Management Of Acute Ischemic Stroke Research Articles

Abstract 152: Endovascular Therapy versus Medical Management for Acute Ischemic Stroke With Large Infarct: A Time-Benefit Relationship Analysis

Objective: Recent randomized trials demonstrated the benefit of endovascular thrombectomy for acute ischemic stroke with large infarct. We aimed to characterize the effect of time to treatment on the benefit of endovascular therapy compared to medical management among patients with acute large ischemic stroke. Methods: Analysis the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core trial (ANGEL-ASPECT), which was a multicenter, randomized trial at 46 comprehensive stroke centers in China from August 2020 to October 2022. Onset to arterial puncture time (OPT) associated with outcomes of endovascular therapy were analyzed as a category and continuous variable. The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Secondary outcomes included degree of disability (modified Rankin scale range), symptomatic intracranial hemorrhage, any intracranial hemorrhage, and mortality. Results: Among 455 eligible patients, the median age was 68 years, and median Alberta Stroke Program Early Computed Tomography Score was 3 (interquartile range 3-4). Compared with medical management alone, endovascular therapy plus medical management was associated with higher rates of favorable outcome with OPT within 6 hours (44.4% vs 29.9%, adjusted odds ratio[aOR] 2.78 [95% confidence interval [CI] 1.22-6.32]), 6-12 hours (45.7% vs 29.6%, aOR 2.39 [95% CI 1.21-4.71]), but not in OPT beyond 12 hours (51.6% vs 41.4%, aOR 2.05 [95% CI, 0.88-4.77]). The benefit in favorable outcome became nonsignificant after OPT of 13 hours and 22 minutes. In three OPT intervals, the odds of better disability outcome with endovascular therapy plus medical management than medical management alone were observed; the rates of symptomatic intracranial hemorrhage and mortality were similar, though the rates of any intracranial hemorrhage increased. Conclusion: In patients with large cerebral infarction, endovascular therapy plus medical management was efficacious in improving functional outcomes with acceptable safety in a broad time window of 0 to 24 hours, but greater benefit was observed with earlier treatment. A pooled analysis with larger sample size is needed.

Abstract TMP16: Impact of Door-to-Imaging and Imaging-to-Door Times on Door-in-Door-out Times in Interhospital Transfers of Patients With Stroke

Introduction: Urgent inter-hospital transfer ensures timely access to therapies for acute ischemic stroke. Door-in-door-out (DIDO) represents the total amount of time a patient spends in the transferring emergency department (ED) before transfer. DIDO time is an important quality metric for the care of acute stroke; however, little is known about the influence of process steps on DIDO times and which steps most often cause delays. Methods: This was a retrospective cohort study of patients in the American Heart Association Get With The Guidelines®-Stroke registry with ischemic stroke presenting January 2019 to December 2021 transferred from the ED at the presenting hospital to another acute care hospital for evaluation of thrombolytics, endovascular therapy or post-thrombolytic care. The primary independent variables were door-to-imaging and imaging-to-door times, and the primary outcome was DIDO time. Multivariate GEE regression models were performed to assess the comparative contributions of interval process times to variation in DIDO time, controlling for patient and hospital-level characteristics. Results: Among 24,662 patients (50.5% male, mean age 68.3 years, 73.2% White), mean DIDO time was 171.4 min (SD: 149.5), mean door-to-imaging time was 18.3 min (SD: 34.1) and mean imaging-to-door time was 153.1 min (SD: 141.5). A 1 min increase in door-to-imaging time was associated with a 1.33 min increase in the mean DIDO time, while a 1 min increase in imaging-to-door time was associated with a 1.02 min increase in mean DIDO time. The baseline model (without door-to-imaging or imaging-to-door included) had an R2 of 0.03. With door-to-imaging included in the GEE model, R2 was 0.13; whereas the model with imaging-to-door included had an R2 of 0.95. Conclusion: Imaging-to-door time accounts for a greater proportion of the variance in DIDO times than door-to-imaging time. Though the opportunity for improvement in DIDO is greater through reduction of imaging-to-door time, door-to-imaging time has greater per-minute effect on DIDO. While existing guidelines and care resources heavily focus on reducing door-to-imaging times, further attention is warranted to reduce imaging-to-door times in the management of acute ischemic stroke.

Clinical and organisational quality indicators for the optimal management of acute ischaemic stroke in the era of thrombectomy: a scoping review and expert consensus study

ObjectiveThe purpose of this study is to identify clinical and organisational quality indicators conducive to the optimal interdisciplinary management of acute-phase ischaemic stroke.MethodA scoping review based on the six-step methodological...

