Symptomatic ICH Research Articles

Abstract 9: Autoregulation-based Blood Pressure Targets After Endovascular Thrombectomy

Background: Optimal level blood pressure (BP) targets in acute stroke remain elusive. Tailored hemodynamic management after endovascular thrombectomy (EVT) may reduce the risk of reperfusion injury and promote penumbral recovery. Our study aimed to evaluate the relationship between personalized autoregulation-based BP targets, secondary brain injury, and functional outcomes. Methods: We prospectively enrolled 200 patients with acute ischemic stroke who underwent EVT. Autoregulatory function was continuously measured for >=24 hours using simultaneous recordings of near-infrared spectroscopy and mean arterial pressure (MAP). The resulting autoregulatory index was used to calculate and trend the BP range at which autoregulation was most preserved. Percent time and “dose” that MAP exceeded the upper limit or dropped below the lower limit of autoregulation (ULA, LLA) were calculated for each patient. Hemodynamic parameters were correlated with short-term clinical endpoints (symptomatic ICH), biomarkers of secondary brain injury (net water uptake, hemorrhagic transformation (HT), infarct progression), and 90-day functional outcomes. Results: Personalized BP targets were successfully computed in 195 patients (mean age 70 ± 16, 45% female, mean NIHSS 14, mean monitoring time 31 ± 28 hours). Time above the ULA was associated with worse functional outcomes at 90-days after adjusting for age, sex, NIHSS, ASPECTS and TICI (adjusted OR per 10% increase 1.4, 95% CI 1.1-1.6, P=0.004). The burden of hyperperfusion was significantly greater among patients with HT (median 2.7 vs. 3.2 mmHg*min, p=0.01) and sICH (median 2.8 vs. 4.8 mmHg*min, p=0.05) than in those without it. Furthermore, time spent above the ULA was significantly correlated with net water uptake at 72 hours (r=0.37, p=0.03). Among patients with unsuccessful reperfusion, there was a non-significant correlation between time below the LLA and infarct progression (r=0.35, p=0.064). Conclusions: In the largest study conducted to date, deviations from personalized BP targets were associated with an increased risk of secondary brain injury and worse functional outcomes. Autoregulation-oriented BP management represents a promising strategy for maximizing recovery after ischemic stroke.

Abstract TP144: VARIANCE-S: Variability Of Assessed Bp Readings In Acute Neuro-intervention Cases And Its Effect On Outcomes Pertaining To Sex Differences

Introduction: Sex differences exist in thrombolytic stroke treatment and outcome and likely in endovascular thrombectomy (EVT). Previous analysis has shown a significant correlation of blood pressure variability (BPV) and sex. The purpose of this study was to assess sex differences in a sample of patients with good recanalization post-with EVT and examine the impact of BPV. Methods: We conducted a retrospective analysis of prospectively collected data from an IRB approved Stroke Registry of two academic Comprehensive Stroke Centers in Southern California between 2017 and 2022. Patients were included if they had 1) anterior circulation ischemic stroke due to large vessel occlusions (LVO) and 2) underwent successful EVT defined as a TICI 2b or 3 result. Male and female subjects were compared for age, sex, Hispanic ethnicity, initial NIHSS, history of HTN, current antihypertensive use, symptom onset to groin puncture time, door to groin puncture time, and symptomatic ICH (sICH), BPV, onset to groin, and door to groin . Good outcome was defined as mRS 0-2. Chi squared a t-test were used as appropriate. Results: We included 131 females and 124 males. There was a significant difference between males and females in: 1) history of a fib (76% v 64%, p=0.42); 2) atrial fibrillation during admission (36% v 50%, p=0.01); 3) age (male 67 v female 73 years, p<0.001); 4) post-EVT SBP (137mmHg v 144mmHg, p-0.02). There was a significant difference in onset to groin (p=0.41), but no significant difference in door to groin (p=0.59). When adjusting for time of onset, there was no significant difference in thrombolysis prior to EVT between groups. There was no significant difference in sICH (6 male v 4% female, p=0.50), 90 day mRS (p=0.81); or discharge disposition (p=0.56). BPV was significantly correlated with sex but not significant for any interaction effect with the variables assessed. Conclusion: This study found no significant sex differences in outcome in this sample. The systems of care provided by an academic, CSC ensure that all patients’ care is expedited and provides the best opportunity for a good outcome in both sexes. Studies of sex differences in EVT treatment and outcome in multiple stroke care settings are vital to reduce disparities in care.

