Intravenous Thrombolysis For Acute Ischemic Stroke Research Articles

Temporal sustainability of guideline based door-to-needle times for intravenous thrombolysis for acute ischemic stroke

BackgroundDoor to needle (DTN) time provides valuable insight into stroke care workflow and is a performance indicator of an acute stroke unit. The aim of the current study was to ascertain whether a door to needle time of less than 60 min can be achieved for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) and maintained long term in a comprehensive stroke unit. MethodsPatients with AIS treated with IVT in the stroke unit formed the study group. Demographic and clinical characteristics including door to imaging (DTI) time, DTN time, and 3 month functional outcome were abstracted. Pairwise comparison was done of yearly median DTI and DTN times with Bonferroni correction. ResultsOver a period of 6 years a total of 196 patients with mean age of 61.5 ± 13.1 years and median (IQR) NIHSS 11 (8–16) underwent IVT. The median DTI time and DTN time over the study period was 15 (12–21) minutes and 40 (30–50) minutes respectively. A total of 90.1%, 69.4% and 29.1% patients received IVT within 60 min, 45 min and 30 min respectively. On pairwise comparison of the median yearly DTN Year 2016 and 2017 were lower compared to most of the earlier years (p < 0.0001). Good functional outcome (mRS ≤ 2) was noted in 68.7% patients at 3 months follow-up. ConclusionIt is possible to sustainably reduce DTN time for IVT in AIS to well below the current 60 min benchmark with hospital system training and teamwork.

Safety of Intravenous Thrombolysis Among Patients Taking Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis.

Background and Purpose- There are scarce data regarding the safety of intravenous thrombolysis (IVT) in acute ischemic stroke among patients on direct oral anticoagulants (DOACs). Methods- We performed a systematic review and meta-analysis of the current literature. Data regarding all adult patients pretreated with DOAC who received IVT for acute ischemic stroke were recorded. Meta-analysis was performed by comparing the rate of symptomatic intracerebral hemorrhage in these patients with (1) stroke patients without prior anticoagulation therapy and (2) patients on warfarin with international normalized ratio <1.7. Meta-analyses were further conducted in subgroups as follows: (1) administration of DOAC within 48 hours versus an unknown interval before IVT, (2) consideration of symptomatic intracerebral hemorrhage outcome according to the National Institute of Neurological Disorders (NINDS) versus the European Cooperative Acute Stroke Study II (ECASS-II) criteria. Results- After reviewing 13 392 reports and communicating with certain authors of 12 published studies, a total of 52 823 acute ischemic stroke patients from 6 studies were enrolled in the present meta-analysis: DOACs: 366, warfarin: 2133, and 503 241 patients without prior anticoagulation. We detected no additional risk of symptomatic intracerebral hemorrhage following IVT among patients taking DOACs within 48 hours-DOACs-warfarin: NINDS (odds ratio [OR], 0.55 [95% CI, 0.19-1.59]), ECASS-II (OR, 0.77 [95% CI, 0.28-2.16]); DOACs-no-anticoagulation: NINDS (OR, 1.23 [95% CI, 0.46-3.31]), ECASS-II (OR, 0.87 [95% CI, 0.32-2.41]). Similarly, no additional risk was detected with no time limit between last DOAC intake-DOACs warfarin: NINDS (OR, 0.85 [95% CI, 0.49-1.45]), ECASS-II (OR, 1.11 [95% CI, 0.67-1.85]); DOACs-no-anticoagulation: NINDS (OR, 1.17 [95% CI, 0.43-3.15]), ECASS-II (OR, 0.87 [95% CI, 0.33-2.41]). There was no evidence of heterogeneity across included studies (I2=0%). We also provided the details of 123 individual cases with or without reversal agents before IVT. There was no significant increase in the risk of hemorrhagic transformation (OR, 1.48 [95% CI, 0.50-4.38]), symptomatic hemorrhagic transformation (OR, 0.47 [95% CI, 0.09-2.55]), or early mortality (OR, 0.60 [95% CI, 0.11-3.43]) between cohorts who did or did not receive prethrombolysis idarucizumab. Conclusions- The results of our study indicated that prior intake of DOAC appears not to increase the risk of symptomatic intracerebral hemorrhage in selected AIS patients treated with IVT.

