Large Ischemic Stroke Research Articles

Cerebrovascular Complication and Valve Surgery in Infective Endocarditis.

Infective endocarditis (IE) with neurologic complications is common in patients with active IE. The most common and feared neurological complication of left-sided IE is cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage (ICH), or an infectious intracranial aneurysm with or without rupture. In patients with cerebrovascular complications, valve replacement surgery is often delayed for concern of further neurological worsening. However, in circumstances when an indication for valve surgery to treat IE is present, the benefits of early surgical treatment may outweigh the potential neurologic deterioration. Furthermore, valve surgery has been associated with lower in-hospital mortality than medical therapy with intravenous antibiotics alone. Early valve surgery can be performed within 7 days of transient ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains challenging, and current data in the literature are conflicting about the risks and benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often recommended, balancing the risks and benefits of surgery. The range of timing of valve surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary decision between cardiothoracic surgeons, cardiologists, infectious disease experts, and vascular neurologists in an experienced referral center.

Association of Carotid Artery Endothelial Signal Intensity Gradient with Unilateral Large Artery Ischemic Stroke

Background: Common carotid artery (CCA) and internal carotid artery (ICA) are aligned linearly, but their hemodynamic role in ischemic stroke has not been studied in depth. Objectives: We aimed to investigate whether CCA and ICA endothelial shear stress (ESS) could be associated with the ischemic stroke of large artery atherosclerosis (LAA). Methods: We enrolled consecutive patients with unilateral ischemic stroke of LAA and healthy controls aged >60 years in the stroke center of Jeonbuk National University Hospital. All patients and controls were examined with carotid artery time-of-flight magnetic resonance angiography, and their endothelial signal intensity gradients (SIGs) were determined, as a measure of ESS. The effect of right or left unilateral stroke on the association between carotid artery endothelial SIG and ischemic stroke of LAA was assessed. Results: In total, the results from 132 patients with ischemic stroke of LAA and 121 controls were analyzed. ICA endothelial SIG showed significant and independent associations with the same-sided unilateral ischemic stroke of LAA, even after adjusting for the potential confounders including carotid stenosis, whereas CCA endothelial SIG showed a significant association with the presence of the ischemic stroke of LAA. Conclusion: Although CCA and ICA are located with continuity, the hemodynamics and their roles in large artery ischemic stroke should be considered separately. Further studies are needed to delineate the pathophysiologic roles of ESS in CCA and ICA for large artery ischemic stroke.

Decompressive Hemicraniectomy for Large Hemispheric Strokes.

Large hemispheric infarcts occur in up to 10% of all ischemic strokes and can cause devastating disability. Significant research and clinical efforts have been made in hopes of mitigating the morbidity and mortality of this disease. Areas of interest include identifying predictors of malignant edema, optimizing medical and surgical techniques, selecting the patient population that would benefit most from decompressive hemicraniectomy, and studying the impact on quality of life of those who survive. Decompressive surgery can be a life-saving measure, and here we discuss the most up-to-date literature and provide a review on the surgical management of large hemispheric ischemic strokes.

Adapting a Traumatic Brain Injury Goals-of-Care Decision Aid for Critically Ill Patients to Intracerebral Hemorrhage and Hemispheric Acute Ischemic Stroke.