Abstract WP164: Acute Carotid Stenting Versus Conservative Management For Tandem Carotid Occlusions: Insights From STAR

Introduction: Management of anterior circulation emergent large vessel occlusion with tandem carotid occlusion (TCO) remains a challenge during mechanical thrombectomy (MT). To day, there is no consensus regarding emergent carotid stenting (ECS) in the setting of MT with TCO. We aimed to compare the outcomes of ECS versus conservative management (MT alone) among patients with TCO. Methods: Data from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 was interrogated. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the ICA or MCA were included in the analyses. We compared baseline, procedural charecteristics, successful reperfusion (mTICI 2b-3), favorable 90-day good outcomes (mRS 0-2), intravenous tPA administration and symptomatic ICH between patients who did or did not undergo ECS. Multivariate regression was performed adjusting for variables of clinical importance. Propensity score matching for IV tPA use was performed to explore its safety with stenting. Results: Among 9812 thrombectomy patients, 688 patients had TCO; 132 underwent emergent stenting and 444 had MT alone. Patients who did not undergo ECS had a higher prevalence of atrial fibrillation (33.9% Vs 9.2%, P<.001), higher admission NIHSS scores (18 Vs 14, P<.001), shorter time from symptom onset to puncture (275 minutes Vs 333 minutes, P=0.029), and were predominantly women (59.2% Vs 33.6%, P<0.001).Patients with stenting had lower mortality rates ( 17.5% Vs 29.6%, P=0.009), and higher rates of successful reperfusion (83% Vs 95%, P=0.001). No difference in mRS 0-2 (37.5% Vs 30.4%, P=0.178) or sICH were seen (11.1% Vs 15.4%, P=0.219). Propensity score matching analysis (n=129 in each group) demonstrated better rates of reperfusion (94.8 Vs 84.4%, P=0.011) in the stenting group. Advanced age, higher admission NIHSS and lower ASPECT scores were associated with worse clinical outcomes. Conclusion: ECS during MT for TCO appears to be safe and is associated with better clinical and angiographic outcomes compared to conservative management.

Abstract WMP96: A Prospective Trial Of The Rapidpulse Tm Aspiration System As Frontline Approach For Stroke Thrombectomy (RapidPulseFS)

Introduction: First-pass effect (FPE) is associated with improved clinical outcomes and reduced mortality in mechanical thrombectomy (MT) for large vessel occlusion strokes (LVOS). However, FPE is achieved in only 30-40% of patients with the current devices. The RapidPulse TM Cyclic Aspiration System (RP) is a novel technology consisting of a valve box that precisely cycles pressure from full to no vacuum multiple times per second adding kinetic energy to the suction forces. Initial clinical evaluation suggests that the system can achieve FPE rates in the 70% range. We aim to evaluate the RP as a frontline approach in LVOS. Methods: Prospective, multicenter, open-label, core lab adjudicated, two-arm study comparing the safety and efficacy of the RP System with non-randomized retrospective controls who were consecutively treated at the study sites based on similar eligibility criteria. Patients with LVOS involving the anterior or posterior circulations in whom the target lesion could be treated with the Medtronic React 71 aspiration catheter up to 24 hours from stroke onset were included in the RP arm. Controls consisted of comparable patients treated with 070-072 ID catheters. The primary outcome was the rate of FPE (complete/near reperfusion [mTICI ≥2c] after a single pass). Secondary outcomes include frontline technical success (defined as mTICI ≥2b after final device pass with no rescue therapy), final mTICI after all passes, symptomatic ICH, device-related complications, the proportion of patients achieving a modified Rankin Scale score of 0-2 at 90 days, and all-cause 90-day mortality. The study will enroll a maximum of 100 participants in the RP and 200 in the control arm at 5 centers in Spain, Turkey, Denmark, Latvia, and Brazil. Results: Final results will be presented at the conference. Conclusion: RapidPulseFS is the first prospective clinical trial aiming to compare cyclic versus standard aspiration technologies. This novel device may allow clinicians to achieve faster and better reperfusion while significantly reducing the disposable device costs associated with treating LVOS (ClinicalTrials.gov Identifier: NCT05122637).