Abstract TP158: Risk prediction for symptomatic Intracranial Hemorrhage (sICH) in Acute Ischemic Stroke (AIS) Patients Treated With Intravenous Thrombolysis (IVT): Does Infarct Location Matter?

Introduction: There are mounting data supporting a substantially lower risk of sICH in AIS patients with posterior circulation stroke (PCS) following treatment with IVT. However, stroke location is not included in any of the numerous risk prediction scores for sICH complicating IVT in AIS. We sought to compare the safety and efficacy of IVT for AIS with respect to the location of acute cerebral ischemia in a high-volume tertiary care stroke center. Methods: Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Stroke location was classified as posterior (PCS) vs. anterior circulation (ACS), and supratentorial (STN) vs. infraterorial (ITN) infarction. Safety of IVT was evaluated using the SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1008 IVT-treated AIS patients [52% men, mean age 64±15years, median baseline NIHSS-score: 8 pts (IQR: 4-4)], 181 (18%) had PC and 88 (9%) had STN location. The rates of sICH were lower in patients with PCS [2.8% vs. 6.9%; p=0.039 by Fisher’s exact test (FET)] and ITN infarction (0% vs. 6.7%; p=0.005 by FET). PCS and ITN strokes (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.82) were not independently associated with lower likelihood of sICH on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, baseline stroke severity, serum glucose, BP parameters and ASPECTS, pretreatment with antiplatelets (single or dual), statins and oral anticoagulants. Conclusions: Our study indicates that infarct location appears not to be independently related to the risk of sICH in AIS patients treated with IVT.

Abstract TP36: Readmissions After Intravenous Thrombolysis for Acute Ischemic Stroke-A Review of 5-Year National Data

Background: Despite widespread use of Intravenous thrombolysis (IVT) for acute ischemic stroke (AIS), little is known about the frequency and etiologies of early readmission rates to the hospital soon after initial discharge. Understanding the causes associated with 30-day readmissions following IVT is critical to reduce cost and improving the quality of life in AIS patients. Methods: Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify AIS and IVT using appropriate ICD-9CM codes in primary diagnosis and ICD9 procedure code 99.10 in any procedural field. Admissions within 30 days of discharge were considered as early readmission. Readmission causes were identified by ICD 9 CM code in primary diagnosis field of readmissions. P values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. Results: We identified 164,007 AIS patients undergoing IVT (Mean age=69.5 years,49.6% Female) of which 10.9% (N=17,844) were readmitted. Significant decline in readmission rate has been observed during our study period (from 11.8% in 2010 to 10.4% in 2014, Ptrend =&lt;0.001) and half of all readmissions were within 12 days post discharge. Common etiologies of readmissions were Neurological (32.2%), cardiac (15.5%), infections (10.3%), Pulmonary (8.6%), Kidney or urinary (7.4%), Gastrointestinal (4.5%) and Bleeding (3.6%). Among neurological readmissions causes, Ischemic stroke accounted for 18.6%, Transient cerebral ischemia (2.9%), and Intracerebral hemorrhage (2.6%). Heart failure (3.8%) and Atrial fibrillation (2.7%) were the most common cardiac causes. Conclusion: About 1 in 10 patients who received IVT for AIS are prone to get readmitted within 30 days, most likely secondary to neurological or cardiac complications. Additional interventions, consultations or workup may be warranted to recognize and mitigate preventable post-thrombolysis readmissions.

Rationale and design of a randomized trial of early intensive blood pressure lowering on cerebral perfusion parameters in thrombolysed acute ischemic stroke patients.

Background and Rationale:Uncertainty persists over the optimal management of blood pressure (BP) in the early phase of acute ischemic stroke (AIS). This study aims to determine the safety and effects of intensive BP lowering on cerebral blood flow (CBF) and functional in AIS patients treated with intravenous thrombolysis.Methods:In a randomized controlled trial, 54 thrombolysed AIS patients with a systolic BP of 160 to 180 mm Hg will be randomized to early intensive BP lowering (systolic target range 140–160 mm Hg) or guideline-based BP management (systolic range 160–180 mm Hg) during first 72-hours using primarily intravenous labetalol. We hypothesize that early intensive BP lowering will not reduce CBF by 20% and/or increase the volume of hypoperfused tissue by >20% on computed tomographic perfusion. Clinical outcome will be assessed using a dichotomized modified Rankin scale (scores 0–1 as excellent outcome vs scores 2–6 as dead or dependent) at 90 days. Other outcome would be symptomatic intracerebral hemorrhage. The trial is registered at ClinicalTrials.gov, NCT03443596.Conclusion:This randomized study will provide important information about the physiological effects of BP reduction on cerebral perfusion after intravenous thrombolysis in AIS.

Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis.

The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.

Abstract TMP22: Safety of Pretreatment With Dual Antiplatelet Therapy in Intravenous Thrombolysis for Acute Ischemic Stroke

Introduction: There are preliminary data indicating that pretreatment with dual antiplatelet therapy (DAPT) may increase the risk of symptomatic intracranial hemorrhage (sICH) following intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to identify the safety and efficacy of pretreatment with DAPT in IVT for AIS in a prospective, multi-center study. Methods: AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Three-month functional status was assessed using modified Rankin Scale (mRS). We compared the following outcomes between DAPT (+) and DAPT (-) patients before and after propensity score matching (PSM): 1.sICH, 2. asymptomatic intracranial hemorrhage (aICH) 3. favourable functional outcome (FFO; mRS scores of 0-1), 4. 3-month mortality. Results: Out of total 790 IVT-treated AIS patients, we identified 58 (7%) pretreated with DAPT (mean age 68±13 years; 57% men; median NIHSS-score 8, IQR: 4-14). The two groups did not differ (p&gt;0.05) in terms of sICH [DAPT(+): 3% vs. DAPT(-): 3%], FFO (64% vs. 50%) and 3-month mortality (9% vs. 9%) in unmatched analyses. DAPT pretreatment was associated with higher odds of aICH before (17% vs. 6%) and after adjustment (OR: 2.4; 95%CI: 1.1-5.5) for potential confounders. After PSM, patients with (n=41) and without (n=82) DAPT pretreatment did not differ in any of the baseline characteristics. The differences in rates of all outcome events were non-significant in the two groups including sICH (2% vs. 1%, p=0.63), aICH (17% vs. 7%, p=0.06) and 3-month mRS (p=0.60; Figure). Conclusions: Pretreatment with DAPT is not associated with higher rates of sICH or three-month mortality and does not reduce the odds of FFO following IVT for AIS. IVT should not be withheld in otherwise eligible candidates due to pretreatment with DAPT.

Practice Patterns and Barriers for Intravenous Thrombolysis: A Survey of Neurologists in Saudi Arabia.

Only a small fraction of patients with acute ischemic stroke receive intravenous thrombolysis (IVT). We sought to assess barriers and practice patterns in using IVT for acute ischemic stroke among neurologists in Saudi Arabia. An electronic survey was sent to all neurologists registered with the Saudi Commission for Health Specialties. A total of 148 (77.5%) neurologists responded. The most common reported barriers for IVT administration were delayed presentation to hospitals (82.4%) and unclear time of symptom onset (50.0%). Only 9.9% of neurologists reported strict adherence to the American Heart Association/American Stroke Association guidelines for IVT administration. The most frequently waived criteria were “minor stroke with National Institutes of Health Stroke Scale [NIHSS] < 5” (49.4%) and “seizure at onset” (45.7%). For the extended 3–4.5-hour window, 18.5% of neurologists reported strict adherence to the four exclusion criteria. The most frequently waived criteria were “age older than 80 years” (53.1%) and “history of both diabetes and prior stroke” (42.0%). In conclusion, most neurologists do not adhere to the IVT exclusion criteria. However, little consensus exists regarding which criteria do not interfere with IVT administration. Barriers to IVT administration were identified and require immediate action by healthcare authorities in Saudi Arabia.

Safety of Early Carotid Endarterectomy after Intravenous Thrombolysis in Acute Ischemic Stroke

The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2days (range: 0-13). A subgroup of 6 patients underwent CEA within 24hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P=0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.