Families in the neurologic ICU urgently request goals-of-care decision support and shared decision-making tools. We recently developed a goals-of-care decision aid for surrogates of critically ill traumatic brain injury patients using a systematic development process adherent to the International Patient Decision Aid Standards. To widen its applicability, we adapted this decision aid to critically ill patients with intracerebral hemorrhage and large hemispheric acute ischemic stroke. Prospective observational study. Two academic neurologic ICUs. Twenty family members of patients in the neurologic ICU were recruited from July 2018 to October 2018. None. We reviewed the existing critically ill traumatic brain injury patients decision aid for content and changed: 1) the essential background information, 2) disease-specific terminology to "hemorrhagic stroke" and "ischemic stroke", and 3) disease-specific prognosis tailored to individual patients. We conducted acceptability and usability testing using validated scales. All three decision aids contain information from validated, disease-specific outcome prediction models, as recommended by international decision aid standards, including careful emphasis on their uncertainty. We replaced the individualizable icon arrays graphically depicting probabilities of a traumatic brain injury patient's prognosis with icon arrays visualizing intracerebral hemorrhage and hemispheric acute ischemic stroke prognostic probabilities using high-quality disease-specific data. We selected the Intracerebral Hemorrhage Score with validated 12-month outcomes, and for hemispheric acute ischemic stroke, the 12-month outcomes from landmark hemicraniectomy trials. Twenty family members participated in acceptability and usability testing (n = 11 for the intracerebral hemorrhage decision aid; n = 9 for the acute ischemic stroke decision aid). Median usage time was 22 minutes (interquartile range, 16-26 min). Usability was excellent (median System Usability Scale = 84/100 [interquartile range, 61-93; with > 68 indicating good usability]); 89% of participants graded the decision aid content as good or excellent, and greater than or equal to 90% rated it favorably for information amount, balance, and comprehensibility. We successfully adapted goals-of-care decision aids for use in surrogates of critically ill patients with intracerebral hemorrhage and hemispheric acute ischemic stroke and found excellent usability and acceptability. A feasibility trial using these decision aids is currently ongoing to further validate their acceptability and test their feasibility for use in busy neurologic ICUs.

MANAGEMENT OF INTRACRANIAL HIGH PRESSURE ON STROKE: A NARRATIVE REVIEW

Intracranial pressure (ICP) is a dynamic and fluctuating pressure within the cranial vault influenced by cerebrospinal fluid (CSF), brain tissue, and blood. Any increase in the volume of its contents will increase the pressure within the cranial vault. As a response to ICP, compensation begins by the movement of CSF from the ventricle to cerebral subarachnoid space and increases CSF absorption. Increased ICP is a state of neurological emergency caused by various neurological injuries. It is associated with poor outcomes, including traumatic brain injury, large acute ischemic stroke, intracerebral hemorrhage, or even death. This article aims to review the symptoms and signs of increased ICP, particularly on infarction stroke and hemorrhagic stroke condition, how the therapeutic goals of the treatment strategies, and pharmacological or non-pharmacological management to mitigate the elevation of ICP on stroke.

Abstract P330: Optimizing Predictions of Infarct Core Using Machine Learning

Introduction: Evaluation of infarct core by advanced neuroimaging has facilitated patient selection for endovascular stroke therapy (EST), however the accuracy of machine-learning analysis compared to these modalities remains unexplored. We test the performance of computed tomography-Alberta Stroke Program Early Computed Tomography Score (CT- ASPECTS) vs. Computed Tomography Perfusion (CTP)-RAPID, vs. an extension of our novel machine-learning model, Deep Symmetry-sensitive Network (DeepSymNet [ref]), using the final infarct volume (FIV) in patients with rapid and successful endovascular reperfusion as the gold standard. Methods and Materials: We identified consecutive patients with large vessel occlusion acute ischemic stroke that underwent EST with TICI 2b/3 reperfusion. FIV was determined by volumetric measurements on 24-48h DWI MRI. The DeepSymNet algorithm combines symmetric and absolute brain representations and had been trained to predict CTP-RAPID core size from CTA source images acquired at presentation. Performance at predicting FIV was determined by Pearson’s correlation for CT- ASPECTS, CTP-RAPID, and DeepSymNet. Data are presented as median [IQR]. Results: Among the 76 patients that met inclusion criteria, 55.2% were male, the median age was 68 years [54-77], and 32.8% were White. 71% of the patients demonstrated an MCA occlusion, and 55% of all occlusions were left-sided. Median ASPECTS on presentation was 8 [7-8.5] and the median FIV was 10 mL [2-37]. ASPECTS, CTP-RAPID and DeepSymNet all correlated with FIV, with comparable performances from ASPECTS (R 2 =-0.398) and CTP-RAPID (R 2 =0.403) and superior performance by DeepSymNet (R 2 =-0.606)(Table). Conclusions: The DeepSymNet machine learning model analyzing CTA source images demonstrated superior performance to ASPECTS and CTP-RAPID in FIV prediction. These findings suggest machine learning models may provide improved predictions of infarct core and selection for EST.