Abstract TP135: Underlying Intracranial Atherosclerotic Disease Is Associated With Worse Outcomes In Acute Large Vessel Occlusion Undergoing Endovascular Thrombectomy

Introduction: Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in-hospital mortality, 90-day mortality, and 90-day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results: Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p=0.027 and 29.0% vs. 14.7%, p=0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p=0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p=0.054). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p=0.003 and 52.6% vs. 26.6%, p=0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p=0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4). Conclusions: Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high-risk population.

Abstract TP151: Predictors Of Mechanical Thrombectomy Failure

Background: Mechanical thrombectomy is standard of care for acute ischemic stroke secondary to LVO however MT failure (MTF) occurs in approximately 15% of cases. Objective: Investigate patient and procedural characteristics that predict MTF. Methods: Retrospective review of prospectively collected, Stroke Thrombectomy and Aneurysm Registry. Patients who underwent MT for LVO were included and categorized by MT Success (MTS) or MTF, defined as mTICI≥2b or <mTICI2b, respectively. Demographics, pretreatment, and treatment information were included in UVA and MVA for prediction of MTF. Results: A total of 8452 patients were analyzed, and 1301(15.4%) experienced MTF.MTF patients were older(73 vs.71, p=0.008)had higher poor premorbid mRS(10.8% vs 8.4%, p=0.17).Onset to puncture was greater in MTF group(442 vs.411 min, p=0.006).There were more ICA occlusions(15.6% vs. 13.5%)and basilar occlusions(7.8% vs.6.2%)in the MTF group and more M1 occlusions(42.2%vs.37.5%)in the MTS group (p<0.001).More patients underwent aspiration as the final technique in the MTS group(35.3% vs 32.9%).Number of passes(3 vs 2)and procedure time (77.3 vs 46.1 min) were higher in the MTF group (p<0.001). More patients in the MTF group required IA thrombolytic(14.7% vs. 8.3%, p<0.001).More patients in the MTS group had rescue stenting(7.9% vs 4.8%).There were more complications (14.7% vs 6.2%) and more symptomatic ICH(9.9% vs 5.7%, p<0.001)in the MTF group. Favorable outcome at 90 days was greater in the MTS group(42.6% vs 18.3%, P<0.001).On UVA, age, poor pretreatment mRS, posterior circulation occlusion, final technique SR, increased number of passes, increased procedure time were associated with increased odds of MTF, while M1-M2 occlusions and rescue intracranial stenting with decreased odds of MTF. These correlations remained significant on MVA for final technique SR, rescue intracranial stenting, number of passes, and procedure time. Conclusion: MTF is associated with more complications and worse outcome. Final use of aspiration and rescue intracranial stenting may increase chances of recanalization.

Abstract WP150: Asymptomatic Intracranial Hemorrhage Following Endovascular Treatment Is Not Benign: A Systematic Review And Meta-analysis

Introduction: Asymptomatic intracerebral hemorrhage (aICH) occurs in ~40% of acute ischemic stroke patients after endovascular thrombectomy (EVT). Unlike symptomatic ICH, which is undoubtedly associated with worse outcomes, studies evaluating the association of aICH on long-term outcomes have been inconclusive. We performed a systematic review and meta-analysis to evaluate the long-term effects of post-EVT aICH. Methods: The meta-analysis protocol was submitted to PROSPERO a priori. PubMed, SCOPUS and Web of Science were searched from inception through April 2022 using database-specific searches with combination of keywords and controlled vocabulary. After deduplication, two authors independently reviewed all abstracts. Included studies contained adult AIS patients undergoing EVT with follow-up imaging assessment of ICH reporting comparative outcomes according to aICH vs no ICH . Meta-analysis was performed using Cochrane Review Manager v5.4. Summary effects were estimated by a fixed-effects model to estimate summary odds ratio (OR) of the effect of aICH vs no ICH on primary outcomes of 90-day modified Rankin score 3-6 and mortality. Results: Systematic review yielded 278 studies; 52 abstracts were fully reviewed ; 8 studies fulfilled inclusion criteria (n=4701 patients total; 1562 with aICH). aICH was associated with 90-day mRS 3-6 (OR 2.11 [95% CI 1.85-2.40]; Figure 1A) and higher mortality (OR 1.66 [95% CI 1.41-1.96]; Figure 1B) compared to no ICH. There was insufficient evidence of difference in 90-day mRS 3-6 when studies were grouped according to Heidelberg (n=2 studies; OR 2.37 [95% CI 0.92, 6.12]) vs ECASS (n=5 studies; OR 2.07 [95%CI 1.62, 2.64]) criteria for ICH. Meta-regression analysis adjusting for covariates will be presented Conclusion: aICH is associated with worse 90-day functional outcomes and higher mortality. Further studies to evaluate the factors predicting aICH and treatments aimed at reducing its occurrence are warranted.