Patient Selection For Acute Stroke Intravenous Thrombolysis

Stroke is a leading cause of mortality worldwide. Unfortunately its incidence is more and the age of occurrence is one decade earlier in our country, Iran. About 75-90 percent of stroke etiology is ischemic. The only approved drug treatment for eligible acute ischemic stroke (AIS) patients is thrombolytic therapy by recombinant tissue plasminogen activator (tPA). Related level of evidence is the highest (1a) and it has been approved by FDA following NINDS study since 1996. First golden time for use of tPA was less than 3 hours but later it has extended to 4.5 hours following re-analysis of the data since 2009. In the beginning, related exclusion criteria was strict considering many absolute items, however, some of them changed or removed as relative exclusion criteria by practicing and performing researches and analysis of results and it is going to be more simplified. For example, in 2013 there were 15 absolute and 10 relative exclusion criteria for intravenous thrombolysis in AIS in less than 4.5 hours period from onset of symptoms but in 2016 following publishing American heart and Stroke Association (AHA/ASA) scientific statement this criteria was more clarified and some of relative exclusion criteria removed. And finally new published researches extended this therapeutic time window to 6 hours by using mechanical thrombectomy in defined patients not responding to IV thrombolysis. In the ninth national Iranian Stroke Congress this updated criteria will be discussed.

Carotid endarterectomy following thrombolysis for acute ischaemic stroke.

Insufficient evidence exists to support the safety of carotid endarterectomy (CEA) following intravenous thrombolysis (IVT) for acute ischaemic stroke. Our study aimed to report a single-centre experience of patients treated over a five-year period. Departmental computerised databases were interrogated to identify patients who suffered an ischaemic stroke and subsequently underwent thrombolysis followed by CEA. Mortality and stroke within 30 days of surgery were defined as the primary outcome end points. Over a five-year period, 177 out of a total of 679 carotid endarterectomies (26 %) were performed in patients presenting with acute ischaemic stroke. Twenty-five patients (14 %) received IVT prior to CEA in the form of alteplase. Sixty percent of patients were male with a mean age of 68 years. Sixteen patients (64 %) underwent CEA within 14 days of IVT and the median interval between thrombolysis and CEA was 7.5 days (range, 3-50 days). One female patient died of a further intraoperative stroke within 30 days of surgery, yielding a mortality rate of 4 %. Two patients (8 %) suffered from cardiac complications postoperatively resulting in a short high dependency unit stay. Another two patients (8 %) developed local wound complications, which were managed conservatively without the need for re-operation. The median hospital length of stay was 4.5 days (range, 1-33 days). Our experience indicates that CEA post-thrombolysis has a low incidence of mortality. Further high quality evidence is required before CEA can be routinely recommended following IVT for acute ischaemic stroke.

Intravenous Thrombolysis for Acute Ischemic Stroke: Review of 97 Patients.

Background:Intravenous thrombolysis (IVT) has now become a standard treatment in eligible patients with acute ischemic stroke (AIS) who present within 4.5 h of symptom onset.Objective:To determine the usefulness of IVT and the subset of patients who will benefit from IVT in AIS within 4.5 h.Materials and Methods:Patients with AIS within 4.5 h of symptom onset who underwent IVT were studied prospectively. The study period was from October 2011 to October 2015.Results:A total of 97 patients were thrombolysed intravenously. The mean onset to needle time in all patients was 177.2 ± 62 min (range: 60–360). At 3 months follow-up, favorable outcome was seen in 65 patients (67.1%) and poor outcome including death in the remaining 32 patients (32.9%). Factors predicting favorable outcome was age <65 years (P = 0.02), the National Institute of Health Stroke Scale (NIHSS) <15 (P < 0.001), small vessel occlusion (P = 0.006), cardioembolism (P = 0.006), and random blood sugar (RBS) <250 mg/dl (P < 0.001). Factors predicting poor outcome was diabetes mellitus (P = 0.01), dyslipidemia (P = 0.01), NIHSS at admission >15 (P = 0.03), RBS >250 mg/dl (P = 0.01), Dense cerebral artery sign, age, glucose level on admission, onset-to-treatment time, NIHSS on admission score >5 (P = 0.03), and occlusion of large artery (P = 0.02).Conclusion:Milder baseline stroke severity, blood glucose <250 mg/dL, younger patients (<65 years), cardioembolic stroke, and small vessel occlusion benefit from recombinant tissue plasminogen activator.