Abstract P376: ASPECTS Decay and Functional Outcomes in Inter-Facilities Transferred Large Vessel Occlusion Acute Ischemic Stroke

Background and objective: Endovascular Thrombectomy (EVT) treatment for patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) was shown to improve functional outcomes. However, many eligible patients have no direct access to EVT capable centers, necessitating emergent inter-facilities transfers. Prolonged transfer time and reperfusion delay result in stroke progression and poor long-term outcomes. We evaluated the correlation between stroke evolution on non-enhanced Computed Tomography (CT) determined by Alberta Stroke Program Early CT Score (ASPECTS) decay and functional outcomes in transferred LVO patients. Method: Retrospective analysis of prospectively collected comprehensive stroke center data of patients with anterior circulation LVO (ICA, MCA M1 & M2) transferred for EVT. Stroke evolution was assessed based on CT ASPECTS decay defined as: [Outside hospital ASPECTS - Arrival pre-treatment ASPECTS]. A significant ASPECTS decay was defined as at least 2 points decrement in ASPECTS from initial imaging. Primary outcome was functional independence at 90-days, mRS 0-2. The correlation between functional independence and ASPECTS decay was assessed using logistic regression. Results: Of 108 patients transferred for EVT both initial outside and follow up CTs were available for 78 patients. Median IQR NIHSS was 16 (11, 20), age was 65.5 (54, 77), 33 (42%) of patients were women. Time from LKW to groin puncture was 9.91 (5.77, 13.35) hours and time from initial CT to repeat images was 3.6 (2.5, 4.8) hours. Median IQR ASPECTS decay was 1 (1, 2). Median IQR ASPECTS decay/hour 0.3 (0.0, 0.6). Significant ASPECTS decay was observed in 32 (41%) patients, and was more likely to occur with images repeated more than 3 hours from initial imaging (38% vs 10%, P<0.001). Significant ASPECTS decay correlated with decreased likelihood of achieving independence at 90-days (AOR: 0.21, 95% CI 0.04-0.99, P-value=0.048). Conclusion: ASPECTS decay was more likely to occur in prolonged transfers and correlated with lower likelihood of functional independence following EVT. Expedited transfers and faster reperfusion are vital to optimize thrombectomy outcomes in transfer patients.

ISCHEMIC STROKE IN COVID-19 PATIENT: A RARE CASE REPORT.

Background: COVID-19 is shown to be associated with hypercoagulable state which may cause neurological and cardiovascular complications. COVID-19 has been represented as an independent risk factor for acute ischemic stroke. Objective:We report a case of acute ischemic stroke as a COVID-19 complication. Material and methods: A 62-year-old known hypertensive male was diagnosed with COVID-19. He developed neurological symptoms 10 days after being tested positive. On doing an NC-CT head, a large acute ischemic stroke involving left Middle Cerebral Artery infarct was detected. Result and Conclusion: Our case represents the development of acute ischemic stroke as a neurological manifestation in patient with COVID-19. Early evaluation for acute neurological changes and timely management may reduce morbidity and mortality in such cases.

Abstract P750: 3K3A-APC Restores Oligodendrocyte Pools in Models of White Matter Stroke via PAR1 Signaling