The optimum anticoagulation time after endovascular thrombectomy for atrial fibrillation-related large vessel occlusion stroke: a real-world study

ObjectivesTo investigate the relationship between the initiation time of anticoagulation after endovascular treatment (EVT) and the outcomes in atrial fibrillation (AF)-related acute ischemic stroke (AIS) patients.MethodsIn this prospective registry study, from March 2013 to June 2022, patients with anterior circulation territories AF-related AIS who underwent EVT within 24 h were included. The primary outcome was favorable [modified Rankin Scale (mRS) 0–1) at ninety days and the secondary outcome was hemorrhage events after anticoagulants. Factors affecting the outcomes were pooled into multivariate regression and ROC curve analysis.ResultsOf 234 eligible patients, there were 63 (26.9%) patients achieved a favorable outcome. The symptomatic intracranial hemorrhage (sICH), ICH, and systemic hemorrhage events after anticoagulants occurred in 8 (3.4%), 28 (12.0%), and 39 (16.7%) patients, severally. A longer EVT to anticoagulation time (p = 0.033) was associated with an unfavorable outcome (mRS 3–6). An earlier EVT to anticoagulation time was the independent risk factor of sICH (p = 0.043), ICH (p = 0.005), and systemic hemorrhage (p = 0.005). There was no significant difference in recurrent AIS/ transient ischemic attack (TIA) or mortality among patients who started anticoagulation at ≤ 4 days, ≥ 15 days, or 4 to 15 days. The optimum cut-off for initiating anticoagulants to predict a favorable outcome and hemorrhage events was 4.5 days and 3.5 days after EVT, respectively.ConclusionsIn AF-related AIS, the time of EVT to anticoagulation is an independent factor of the functional outcome and hemorrhage events after anticoagulation. The optimal initiate time of anticoagulant after EVT is 4.5 days.ClinicalTrialRegisterNCT03754738.

Cerebral hemorrhage after thrombolysis in stroke patients with unruptured intracranial aneurysms: a systemic review and meta-analysis.

For ischemic stroke patients with concomitant unruptured aneurysm, intravenous thrombolysis therapy (IVT) remains a disputable decision. We hence performed a meta-analysis to identify the related brain hemorrhage rate of unruptured aneurysms and the risk ratio for their rupture comparing to stroke patients who do not have aneurysms. A comprehensive search was conducted to identify the studies from the online database from 2000 to September 1st, 2022. Cohort studies were included and assessed by Newcastle-Ottawa Scale (NOS) for quality. The research procedures were subjected to thePreferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Fixed-effects model was used based on the heterogeneity tests. In 10 eligible studies, 7238 ischemic stroke patients were screened, a total of 302 patients with 348 aneurysms were included. 10 studies were eligible for ICH rate analysis, 8 for SAH rate analysis and 7 for risk ratio of stroke patients with unruptured aneurysms. The pooled any ICH rate was 16% (95% CI 11-21%), symptomatic ICH rate was 4% (95% CI 1-7%, I2 = 0.00%, p = 0.90), and 0% (95% CI 0-1%) for aneurysm-related ICH. Subarachnoid hemorrhage was as low as 2% (95% CI 0-5%), while 0% (95% CI 0-2%) directly related to the aneurysm rupture. The risk ratio of ICH in stroke patients with aneurysms was 1.18 (95% CI 0.79-1.77). Additionally, the hemorrhage rate difference was not evident between saccular and fusiform aneurysms due to a lack of details. IVT is unlikely to induce hemorrhage of pre-existing unruptured aneurysms in stroke patients. Further randomized control studies are warranted to validate these conclusions.

Outcome of endovascular thrombectomy in patients with end-stage renal disease undergoing dialysis

BackgroundPatients with end-stage renal disease (ESRD) are often excluded from clinical trials of endovascular thrombectomy (EVT). This study investigated the outcome in these patients.MethodsFrom September 2014 to July 2021, all...