Platelet-to-White Blood Cell Ratio: A Prognostic Predictor for 90-Day Outcomes in Ischemic Stroke Patients with Intravenous Thrombolysis

This study is aimed to investigate the relationship between platelet-to-white blood cell ratio (PWR) and 90-day outcomes in acute stroke patients with intravenous thrombolysis (IVT). A retrospective analysis was performed on 168 patients receiving IVT for acute ischemic stroke. Complete blood count evaluation was conducted at admission before IVT. A modified Rankin Scale (mRS) score of 3-6 at 90 days was considered an unfavorable outcome. A total of 168 patients were included from 2013 to 2015. The mean age of the sample was 64.6 (±12.3) years, and 23.2% were women. The median baseline National Institutes of Health Stroke Scale score was 7.5 (interquartile range [IQR] 8.0) and the 90-day mRS score was 2 (IQR 2). In our multivariate logistic regression model, a PWR greater than 23.52 (odds ratio .454, 95% confidence interval: .212-.973, P < .050) was a predictor of 90-day outcomes. In addition, there was a significant difference in the PWR values of patients between favorable outcome and unfavorable outcome in the large-artery atherosclerosis subtype (28.241 ± 11.581 and 21.899 ± 9.107, respectively; P = .005). The PWR at admission predicts 90-day outcomes in ischemic stroke patients with IVT. With the easy and routine use of hemogram analysis, the PWR should be investigated in further prospective randomized controlled trials of acute stroke.

Risk of Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis in Patients With Acute Ischemic Stroke and High Cerebral Microbleed Burden: A Meta-analysis.

Cerebral microbleeds (CMBs) have been established as an independent predictor of cerebral bleeding. There are contradictory data regarding the potential association of CMB burden with the risk of symptomatic intracerebral hemorrhage (sICH) in patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT). To investigate the association of high CMB burden (>10 CMBs on a pre-IVT magnetic image resonance [MRI] scan) with the risk of sICH following IVT for AIS. Eligible studies were identified by searching Medline and Scopus databases. No language or other restrictions were imposed. The literature search was conducted on October 7, 2015. This meta-analysis has adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was written according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) proposal. Eligible prospective study protocols that reported sICH rates in patients with AIS who underwent MRI for CMB screening prior to IVT. The reported rates of sICH complicating IVT in patients with AIS with pretreatment MRI were extracted independently for groups of patients with 0 CMBs (CMB absence), 1 or more CMBs (CMB presence), 1 to 10 CMBs (low to moderate CMB burden), and more than 10 CMBs (high CMB burden). An individual-patient data meta-analysis was also performed in the included studies that provided complete patient data sets. Symptomatic intracerebral hemorrhage based on the European Cooperative Acute Stroke Study-II definition (any intracranial bleed with ≥4 points worsening on the National Institutes of Health Stroke Scale score). We included 9 studies comprising 2479 patients with AIS. The risk of sICH after IVT was found to be higher in patients with evidence of CMB presence, compared with patients without CMBs (risk ratio [RR], 2.36; 95% CI, 1.21-4.61; P = .01). A higher risk for sICH after IVT was detected in patients with high CMB burden (>10 CMBs) when compared with patients with 0 to 10 CMBs (RR, 12.10; 95% CI, 4.36-33.57; P < .001) or 1 to 10 CMBs (RR, 7.01; 95% CI, 3.20-15.38; P < .001) on pretreatment MRI. In the individual-patient data meta-analysis, high CMB burden was associated with increased likelihood of sICH before (unadjusted odds ratio, 31.06; 95% CI, 7.12-135.44; P < .001) and after (adjusted odds ratio, 18.17; 95% CI, 2.39-138.22; P = .005) adjusting for potential confounders. Presence of CMB and high CMB burdens on pretreatment MRI were independently associated with sICH in patients with AIS treated with IVT. High CMB burden may be included in individual risk stratification scores predicting sICH risk following IVT for AIS.

Primary acute stroke thrombectomy within 3 h for large artery occlusion (PAST3-LAO): a pilot study

Background and purposeIn recent trials, acute ischemic stroke (AIS) from large artery occlusion (LAO) was resistant to intravenous thrombolysis and adjunctive stent retriever thrombectomy (SRT) was associated with better perfusion...