Abstract WMP72: Accurate LVO and MeVO Detection Using a Multiphase CT Angiography Perfusion-Based Tool

Background and Aims: Early and accurate detection of vessel occlusion is essential for the management of acute ischemic stroke (AIS). Current automated occlusion detection tools mostly rely on single-phase CTA (sCTA), which makes it challenging to accurately identify Medium Vessel Occlusions (MeVO). Multiphase CTA (mCTA), which consist of an additional two low-dose scans to the traditional CTA workflow, may be able to allow precise detection of MeVO occlusions. In this work, we aim to validate StrokeSENS mCTA Occlusion Detection in its ability to detect LVOs and MeVOs up to and including the M3/A3/P3 segments of the Middle/Anterior/Posterior Cerebral Arteries (MCA/ACA/PCA). Methods: Validation was performed on 512 studies of suspected AIS patients with baseline mCTA. Studies had MeVO (PCA:11, ACA:4, MCA:83), LVO (ICA:116, PCA:8, MCA:263), and no occlusion: 27. Expert neuroradiologists annotated the presence and location of the occlusion. StrokeSENS mCTA Occlusion Detection processed mCTA data to produce hypoperfusion extent probability maps, and presence or absence of occlusion. To validate the ability of the tool to detect occlusion, we used ROC analysis, specificaly the AUC and Sensitivity/Specificity metrics. Results: The full cohort AUC was 96.7% (95% C.I.: [94.7%,97.7%]). For LVO subgroups, ICA AUC=98.2%, MCA AUC=98.0%, PCA AUC=68.5%. For MeVO, MCA AUC=95.0%, ACA AUC=78%, PCA AUC=91.2%. At the selected operational point, overall Sensitivity was 86.0% (95% C.I.: [0.829, 0.891], N=485), and Specificity was 92.6% (95% C.I.: [0.766, 0.979], N=27). Figure 1 shows examples of the hypoperfusion extent produced by the tool for LVO and MeVO cases. Conclusion: In this work, we evaluated the tool StrokeSENS Occlusion Detection in its ability to detect LVO and MeVO occlusions. The tool has shown very high accuracy in detection occlusions up to and including the M3/A3/P3 segments of the Middle/Anterior/Posterior Cerebral Arteries (MCA/ACA/PCA).

Abstract WP146: Critical Care After Thrombolytic Therapy in Acute Stroke: Who Really Needs the ICU?

Introduction: Intravenous thrombolytic therapy remains the cornerstone of management in acute ischemic stroke (AIS) patients. Given the potential adverse effects of thrombolysis, patients are admitted to an intensive care unit (ICU) for close monitoring following administration. Alternative post-thrombolytic pathways may provide for safe cost-effective care in certain populations. We aimed to determine the proportion of patients treated with thrombolytics who required ICU care for reasons other than frequent neurologic monitoring and define their characteristics. Methods: We retrospectively reviewed patients ≥ 18 years of age who received TNK/ tPA for AIS at our community-based stroke center between May 2020 and August 2022. Patients were classified as requiring ICU care if they required intubation within 24 hours of admission or neurosurgical intervention, had symptomatic hemorrhagic conversion or brain compression, required a continuous infusion for hemodynamic management, or were in status epilepticus. Univariate and multivariate statistical analysis was performed. The study protocol was deemed exempt by our institutional IRB. Results: 262 patients met inclusion criteria. 54 (20.6%) required ICU level of care. Characteristics of those requiring ICU level of care are described in Table 1. Multivariate analysis showed that patients on antiplatelet or anticoagulant therapies prior to arrival (AOR: 2.205, p= 0.021) or who presented with higher initial NIH stroke scale (AOR: 1.108, p < 0.001) had significantly higher likelihood of requiring ICU level of care. Conclusions: In our cohort, approximately 21% of patients required critical care. Anticoagulant or antiplatelet therapy prior to admission and greater NIH stroke scale on arrival were associated with an increased likelihood of requiring ICU level of care. Further prospective studies are indicated to assess the efficacy of alternative settings for post-thrombolytic care in selected AIS patients.

Body fluids biomarkers associated with prognosis of acute ischemic stroke: progress and prospects.

Acute ischemic stroke (AIS) is one of the most common strokes posing a grave threat to human life and health. Predicting the prognosis of AIS allows for an understanding of disease progress, and a better quality of life by making individualized treatment scheme. In this paper, we conducted a systematic search on PubMed, focusing on the relevant literature in the last 5 years. Summarizing the candidate prognostic biomarkers of AIS in body fluids such as blood, urine, saliva and cerebrospinal fluid is often of great significance for the management of acute ischemic stroke, which has the potential to facilitate early diagnosis, treatment, prevention and long-term outcome improvement.

Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review.

To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.

Critical care management of acute ischemic stroke – An overview of current concepts

Acute ischemic stroke is a major cause of morbidity and mortality globally. Early recognition and prompt revascularisation are the cornerstones of treatment. Advances in the management of stroke, notably with the endovascular interventions has led to improved functional outcomes. Identification of stroke subtype, timely decision making, institution of specific therapy and periprocedural care in an intensive care unit make the difference between a favourable and an unfavourable outcome. To this effect, dedicated stroke centres, multidisciplinary teams with trained experts and critical care management play an important role. Improvements in the understanding of the disease process, ever expanding literature and development of promising novel therapeutic strategies, not withstanding, stroke is still a leading cause of acquired long term disability and mortality worldwide. End of life care and associated decision making precariousness, pose a significant prognostication challenge to the critical care team. The aim of this review is to discuss the current evidence regarding diagnosis, revascularisation modalities and optimal critical care management strategies.

Automated evaluation of collateral circulation for outcome prediction in acute ischemic stroke

IntroductionThe assessment of collateral circulation in acute ischemic stroke management is essential. Modern tools, such as Brainomix's e-CTA, powered by artificial intelligence, provide detailed insights into collateral assessment. This retrospective study aims to identify factors contributing to favorable collateral status and compare outcomes between patients with good collaterals (grade 3) and fair collaterals (grade 0–2). MethodThis retrospective study included 97 patients admitted to the Stroke Unit at the Hospital de Clínicas of the Federal University of Paraná, Brazil, from September 2021 to January 2023. Comparative analyses involved demographic factors, cardiovascular risk factors, and the combined outcome of mortality and moderate to severe disability at discharge, 30-day, and 90-day follow-ups. ResultsAmong the 97 cases, 58.8 % showed 'good collaterals' with a grade 3 status. Variables affecting collateral status included age (p = 0.042), neutrophil-lymphocyte ratio (p = 0.005), and initial NIHSS scores (p<0.001). The presence of good collaterals according to e-CTA reduced the odds of death and moderate-severe disability at discharge (p = 0.003; OR 0.27) and at 30 days (p = 0.015; OR 0.33), although this effect diminished at the 90-day mark after multivariate analysis. DiscussionAutomated collateral assessment through e-CTA is a valuable tool in acute ischemic stroke evaluation. Good e-CTA collateral score serve as a promising imaging biomarker, guiding informed clinical decisions during Stroke Unit hospitalizations. This study highlights the relationship between collaterals and stroke outcomes and underscores the potential for AI-driven tools to enhance stroke care management.

Efficacy of antiplatelet drugs combined with Argatroban in treating acute ischemic stroke and its impact on patients’ coagulation function and neurological function: a preliminary trial

This retrospective study analyzed the efficacy of combined antiplatelet therapy with Argatroban in treating acute ischemic stroke (AIS) and its impact on patients’ coagulation and neurological functions. Clinical data of 113 AIS patients admitted between January 2021 and January 2023 were retrospectively analyzed. Patients were divided into control (n = 56) and observation (n = 57) groups based on treatment interventions. The control group patients were treated with antiplatelet drugs, while the observation group patients received combination therapy with apatinib on the basis of the control group treatment. Compared to the control group, the observation group demonstrated higher clinical efficacy, improved coagulation parameters, reduced stroke severity (measured by NIHSS), enhanced daily living abilities (BI scores), and lowered inflammatory and neural injury markers post-treatment. Adverse reaction incidence was similar between groups. Combining Argatroban with antiplatelet drugs in AIS management showed superior efficacy without increasing adverse effects, suggesting its potential for clinical application.

Factors Affecting Management of Acute Ischemic Stroke with Reference to Intravenous Thrombolysis and its Impact on Short Term Outcome

Factors Affecting Management of Acute Ischemic Stroke with Reference to Intravenous Thrombolysis and its Impact on Short Term Outcome

Role of decompressive craniectomy in the management of acute ischemic stroke (Review)

Role of decompressive craniectomy in the management of acute ischemic stroke (Review)

Clinicoradiological application of the use of spectral cranial computed tomography in the management of acute ischemic stroke after mechanical thrombectomy.