A recombinant variant of activated protein C, 3K3A-APC, was recently tested in a successful phase II clinical trial for ischemic stroke (RHAPSODY), which demonstrated that the treatment may reduce hemorrhages and is safe in patients that were treated with tPA and/or thrombectomy. Animal models of large ischemic stroke (middle cerebral artery occlusion) and neurodegeneration have shown that the effects of 3K3A-APC are mediated by preserved APC cell signaling activities (anti-apoptotic neuronal protection, protection of blood-brain barrier (BBB) integrity and anti-inflammatory activities). Because recent studies have suggested a role of protease activated receptor 1 (PAR1) in oligodendrocyte recovery after white matter damage, we wanted to test whether biased PAR1 signaling mediated by 3K3A-APC would protect oligodendrocytes in in vivo and ex vivo models of ischemic white matter stroke. First, we used a mouse model of white matter stroke induced by injecting a vasoconstrictor N 5 -(1-Iminoethyl)-L-ornithine (L-NIO) into the corpus callosum. Our results show that treatment with recombinant murine 3K3A-APC (0.2 mg/kg, starting 4h after stroke) protected oligodendrocytes (OLS, Olig2+CNPase+) and oligodendrocyte precursor cells (OPCs, Olig2+PDGFRα+) from cell death at 1 and 7 days after stroke. In vitro , 3K3A-APC protected primary mouse oligodendrocytes from apoptosis when exposed to OGD conditions at nanomolar concentrations (EC50 concentration was 5.2 nM). Improved oligodendrocyte viability in vivo was associated by about ~67% reduction in overall cell death (cresyl violet staining, T2w and diffusion tensor MRI) and reduced BBB leakage (fibrin staining and DCE-MRI) as well as improved functional recovery (adhesive removal and grid walking tests). Protective effects of 3K3A-APC were abolished by silencing of PAR1 with small interfering RNA (siRNA) in vivo and in vitro . In conclusion, PAR1 mediated signaling initiated by 3K3A-APC protects oligodendrocyte pools in models of ischemic white matter damage with preservation of neurovascular unit integrity.

Identification of Biomarkers in Patients with Thrombotic Thrombocytopenic Purpura Presenting with Large and Small Ischemic Stroke

Background: Thrombotic thrombocytopenic purpura (TTP) is a rare blood disorder resulting in organ damage including ischemic strokes. We sought to characterize the neuroimaging patterns of stroke in a large cohort of patients with immune-mediated TTP (iTTP) and determined their associations with clinical and laboratory parameters and outcomes. Methods: We analyzed the Alabama TTP Registry who had laboratory confirmation of acute iTTP. We reviewed the neuroimaging patterns of those with ischemic stroke on MRI, clinical information, and laboratory results. Small ischemic strokes were ≤20 mm in their maximum diameter in the axial plane. Large ischemic strokes were >20 mm. Student t test, Mann-Whitney U test, and χ² test were all used for data analysis. Results: Of 108 iTTP patients, 21 had ischemic stroke on neuroimaging. The median platelet count in these patients was 12 × 10⁹/L (interquartile range, IQR, 8.8–21 × 10⁹/L), plasma ADAMTS13 activity 1.8 U/dL (IQR 0–4.5 U/dL), and the mean plasma level of anti-ADAMTS13 IgG was 6,595.8 U/mL (SD 3,448.9 U/mL). Comparison between patients with large ischemic strokes (n = 10) and small ischemic strokes (n = 11) revealed that patients with small stroke were older (p = 0.043) and had higher plasma levels of citrullinated histone 3 (p = 0.006) and histone/DNA complex (p = 0.014) than those with large strokes. There were no significant differences between 2 stroke groups in mortality or exacerbation. Conclusions: iTTP patients can present with large ischemic strokes and are usually younger. Further research should be performed in assessing different etiologies of iTTP-associated stroke based on neutrophil extracellular trap formation biomarkers (e.g., histone markers) seen in small ischemic stroke.

To Decompress or Not? An Expected Utility Inspired Approach To Shared decision-making For Supratentorial Ischemic Stroke.

Patients with large territorial supratentorial infarctions are at high risk of cerebral edema, increased intracranial pressure, tissue herniation and death. There is strong evidence supporting prompt decompressive craniectomy after large hemispheric ischemic stroke as a means to reduce mortality. Nevertheless, functional outcomes can vary significantly. Clinical trials have traditionally judged these outcomes by a priori dichotomization without taking into account individual patient and caregiver preferences. If these are not incorporated into shared decision-making, there are significant risks in both directions, i.e. producing outcomes that may be judged as unacceptable to survivors, or not offering life-saving treatments to patients that according to their own values could be beneficial. In the absence of decision aids, we explore insights from decision theory and propose an expected utility-inspired approach as a supplementary navigating tool in the decision-making process. Four patient case scenarios are discussed as a demonstration of using individualized rankings of outcome preferences, and deriving expected utilities for interventions such as decompressive craniectomy versus medical therapy. The ultimate aim of the suggested approach is to assure that patient values are elicited and incorporated, and possible range and nature of outcomes are discussed, and by attempting to connect best available means to patient individualized ends.