Stroke : Highlights of Selected Articles

HomeStrokeVol. 45, No. 10Stroke: Highlights of Selected Articles Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBStroke: Highlights of Selected Articles Originally published1 Oct 2014https://doi.org/10.1161/STROKEAHA.114.007187Stroke. 2014;45:2855Copeptin for the Prediction of Recurrent Cerebrovascular Events After Transient Ischemic Attack: Results From the CoRisk StudyCopeptin is a stress hormone that has previously been shown to be associated with recurrent cerebrovascular events after transient ischemic attack (TIA). The ABCD2 (age, blood pressure, clinical features, duration, diabetes) score and the ABCD3-I (ABCD2 plus dual TIA) score both provide risk assessment for recurrent stroke after TIA. The current study aimed to determine the effect of copeptin in the prediction of recurrent cerebrovascular events (stroke or TIA) within 3 months of TIA. In their cohort, 28 of 302 (9.3%) patients had a recurrent cerebrovascular event within 3 months of TIA. There was no statistically significant difference in copeptin levels in patients with or without recurrent cerebrovascular events. A total of 11 patients had recurrent stroke within 3 months. Copeptin levels were >4× higher in patients with recurrent stroke in comparison with those without stroke. A 10-fold increase in copeptin was associated with an odds ratio of stroke of 3.39 after adjustment for the ABCD2 score. Copeptin increased the prognostic ability of the ABCD2 score in predicting recurrent stroke in 31.2% of patients. In sum, copeptin seems to represent a biomarker with strong prediction value for recurrent stroke after TIA. Further validating studies are needed. But at this time it seems to add in risk stratification of patient presenting with TIA. See p 2918.Long-Term Outcomes After Combined Revascularization Surgery in Adult Moyamoya DiseaseMoyamoya disease is an idiopathic condition of progressive occlusions of both internal carotid arteries with abnormal vascular networks. Controversy exists on the optimal revascularization procedure in adults with moyamoya disease. The authors of this study report on the outcomes of combined revascularization surgery (direct bypass between the superficial temporal artery and a cortical branch of the MCA and indirect bypass known as encephalodurogaleosynangiosis) done on 77 hemispheres in 60 patients. The clinical status of patients, as assessed by the modified Rankin Scale and the Karnofsky Performance Scale, improved until 6 months after surgery and stayed stable after that. The relative revascularization area significantly increased in the long-term compared with the short-term follow-up period. The cerebral blood flow as measured by single photon emission computed tomography improved significantly in the short-term compared with the preoperative period and remained stable after that. Perioperative cerebral infarcts occurred in 13% of cases. However, the long-term risk of stroke was low with the annual rates of symptomatic cerebral hemorrhage and infarction in the operated hemispheres as 0.4% and 0.2%, respectively. In sum, this study showed improvement in clinical, angiographic, and hemodynamic states after combined revascularization surgery in moyamoya disease. However, there is no comparative arm. And thus further study will most definitely be needed to best define the optimal surgical procedure in this patient population. See p 2983.Early Deterioration After Thrombolysis Plus Aspirin in Acute Stroke: A Post Hoc Analysis of the Antiplatelet Therapy in Combination With Recombinant t-PA Thrombolysis in Ischemic Stroke TrialAddition of aspirin within 90 minutes after intravenous thrombolysis (IVT) in acute ischemic stroke has previously been shown to increase the risk of symptomatic intracranial hemorrhage (SICH) while having no effect on 3-month functional outcome in the Antiplatelet Therapy in Combination With Recombinant t-PA Thrombolysis in Ischemic Stroke (ARTIS) trial. The authors explored a post hoc analysis on the effect of aspirin on early neurological deterioration (END). END was defined as ≥4 points on the National Institutes of Health Stroke Scale worsening <24 hours after IVT and further divided into SICH and cerebral ischemia. A total of 31 of 640 patients (4.8%) receiving early aspirin after IVT experienced END: 14 because of SICH and 17 because of cerebral ischemia. On univariate analysis, aspirin increased the risk of END because of SICH but not of END because of cerebral ischemia. After multivariate analysis, aspirin remained significantly associated with END because of SICH. In summary, this post hoc analysis of the ARTIS trial shows that early aspirin after IVT is associated with early neurological deterioration because of symptomatic intracranial hemorrhage and has no beneficial effect on early neurological deterioration because of cerebral ischemia. Although the available literature suggests that early aspirin after IVT in acute ischemic stroke is harmful, further study is needed as there may potentially be certain subgroups of patients with stroke who may benefit from its use. See p 3080. 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Abstract T P47: Response to Thrombolysis in Ischemic Stroke Depends on the Presence of Initial Arterial Occlusion