Good outcome associated with blood-brain barrier disruption and lower blood pressure after endovascular therapy

ObjectivesTo evaluate the association between post-endovascular thrombectomy (EVT) blood-brain barrier (BBB) disruption on MRI or CT and average systolic blood pressure (SBP) with favorable 90-day functional outcome. Observational studies have found elevated SBP associated with worse outcomes post-EVT, while recent randomized trials found no difference in targeted BP reduction. There may be a subgroup of patients who benefit from targeted BP reduction post-EVT. MethodsThis is a single-center study of 1) anterior large vessel occlusion stroke patients treated with EVT from 2015 to 2021, 2) achieved mTICI grade 2b or 3. Hyperintense acute reperfusion marker (HARM), hemorrhagic transformation (HT), and midline shift at 3 h post-EVT and 24 h imaging were assessed independently by multiple raters. Binary logistic regression models were used to determine the association of post-EVT SBP with outcomes. BBB disruption was defined as HT or HARM on 3h post-EVT imaging. ResultsOf 103 patients, those with SBP 100-129 versus SBP 130-160 found no significant difference in favorable 90-day outcome (64% vs. 46%, OR 2.11, 95% CI 0.78-5.76, p=0.143). However, among 71 patients with BBB disruption, a significant difference in favorable outcome of 64% in SBP 100-129 vs. 39% in SBP 130-160 group (OR 5.93, 95% CI 1.50-23.45, p=0.011) was found. There was no difference in symptomatic ICH, 90-day mortality, midline shift (≥5 mm), and hemicraniectomy, between BP or BBB groups. ConclusionsBBB disruption on 3h post-EVT imaging and lower SBP was associated with favorable outcome. This imaging finding may guide targeted BP therapy and suggests need for a randomized control trial.

Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis

IntroductionIt is poorly understood if endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) better facilitates clinical outcomes in patients with acute basilar artery occlusion (BAO) ischemic stroke. MethodsA systematic literature review and meta-analysis was completed to investigate the outcomes of EVT with IVT versus direct EVT alone in acute BAO. Data was collected from the literature and pooled with the authors’ institutional experience. The primary outcome measure was 90-day modified Rankin sale (mRS) of 0-2. Secondary measures were successful post-thrombectomy recanalization defined as mTICI ≥2b, 90-day mortality, and rate of symptomatic ICH. ResultsOur institutional experience combined with three multicenter studies resulted in a total of 1,127 patients included in the meta-analysis. 756 patients underwent EVT alone, while 371 were treated with EVT+IVT. Patients receiving EVT+IVT had a higher odds of achieving a 90-day mRS of ≤ 2 compared to EVT alone (OR: 1.50, 95% CI 1.15 to 1.95, P =0.002, I2 =0%). EVT+IVT also had a lower odds of 90-day mortality (OR: 0.57, 95% CI 0.37 to 0.89, P=0.01, I2=24%). There was no difference in sICH between the two groups (OR: 1.0, 95% CI: 0.56 to 1.79, P=0.99, I2=0%). There was also no difference in post-thrombectomy recanalization rates defined as mTICI ≥2b (OR: 1.11, 95% CI 0.70 to 1.75, P = 0.65, I2=37%). ConclusionsOn meta-analysis, EVT with bridging IVT results in superior 90-day functional outcomes and lower 90-day mortality without increase in symptomatic ICH. These findings likely deserve further validation in a randomized controlled setting.

Type of intracranial hemorrhage after endovascular stroke treatment: association with functional outcome

BackgroundIntracranial hemorrhage (ICH) is a frequent complication after endovascular stroke treatment.ObjectiveTo assess the association of the occurrence and type of ICH after endovascular treatment (EVT) with functional outcome.MethodsWe analyzed data...

327 Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Finding the Correct '-ase' and 'Dosage' Using Network Meta-analysis Approach

327 Tenecteplase Versus Alteplase in Acute Ischemic Stroke: Finding the Correct '-ase' and 'Dosage' Using Network Meta-analysis Approach

Feasibility of rescue stenting technique in patients with acute ischemic stroke due to middle cerebral artery occlusion after failed thrombectomy: A single-center retrospective experience.