The neurointerventional paradox: ensuring patient safety without restricting technological innovation

As a result of the collaboration between scientists, physicians, the pharmaceutical and medical device industry, and overseeing regulatory bodies such as the Food and Drug Administration (FDA), the diagnosis and...

Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature

ObjectivesCost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. Materials and MethodsThis systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. ResultsTwenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09–3.5. All studies but 1 reported that EVT was cost-effective. ConclusionsEvidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.

Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes.

The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.

Edaravone Therapy Could be a Substitute for Decompressive Craniotomy/Craniectomy for Large Ischemic Stroke in Remote Areas with no Neurosurgeons

The incidence of stroke has been a major task for medics and relatives globally. Stroke is the second most frequent disease with high morbidity as well as mortality worldwide. This is a very short and focus review on edaravone therapy. Due to the success story of edaravone in the management of stroke, it could be beneficial for severe stroke patients. The impact of edaravone was highest in the most severely afflicted stroke patients with National Institutes of Health Stroke Scale (NIHSS) scores ≥15 during admission. Large-artery atherosclerosis or cardioembolism stroke subtypes had the highest NIHSS scores. On the other hand, decompressive craniectomy is the resection of part of the skull so that edematous brain tissue can herniate outside. It is thus advocated that, edaravone therapy could be a substitute for decompressive craniotomy for large ischemic stroke in remote facilities with no neurosurgeons.

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.

Mismatch Profile Influences Outcome After Mechanical Thrombectomy.

Mechanical thrombectomy (MT) is the recommended treatment for acute ischemic stroke caused by anterior circulation large vessel occlusion. However, despite a high rate of reperfusion, the clinical response to successful MT remains highly variable in the early time window where optimal imaging selection criteria have not been established. We hypothesize that the baseline perfusion imaging profile may help forecast the clinical response to MT in this setting. We conducted a prospective multicenter cohort study of patients with large vessel occlusion-related acute ischemic stroke treated by MT within 6 hours. Treatment decisions and the modified Rankin Scale evaluation at 3 months were performed blinded to the results of baseline perfusion imaging. Study groups were defined a posteriori based on predefined imaging profiles: target mismatch (TMM; core volume <70 mL/mismatch ratio >1.2 and mismatch volume >10 mL) versus no TMM or mismatch (MM; mismatch ratio >1.2 and volume >10 mL) versus no MM. Functional recovery (modified Rankin Scale, 0-2) at 3 months was compared based on imaging profile at baseline and whether reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved. Two hundred eighteen patients (mean age, 71±15 years; median National Institutes of Health Stroke Scale score, 17 [interquartile range, 12-21]) were enrolled. Perfusion imaging profiles were 71% TMM and 82% MM. The rate of functional recovery was 54% overall. Both TMM and MM profiles were independently associated with a higher rate on functional recovery at 3 months Adjusted odds ratios were 3.3 (95% CI, 1.4-7.9) for TMM and 5.9 (95% CI, 1.8-19.6) for MM. Reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved in 86% and was more frequent in TMM and MM patients. Reperfusion was associated with a higher rate of functional recovery in MM and TMM patients but not among those with no MM. In this cohort study, about 80% of the patients with a large vessel occlusion-related acute ischemic stroke had evidence of penumbra, regardless of infarction volume. Perfusion imaging profiles predict the clinical response to MT.

Seria niefortunnych zdarzeń — przewlekła okluzja tętnicy wieńcowej, migotanie przedsionków i udar niedokrwienny. Czy optymalna antykoagulacja jest w tym przypadku możliwa?

Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been related to discordant benefits concerning clinical and quality life measures. We present a patient previously diagnosed with hypertrophic cardiomyopathy with left ventricular outflow obstruction referred for a CTO of the left anterior descending artery PCI. Crossing via left anterior descending artery was complicated by perforation resulting in haemopericardium (no evidence of tamponade; the patient remained hemodynamically stable). On subsequent days the patient presented with two asymptomatic paroxysmal atrial fibrilation (AF) episodes ( de novo ). In this patient’s case, the stroke’s risk factors did not mandate anticoagulation due to haemopericardium and arrhythmia duration of < 48 hours. Twenty-six hours after the second AF episode, the patient suffered a large ischemic stroke in the territory supplied by the right middle cerebral artery. Despite mechanical thrombectomy (MT), the patient died. Even though CTO PCI is an appealing choice in patients with complex coronary artery disease and chronic total occlusion, the risk still should not be underestimated. Another issue is assessing the thromboembolic risk associated with acute cardioversion of patients with AF estimated to be of < 48 hours duration — it is usually considered low. However, there is increasing evidence that short runs of AF confer a significant risk of stroke. Moreover, it was shown that, among patients undergoing MT for acute ischemic stroke, women had worse outcomes at 90 days.

Computed Tomography Perfusion Core Infarct Measurement Compared to Diffusion-Weighted Magnetic Resonance Imaging in Patients with Revascularization of Anterior Circulation, Large Artery Occlusion Ischemic Stroke

Relative cerebral blood flow (CBF) < 30% has been identified as a predictor of infarct core on computed tomography perfusion (CTP). We investigated the relationship between CTP-predicted infarct core and diffusion-weighted imaging magnetic resonance imaging (DWI MRI). We conducted a retrospective analysis comparing infarct core (CBF < 30%; RAPID iSchemaView) and post-revascularization DWI MRI (ADC < 620 cc; RAPID iSchemaView) in patients with internal carotid artery (ICA) or proximal middle cerebral artery (MCA) stroke between November 2016 and May 2019. Included subjects had a modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or better and presented within 24 h of last known well (LKW) time. Two hundred one cases were identified. Mean duration from LKW time to CTP and MRI was 4.3 and 28.6 h, respectively. Median ischemic core volume was 8 cc, and median MRI infarct volume was 17 cc. CTP core volume showed fair correlation with MRI infarct volume (r = 0.294, p < 0.0001). There was a stronger association between CBF < 30% and DWI MRI in subjects presenting beyond 6 h (r = 0.359, p = 0.011). In a multivariate analysis, greater volumetric difference was associated with younger age (p = 0.001), longer duration from LKW time to revascularization time (p < 0.020), and longer CTP to revascularization time (p < 0.0001). Reduced relative CBF < 30% is a fair measure of infarct size within 24 h of anterior circulation, large artery occlusion (LAO) stroke when adequate reperfusion is achieved.

Comparision of Mechanical Thrombectomy With Contact Aspiration or Stent Retriever in Patients With Large-vessel Occlusion in Acute Ischemic Stroke.

Whether the direct aspiration approach of thrombectomy for recanalization in patients with acute ischemic stroke has a similar efficacy and safety compared to the stent-retriever still remains uncertain. A retrospective data analysis was performed to identify patients with large cerebral artery acute ischemic stroke treated with endovascular thrombectomy. The study was conducted between January 2018 and December 2019 in a single stroke center. Twenty patients met inclusion criteria for this study with a mean age 66.64 ± 17.92 years' old. The symptom occurred on the left side were in 13, and the right side in 7. The location of occlusion was 8 in M1 of the middle cerebral artery of M2, and 6 in internal carotid artery. Nine patients were randomized to first-line treatment with contact aspiration and eleven to first-line treatment with a stent retriever. The mean time from admission time to groin puncture was 55.51 ± 31.03 minutes. The average time from groin puncture to maximal revascularizion after mechanical thrombectomy was 50.9 ± 22.5 minutes in contact aspiration group, but this time was 71.37 ± 25.45 minutes in the group of stent retriever. The overall successful revascularization rate (TICI 2b-3) was 88.9% in contact aspiration (TICI2a = 1, TICI 2b = 4 patients, TICI 3 = 4 patients), and 90.1% in stent retriever (TICI2a = 1, TICI 2b = 6 patients, TICI 3 = 4 patients). First-line thrombectomy with contact aspiration did not result in a higher successful revascularization rate at the end of the procedure but had a short time from groin puncture to maximal revascularizion.