Acute ischemic stroke is one of the leading global causes of morbidity and mortality. Mechanical thrombectomy has improved the functional prognosis of this condition; however, hemorrhagic transformation is a common complication. Spectral computed tomography (CT) imaging, as a neuroimaging control test, distinguishes contrast extravasation from hemorrhagic transformation due to the differential behavior of materials at dual energy levels. This distinction is valuable in its clinical therapeutic management. A single-center, observational, retrospective study was conducted in which the presence of various clinical, radiological, and therapeutic variables in patients with acute ischemic stroke treated with mechanical thrombectomy at our hospital between July 2022 and March 2023 was investigated using access to a dissociated database and medical records. Out of 155 included patients, spectral cranial CT was performed in 63, and conventional cranial CT in 75. In the spectral CT group, 21 hyperdense images were detected, compared to 28 in the conventional CT group. In 42.8% of cases where hyperdensity was detected in the conventional CT group, it was not possible to distinguish between contrast extravasation and hemorrhagic transformation, in contrast to the 4.8% in the spectral CT group (p < 0.001). Spectral CT provides high diagnostic confidence to the radiologist in identifying the type of detected hyperdensity, thereby offering significant therapeutic confidence to the neurologist in early resuming anticoagulation therapy.

Impacts of futile reperfusion and reperfusion injury in acute ischemic stroke.

Acute ischemic stroke (AIS) remains to be a challenging cerebrovascular disease. The mainstay of AIS management is endovascular reperfusion therapy, including thrombectomy and thrombolysis. However, ineffective (futile) reperfusion (FR) or reperfusion injury (RI) can be seen in a significant number of patients undergoing reperfusion strategy. In this article, we discuss two clinically relevant concepts known as "time window" and "tissue window" that can impact the clinical outcome of reperfusion therapy. We also explore patient risk factors, leading to FR and RI as well as an emerging concept of "no-reflow phenomenon" seen in ineffective reperfusion. These fundamental concepts provide insight into the clinical management of AIS patients and provide references for future research.

Improving stroke care in Indonesia: Integrating CT perfusion for enhanced prognostication and treatment guidance - A case report

Background. Over the last three decades, stroke management has witnessed substantial progress, from the introduction of recombinant tissue plasminogen activator (rtPA) in 1995 to the approval of thrombectomy in 2016. Intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset is the standard for eligible acute ischemic stroke patients, dissolving clots and restoring blood flow. Endovascular thrombectomy (EVT) surpasses intravenous thrombolysis for large vessel occlusion cases, typically within 6 to 24 hours based on CT-perfusion criteria. CT perfusion (CTP) provides crucial quantitative data on cerebral blood flow, aiding in ischemia detection, tissue assessment, treatment guidance, and outcome prediction. This case report marks a pivotal moment in Indonesian stroke management, introducing the inaugural use of CTP for diagnostic purposes. By scrutinizing blood flow dynamics and cerebral conditions, CTP augments conventional diagnostics, offering enhanced prognostic value. Case presentation. The case of a 58-year-old male with notable comorbidities exemplifies this successful integration. He presented with sudden left-sided weakness and dysarthria, without accompanying symptoms. Neurological evaluation revealed a Glasgow Coma Scale score of E3M6V5, 7th cranial nerve paresis, and a positive Babinski reflex on the left side. With a National Institute of Health Stroke Scale (NIHSS) score of 10, a head CT scan rules out cerebral hemorrhage, prompting precise thrombolysis at 0.7 mg/kg. Within one hour post-thrombolysis, the NIHSS score improved to 6, ultimately culminating in an NIHSS score of 2 upon discharge. Conclusion. This case underscores the efficacy of acute ischemic stroke management, fortified by the strategic integration of CTP, heralding a new era in Indonesian stroke care.

Integrated stroke care: providing tools for the evaluation of different parts of the care pathway – A systematic literature search.