BackgroundDespite remarkable advancements in intra-arterial mechanical thrombectomy (IAT), recanalization failure rates up to 24% have been reported. Recently, permanent stent placement (rescue stent, RS) during IAT has been suggested as an optional modality for better reperfusion and outcomes in these patients. However, previous studies were limited owing to non-standardized procedure protocols and small sample sizes. Here, we aimed to determine the efficacy and safety of RS in patients with acute ischemic stroke (AIS) with middle cerebral artery (MCA) occlusion.MethodsOf the 243 patients in our IAT database (2015–2021), 183 were identified as having MCA occlusion alone. Among them, we extracted 53 patients in whom the IAT failed to show thrombolysis in cerebral ischemia (TICI) scores of 2A or worse. Intraoperatively, RS was deployed in 22 patients (RS group), whereas 31 patients (no-stent group) received IAT without stenting. The baseline characteristics and radiologic and clinical outcomes were reviewed. Comparisons between the groups and multivariate logistic analyses for recanalization and good functional outcomes (modified Rankin Scale 0–2) were performed.ResultsNo baseline differences were noted (RS vs. no-stent); however, the recanalization outcomes (59.1% vs. 25.8%, p = 0.15) and proportion of good modified Rankin Scale scores (45.5% vs. 19.4%, p = 0.041) were better in the RS group. The parameters of symptomatic ICH (9.7% vs. 9.4%) and mortality (6.5% vs. 5.7%) showed no significant difference. In the multivariate analyses, ‘hypertension’ and ‘RS deployment’ were identified as significantly associated factors with recanalization and good prognosis.ConclusionIn select patients with MCA occlusion AIS after failed IAT, the RS technique can be an optional rescue treatment modality for acquiring better functional outcomes and delayed recanalization.

IV tPA for acute ischemic stroke in the setting of intracranial tumor: A scoping review

ObjectiveA systematic review of published cases of standard-dose IV tPA for acute ischemic stroke (AIS) within 4.5 hours of symptom onset and intracranial tumor was performed. Materials and MethodsPubMed, Embase, and Cochrane were used to identify studies that included patients given standard-dose IV tPA for presumed AIS within 4.5 hours of symptom onset who had an intracranial tumor. The primary outcome measure was rate of ICH. ResultsTwenty-three studies were included, involving 495 patient cases. One case-control study presented data only in the form of an odds ratio (OR), with OR 0.72 (p=0.16) for risk of ICH in 297 benign brain tumors, and OR for ICH of 2.33 (p value <0.001) in 119 malignant brain tumors, compared to controls. The remaining 22 sources included 79 cases; 49 were classified as benign, 16 malignant, and 14 “not otherwise specified.” ICH occurred in 4; one was an asymptomatic parenchymal hematoma (5.1% total ICH, 3.8% symptomatic ICH). ICH only occurred in cases of malignant or metastatic intracranial tumors. ConclusionThere were no reports of ICH in cases of benign intracranial tumor, and the reported rate of ICH with standard-dose IV tPA in the setting of any brain tumor appears similar to the general AIS population. There is heterogeneity and risk of selection bias with the included studies, and findings are not confirmatory. Further research is indicated to assess the rate of ICH with IV tPA for AIS in the setting of brain tumor.

Hospital Cost for Transferred Patients With Large Vessel Occlusions Undergoing Endovascular Thrombectomy

Hospital Cost for Transferred Patients With Large Vessel Occlusions Undergoing Endovascular Thrombectomy

Outcomes of asymptomatic recombinant tissue plasminogen activator associated intracranial hemorrhage.

Intracranial hemorrhage (ICH) is the most devastating complication of recombinant tissue plasminogen activator (rtPA) treatment in acute ischemic stroke patients. Data on rtPA-associated asymptomatic ICH (aICH) are limited. To determine the incidence, risk factors, characteristics, management, and clinical outcome of rtPA-associated aICH. The data were retrieved from the Chiang Mai University Hospital Stroke Registry between 1995 and 2019. Consecutive ischemic stroke patients were included if they were 18 or older and received rtPA. Study outcomes were the incidence and characteristics of aICH, management, 90-day modified Rankin scale (mRS), National Institute of Health Stroke Scale (NIHSS), Barthel index, and all-cause mortality. Of 725 rtPA treated patients, 166 (16.0%, 95% confidence interval [CI] 13.4-18.9) had aICH, 50 (6.9%, 95% CI 5.2-9.0) had symptomatic ICH (sICH). Patients with aICH had more hemorrhagic infarctions (HI) compared to sICH (81.9% vs 2.0%, P-value < 0.001). Fresh Frozen Plasma and cryoprecipitate were the most common blood products used to reverse the anticoagulant effect in sICH. Craniotomy was performed in 1% and 60% of patients who had aICH and sICH. At 90 days, patients who had aICH had poorer clinical outcomes (mRS, NIHSS and Barthel index) as compared to those without ICH. Compared to non-ICH patients, aICH patients were associated with increased risk of 90-day mortality, the hazard ratio (HR), 3.7, 95% CI 1.6-8.9. The rtPA-associated aICH increased the risk of morbidity and mortality outcomes. Further treatment consensus, guideline generation, or clinical trials focusing on the treatment of rtPA-associated aICH may be required.

