = 0.04). Statins were the only medication independently predicting reduced infarct volume and clinical improvement and this effect depended on CPC. Conclusion: Previous use of statins may preferentially benefit patients with atherothrombotic strokes by favoring the development of CPC.

Abstract 53: The Malignant MRI profile: Implications for Endovascular Therapy

Background: The Malignant MRI profile identifies stroke patients with poor outcomes and an increased incidence of parenchymal hematoma following iv thrombolysis; outcomes following endovascular reperfusion therapy have not been described. Methods: The NIH funded DEFUSE 2 trial enrolled consecutive acute stroke patients in whom endovascular therapy was anticipated. An MRI scan was obtained immediately prior to intra-arterial reperfusion therapy, then repeated following the procedure and on day 5. Perfusion-weighted (PWI) and diffusion-weighted imaging (DWI) maps were created and lesion volumes estimated with an automated software program (RAPID). In the DEFUSE 2, the Malignant profile was pre-specified as a DWI lesion ≥70mL and/or a PWI lesion based on Tmax&gt;10sec threshold (Tmax&gt;10s) ≥100mL. A receiver operating characteristic (ROC) curve analysis was performed to identify Tmax&gt;10s and DWI volumes that predicted poor outcome (defined as a mRS 5-6 at 30 days) with a high specificity. Patients with an M1 or ICA occlusion who did not undergo endovascular therapy based on local site criteria were also included in the ROC analysis. Results: We report a preliminary analysis of the DEFUSE 2 database (full data will be presented at the meeting). One hundred and one patients were triaged to the cath lab for endovascular therapy. Of the 83 patients who had adequate data available for this analysis, 9 (11%) met the predefined criteria for the Malignant profile. 56% of the Malignant patients had poor outcome compared with 30% of the non-Malignant cases (p=0.14). Malignant patients had an increased risk of parenchymal hematoma (PH1 or PH2): 44% vs. 14% (p=0.04). Only 1 of the Malignant patients achieved a mRS of 0-2 at 30 days. Early reperfusion was obtained in 6 of the 9 Malignant patients but was not associated with an increase in favorable clinical outcome or a decrease in the risk of poor outcome. Fifteen patients with an M1 or ICA occlusion did not undergo endovascular therapy based on local site criteria. Ten of these patients had the Malignant profile and 8 of these 10 had a poor outcome. ROC curve analysis identified a DWI lesion of 112 mL and a Tmax&gt;10s lesion of 116 mL as optimal thresholds to predict poor outcome; both achieved a specificity of 98% and sensitivities of 27% and 24% respectively. 81% (13/16) of the Malignant patients identified by the DWI and/or Tmax&gt;10s optimal thresholds had poor outcome. Conclusion: Patients with large baseline DWI and/or large severe PWI lesions are likely to have poor outcomes with or without endovascular reperfusion therapy. Automated imaging software can identify these patients rapidly.

Organization of a United States County System for Comprehensive Acute Stroke Care

Organized systems of care have the potential to improve acute stroke care delivery. The current report describes the experience of implementing a county-wide system of spoke-and-hub stroke neurology receiving centers (SNRC) that incorporated several comprehensive stroke center recommendations. Observational study of patients with suspected stroke of <5 hours duration transported by emergency medical system personnel to an SNRC during the first year of this system. A total of 1360 patients with suspected stroke were evaluated at 9 hub SNRC, of which 553 (40.7%) had a discharge diagnosis of ischemic stroke. Of these 553, intravenous tissue-type plasminogen activator was administered to 110 patients (19.9% of ischemic strokes). Care at the 6 neurointerventional-ready SNRC was a major focus in which 25.1% (99/395) of the patients with ischemic stroke received acute intravenous or intra-arterial reperfusion therapy, and in which provision of such therapies was less common with milder stroke, older age, and Hispanic origin. The door-to-needle time for intravenous tissue-type plasminogen activator met the <60-minute target in only 25% of patients and was 37% longer (P=0.0001) when SNRC were neurointerventional-ready. A stroke system that incorporates features of comprehensive stroke centers can be effectively implemented with substantial rates of acute reperfusion therapy administration. Experiences potentially useful to broader implementation of comprehensive stroke centers are considered.

Prestroke Dementia is Associated With Poor Outcomes After Reperfusion Therapy Among Elderly Stroke Patients

In elderly acute stroke patients, reperfusion therapy is often withheld. We sought to determine whether prestroke dementia contributed to poor outcomes after reperfusion therapy in these patients. All consecutive patients ≥ 80 years of age who received intravenous (IV) or intra-arterial reperfusion therapy (IAT) were identified in our Get With the Guidelines Stroke (GWTG-S) database. Vascular risk factors, presence of dementia, and outcomes were abstracted from the medical record. Dementia was recorded when listed in the medical history or when under medical treatment. Primary outcome was in-hospital mortality. Secondary outcome was discharge destination, "favorable" (home or rehabilitation facility) versus "unfavorable" (skilled nursing facility, hospice, or death). Multivariate logistic regression models were used to assess outcomes. Of 153 patients, 72% received IV tissue plasminogen activator (tPA), 35% IAT, and 7% both. The mean age was 85.8 ± 4.6 years; 13.6% had prestroke dementia. The in-hospital mortality rate was 35%. The likelihood of death increased with National Institutes of Health Stroke Scale (NIHSS; odds ratio [OR] 1.14; 95% confidence interval [CI] 1.07-1.21), IAT (OR 3.43; 95% CI 1.70-6.92), and dementia (OR 3.61; 95% CI 1.39-9.37), and decreased with IV tPA (OR 0.34; 95% CI 0.17-0.71). Increasing NIHSS (OR 0.90; 95% CI 0.85-0.95), symptomatic intracranial hemorrhage (OR 0.08; 95% CI 0.01-0.67), IAT (OR 0.43; 95% CI 0.22-0.84), and dementia (OR 0.37; 95% CI 0.14-0.97) decreased the likelihood of favorable discharge. In multivariate analysis, only NIHSS (OR 1.13; 95% CI 1.06-1.22) and dementia (OR 5.64; 95% CI 1.88-16.89) independently predicted death and unfavorable discharge destination. Among the elderly, prestroke dementia is a powerful independent predictor of in-hospital mortality after acute reperfusion therapy for stroke. Future investigations of thrombolysis outcomes in the elderly are warranted.