Background: Worldwide, Stroke remains the second leading cause of death and the third leading cause of disability. Adequate treatment of stroke is key in the reduction of mortality and morbidity. Management of acute ischemic stroke implicates an evidence-based and multidisciplinary approach. However, integrated care and evaluation of this care process is still a major concern for healthcare professionals, managers, researchers and policymakers in many European countries. Currently, there is an abundance of guidelines describing the care for patients with ischemic stroke. The purpose of these guidelines is offering an easy way of access to evidence-based recommendations, to guide ischemic stroke care planning and delivery across the continuum of care. But it remains difficult to translate the enormous amount of recommendations into care pathways that can be used for patients with ischemic stroke.&#x0D; Aim and target audience: We aim to aid healthcare professionals in developing and evaluating care pathways for patients with ischemic stroke by giving them an overview of the most important recommendations and quality indicators for the different parts of the stroke care process.&#x0D; Materials and Methods: A systematic literature search was conducted in PubMed, from 2014 up to May 2021. The search string was designed on the basis of Medical Subject Heading (MeSH) terms. These included “ischemic stroke” and “guideline” and included all relevant synonyms of these terms. Papers were included if they described the entire care process from admission to the emergency department until discharge from a neuro-related ward. In total, 18 papers were included in this systematic review.&#x0D; Results: In total, 50 recommendations were extracted from the included papers. These recommendations could be divided into four clinical categories: 6 recommendations were subdivided into diagnostic recommendations, 7 into therapeutic, 26 recommendations are part of nursing care, 8 of post stroke rehabilitation and 5 structural recommendations were identified. Administration of thrombolysis was the most common used recommendation (16/18), followed by imaging via CT-scan (15/18), management of glucose (15/18) and blood pressure (15/18) and performing thrombectomy (15/18). The least frequently mentioned recommendations are: differential diagnosis, seizures assessment, early carotid imaging, advanced care planning, treatment of concomitant diseases and tobacco use counselling. They were each mentioned in only one of the 18 included papers. As there is currently a lot of variation on indicator definitions in the literature, making uniform comparisons difficult, we formulated indicator definitions for the most important recommendations. And in addition, we provide information on the validity, feasibility and actionability of these indicators in clinical practice.&#x0D; Practice implications: Our systematic literature search provides tools for healthcare professionals when they want to evaluate their entire or a part of the care pathway for patients with ischemic stroke. Furthermore, we provide an answer to the current variation in indicators for the evaluation of the stroke care process.&#x0D; Next steps: Future research can evaluate whether these recommendations and accompanying indicators are useful in practice and can identify which indicators are most important in stroke care pathways.&#x0D;

The influence of systolic arterial pressure in the first day after systemic thrombolysis on ischemic stroke outcomes and complication rate: a retrospective single-center study

Introduction. Reperfusion (both pharmacological and interventional) is the cornerstone of acute ischemic stroke (AIS) management. Currently, there are only limited data in the scientific literature regarding the influence of systemic hemodynamic parameters on the recanalization status and complications of AIS.The objective of our study was to assess the relationship between the systemic hemodynamic parameters in the early postreperfusion period and the outcomes of AIS.Materials and methods. For retrospective analysis, data of 292 patients who received intravenous thrombolysis (IVT) at the Arkhangelsk Regional Stroke Center between 2010 and 2021 were collected. The main endpoints were functional outcome, mortality, and symptomatic intracranial hemorrhage (sICH). The success of reperfusion was defined as the neurological improvement by 4 or more points of the NIHSS score within the first 24 hours after the start of IVT.Results. The relationship between mean systolic blood pressure (SBP) during the first 24 hours of IVT and functional recovery was obtained: B = 0.016 (β = 0.096) [95 % CI 0.000 – 0.031] (р = 0.49). The relationship between maximal SBP during the first day of IVT and functional recovery was also determined: B = 0.009 (β = 0.102) [95 % CI 0.001 – 0.018] (p = 0.037). The sICH occurred in nine cases, all of them were in the group without achieving successful reperfusion.Conclusion. The baseline levels of SBP ≥ 160 mm Hg at hospital admission in patients with AIS followed by IVT are accompanied by worse functional outcome and greater odds of death. The neurological improvement with significant decline in the NIHSS score during the first 24 hours after IVT is associated with a decreased risk of sICH.

Code ICH: A Call to Action.

Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.

Coronary balloon-assisted navigation of aspiration catheter for stroke thrombectomy.

In recent years, A Direct Aspiration First Pass Technique (ADAPT) has emerged as an effective and safe method of thrombectomy. Large trials have shown noninferiority of ADAPT compared to primary stent retriever approach, while new studies emphasize on its shorter procedural time with potentially fewer complications and costs.1,2. Failure of the A Direct Aspiration First Pass Technique (ADAPT) is often due to the inability to successfully navigate the aspiration catheter to the thrombus site. As a solution, several techniques have been considered such as the use of stiffer microcatheters or a wedge device.3 In Video 1, we present our technique of navigating aspiration catheters with the assistance of coronary balloons. This technique has been very successful in our experience of about 30 cases in the past 6 months. Thanks to its safety and efficacy, this technique has dramatically changed our technical management of acute ischemic stroke. It can increase the ADAPT success rate while potentially reducing procedural costs.

Evaluating the use of intravenous Tenecteplase for the management of acute ischemic stroke in the mobile stroke unit: A multi-institutional survey

Evaluating the use of intravenous Tenecteplase for the management of acute ischemic stroke in the mobile stroke unit: A multi-institutional survey