Objective: We aimed to assess effectiveness of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) depending on the presence or absence of cervical or intracranial arterial occlusion on acute CT angiography (CTA). Methods: Patients from the Acute STroke Registry and Analysis of Lausanne (ASTRAL) were included in the analysis if they had an onset-to-door-time ≤ 4hours, CTA within 24 hours of onset, premorbid modified Rankin scale (mRS) ≤ 2, and a National Institute of Health Stroke Scale score (NIHSS) &gt;4. Patients having significant intracranial stenosis (50-99%) or receiving endovascular treatment were excluded. The primary outcome was a 3 month handicap of mRS &gt;2. We used an interaction analysis of IVT and initial arterial occlusion after adjusting for potential confounders for the primary outcome. Results: Of 655 included patients, 382 patients (58%) showed arterial occlusion, of whom 263 (69%) received IVT. Of the 273 patients without arterial occlusion, 139 (51%) received IVT. In patients with initial arterial occlusion and after multiple adjustments, IVT was associated with lower likelihood of unfavourable outcome (adjusted OR 0.33, 95% CI 0.12-0.91, p=0.03) whereas it had no significant effect in non-occluded patients (OR 1.32, 95% CI 0.36-4.76, p=0.67). Similarly, the presence of arterial occlusion did not significantly worsen the outcome in thrombolysed patients (OR 1.99, 95% CI 0.68-5.81, p=0.21), whereas it did so in non-thrombolysed patients (OR 7.89, 95% CI 2.29-27.25, p&lt;0.01). Conclusions: IVT for AIS is more effective in the setting of visible arterial occlusions on acute imaging. If confirmed in other studies, this information may influence thrombolysis decisions and planning of further randomized trials. Classification of evidence: This retrospective analysis provides class III evidence that IVT has less benefit in patients without visible occlusion on acute CTA.

Thrombolysis for Ischemic Stroke Associated With Infective Endocarditis

Cerebral ischemic events are highly prevalent and associated with high rates of death and disability in patients with infective endocarditis (IE). However, the role of thrombolysis in these patients remains unclear. We sought to determine the rates and outcomes of acute ischemic stroke patients with IE treated with intravenous thrombolysis (IVT). We determined the rates of post-thrombolytic intracerebral hemorrhage and favorable outcome among acute ischemic stroke patients with IE treated with IVT. Patients were identified using Nationwide Inpatient Sample data from 2002 to 2010. We compared the rates of various outcomes with ischemic stroke patients without IE treated with IVT. There were 222 patients (mean age 59±18 years; 46% women) who were treated with IVT for acute ischemic stroke associated with IE and 134,048 patients (mean age 69±15 years; 49% women) who were treated for stroke without IE. The rate of post-thrombolytic intracerebral hemorrhage was significantly higher in patients with IE compared with those without IE (20% versus 6.5%; P=0.006). There was a significantly lower rate of favorable outcome in the IE group (10% versus 37%; P=0.01). High rates of post-thrombolytic intracerebral hemorrhage and low rates of favorable outcome mandate caution in using IVT in acute ischemic stroke patients with IE.

Early Carotid Endarterectomy after Intravenous Thrombolysis for Acute Ischaemic Stroke

After intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS), a severe cervical internal carotid artery (ICA) stenosis may remain and increase the risk of recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in reducing the risk of stroke. However, it is not well known whether CEA can be performed safely after thrombolysis, and, if so, when. We report a prospective study of CEA for residual high-grade cervical ICA stenosis performed within 15 days after IVT for AIS. Methods: All the patients had a brain magnetic resonance imaging (MRI) within 3 h of the stroke onset. One day after IVT in neurovascular unit, computed tomography (CT) angiography was performed to assess the brain and the patency of cervical arteries. CEA was performed on neurologically stable patients after full cerebral artery re-canalisation. Blood pressure was controlled with particular caution before and after CEA. Results: Between January 2005 and January 2008, we operated consecutively on 12 patients. Their median National Institutes of Health Stroke Scale (NIHSS) score was 12 (range: 5–21). Combined intracranial (ICA)–middle cerebral artery (MCA) occlusion was present in 58.3% of the patients. The median time between onset of symptoms until CEA was 8 days (range: 1–16 days). Stroke and death rate at 30 days was 8.3% (one nonfatal haemorrhagic stroke). At 90 days, nine patients had a Rankin score of 0–1, one had a score of 2 and two had a score of 3. Conclusion: In patients with residual cervical ICA stenosis after IVT, we achieved full patency of the occluded artery and good functional prognosis at 3 months in all cases. We advocate for an extremely close monitoring of the blood pressure in the pre-, peri- and post-operative course and a close collaboration between neurologist and surgeon to determine the best timing for CEA.