Dynamic change of neutrophil-to-lymphocyte ratio and symptomatic intracerebral hemorrhage after endovascular recanalization therapy

ObjectivesThe neutrophil-to-lymphocyte ratio (NLR) is a known marker of systemic inflammation. Recent studies demonstrated its applicability as a marker of poor prognosis for stroke patients. In this study, we evaluated the relationship between dynamic changes in the NLR and sICH in patients with successful recanalization following ERT. Materials and methodsThis study included 128 patients with acute ischemic stroke who underwent successful ERT between January 2013 and November 2019. We evaluated the NLR pre-ERT (at admission) and post-ERT (at 24–36 h after ERT). The symptomatic ICH and miserable outcomes at 3 months after ERT were analyzed as outcomes. sICH was defined as type-2 parenchymal hematoma with neurological deterioration (defined as National Institute of Health Stroke Scale score ≥4). Moreover, a modified Rankin Scale score of 5–6 at 3 months was considered a miserable outcome. ResultsAmong the included patients, sICH occurred in 12 (9.4%). The sICH group had significantly higher post-ERT NLR (P < 0.001) and ∆NLR (calculated as the difference between pre-ERT NLR and post-ERT NLR) (P = 0.004). In the multivariate analysis, the post-ERT NLR was independently associated with sICH (odds ratio [OR], 1.166; 95% confidence interval [CI], 1.041–1.306; P = 0.008) and miserable outcome at 3 months (OR, 1.101; 95% CI, 1.002–1.210; P = 0.045). ConclusionsThis study demonstrated that temporal elevation of the NLR is associated with sICH events after successful ERT in patients with acute ischemic stroke. The temporal variation in NLR may help to identify high-risk patients with sICH after ERT.

Endovascular treatment in patients with acute ischemic stroke and cancer: Systematic review and meta-analysis

Introduction: Although stroke occurs frequently in patients with cancer, there is scarce evidence regarding the safety and efficacy of endovascular treatment (EVT) in patients with acute ischemic stroke and concurrent cancer. We performed a systematic review and meta-analysis to summarize the existing literature. Methods: We searched for English written observational studies reporting data on safety and efficacy of EVT in patients with acute ischemic stroke and concurrent cancer. Outcomes of interest were: functional independence (modified Rankin Scale (mRS) ⩽ 2); mortality at 3 months; rate of successful recanalization (modified Treatment In Cerebral Ischemia (mTICI) 2b or 3); occurrence of any hemorrhagic transformation (both symptomatic and asymptomatic). We pooled data with Maentel-Haenszel model to calculate cumulative odds ratios (ORs). Results: We included seven studies with a total of 4465 patients, of whom 262 (6%) with cancer. We observed various definitions of cancer across included studies. Patients with cancer had less likely mRS⩽2 at 3 months (24% vs 42%, OR = 0.44; 95% CI = 0.32–0.60) and increased probability of death (43% vs 19%, OR = 5.02; 95% CI = 2.90–8.69). There was no difference in successful recanalization (70% vs 75%, OR = 0.84; 95% CI = 0.49–1.44); patients with cancer had increased risk of any intracerebral hemorrhage after treatment (49% vs 34%, OR = 1.95; 95% CI = 1.28–2.96), though not for symptomatic ICH (OR 1.04; 95% CI = 0.59–1.85). Conclusion: Patients with acute ischemic stroke and cancer have similar EVT recanalization but higher probability of functional dependence, death, and any hemorrhagic transformation, though not necessarily symptomatic, compared with patients without cancer. Our results may help communication with patients and carers.