General Anesthesia Versus Conscious Sedation for Mechanical Thrombectomy in Acute Anterior Circulation Ischemic Stroke

BACKGROUND Retrospective studies suggested that general anesthesia (GA) for mechanical thrombectomy has worse outcomes compared with conscious sedation (CS). However, randomized single‐center trials suggested noninferiority of GA to CS. We investigated the impact of anesthesia techniques on thrombectomy, and hypothesized that the routine use of GA with a defined protocol would not adversely affect thrombectomy delivery or outcomes. METHODS A total of 451 consecutive patients receiving mechanical thrombectomy for anterior circulation ischemic stroke from 2016 to 2019 were identified from the local registry. Patients were divided into cohort A when both GA and CS were used, and cohort B (from October 2017) when GA became the default method. Favorable functional outcome was defined as modified Rankin scale of 0 to 2 at 3 months. Intraprocedural blood pressures were audited annually. RESULTS In cohort A, compared with patients receiving CS, patients with GA had prolonged median arrival to arterial puncture time (26 versus 18 minutes; P <0.001) and comparable favorable functional outcome at 3 months (37.7% versus 45.1%; P =0.355). In cohort B, the median arrival to arterial puncture was reduced to 10 minutes, with comparable favorable functional outcome of 46.7%, and reduced mortality compared with cohort A (14.2% versus 22.7%; P =0.024). Yearly audits demonstrated good adherence to the protocol. Binary logistic regression analysis showed only old age (odds ratio [OR], 1.04; 95% CI, 1.02–1.07 [ P =0.003]), high National Institute of Health Stroke Scale at presentation (OR, 1.17; 95% CI, 1.08–1.26 [ P <0.001]), and poor collateral status (OR, 0.29; 95% CI, 0.12–0.72 [ P =0.008]) were independent factors predicting for poor prognosis, not GA (OR, 0.71; 95% CI, 0.32–1.60 [ P =0.408]). CONCLUSIONS Patients treated under GA for mechanical thrombectomy achieved comparable functional outcome at 3 months compared with those under CS. Through practice and a defined protocol, GA for mechanical thrombectomy can achieve sustainable good functional outcomes. Large clinical trials are needed to confirm these findings.

Influence of renal impairment on clinical outcomes after endovascular recanalization in vertebrobasilar artery occlusions

BackgroundRenal impairment (RI) is associated with worse outcomes in the treatment of intravenous thrombolysis and emergent endovascular treatment (EVT) in anterior circulation stroke. The objective of this study was to investigate the association of RI with short-term and long-term outcomes in patients with vertebrobasilar artery occlusions (VBAO) who received EVT.MethodsConsecutive patients with VBAO receiving EVT involving 21 stroke centers were retrospectively included. Multivariate regression analyses were used to evaluate the association of RI with mortality and symptomatic intracranial hemorrhage (sICH) during the hospital stay, and also mortality, favorable functional outcome (modified Rankin Scale (mRS) score of 0–3), and functional improvement (shift in mRS score) at 3 months and 1 year follow-up. The association between RI and the risk of recurrent stroke was evaluated with multivariate competing-risk regression analyses.ResultsAfter adjustment for potential confounders, RI was independently associated with sICH (OR 3.30, 95% CI 1.55 to 7.18), as well as mortality (OR 2.54, 95% CI 1.47 to 4.38; OR 3.07, 95% CI 1.72 to 8.08), favorable functional outcome (OR 0.33, 95% CI 0.17 to 0.66; OR 0.25, 95% CI 0.12 to 0.51), and functional improvement (OR 0.45, 95% CI 0.28 to 0.74; OR 0.35, 95% CI 0.21 to 0.60) at 3 months and 1 year follow-up, respectively, but RI was not associated with in-hospital mortality. Additionally, there was no significant association between RI and recurrent stroke within 1 year.ConclusionsOur findings suggest that RI is associated with a higher risk of sICH in hospital and a decrease in survival, favorable functional outcome, and functional improvement at 90 days and 1 year follow-up.Trial registration numberURL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.

Intravenous Thrombolysis by Telestroke in the 3- to 4.5-h Time Window

Background: While intravenous thrombolysis (IVT) in ischemic stroke can be safely applied in telestroke networks within 3 h from symptom onset, there is a lack of evidence for safety in the expanded 3- to 4. 5-h time window. We assessed the safety and short-term efficacy of IVT in acute ischemic stroke (AIS) in the expanded time window delivered through a hub-and-spoke telestroke network.Methods: Observational study of patients with AIS who received IVT at the Stroke Eastern Saxony Telemedical Network between 01/2014 and 12/2015. We compared safety data including symptomatic intracerebral hemorrhage (sICH; according to European Cooperative Acute Stroke Study II definition) and any intracerebral hemorrhage (ICH) between patients admitted to telestroke spoke sites and patients directly admitted to a tertiary stroke center representing the hub of the network. We also assessed short-term efficacy data including favorable functional outcome (i.e., modified Rankin Scale ≤ 2) and National Institutes of Health Stroke Scale (NIHSS) at discharge, hospital discharge disposition, and in-hospital mortality.Results: In total, 152 patients with AIS were treated with IVT in the expanded time window [spoke sites, n = 104 (26.9%); hub site, n = 48 (25.9%)]. Patients treated at spoke sites had less frequently a large vessel occlusion [8/104 (7.7) vs. 20/48 (41.7%); p &lt; 0.0001], a determined stroke etiology (p &lt; 0.0001) and had slightly shorter onset-to-treatment times [210 (45) vs. 228 (58) min; p = 0.02] than patients who presented to the hub site. Both cohorts did not display any further differences in demographics, vascular risk factors, median baseline NIHSS scores, or median baseline Alberta stroke program early CT score (p &gt; 0.05). There was no difference in the frequency of sICH (4.9 vs. 6.3%; p = 0.71) or any ICH (8.7 vs. 16.7%; p = 0.15). Neither there was a difference regarding favorable functional outcome (44.1 vs. 39.6%; p = 0.6) nor median NIHSS [3 (5.5) vs. 2.5 (5.75); p = 0.92] at discharge, hospital discharge disposition (p = 0.28), or in-hospital mortality (9.6 vs. 8.3%; p = 1.0). Multivariable modeling did not reveal an association between telestroke and sICH or favorable functional outcome (p &gt; 0.05).Conclusions: Delivery of IVT in the expanded 3- to 4.5-h time window through a telestroke network appears to be safe with equivalent short-term functional outcomes for spoke-and-hub center admissions.

Optimal Tissue Reperfusion Estimation by Computed Tomography Perfusion Post-Thrombectomy in Acute Ischemic Stroke

Background and Purpose: Modified Thrombolysis in Cerebral Infarction score (mTICI) ≥2b is defined as successful reperfusion. However, mTICI has rarely been correlated with dynamic perfusion imaging postendovascular therapy for acute stroke. We aimed to study the proportion of tissue optimal reperfusion (TOR) postendovascular therapy across different grades of mTICI. Methods: We conducted a single-center retrospective analysis of patients with acute ischemic strokes who had endovascular therapy between 2018 and 2019. Computer tomography perfusion or magnetic resonance perfusion was performed before and after endovascular therapy. Tmax+6 volume reduction of >90% was defined as TOR. Comparisons of proportions of TOR in different grades of mTICI were performed. In the present study, the requirement for informed consents was waived. Results: Eighty-two patients were included. The difference in the proportion of TOR for TICI categories was statistically significant (mTICI score 0, 0%, mTICI score 2A, 0%, mTICI score 2b, 50.0%, mTICI score 2c, 80.0%, mTICI score 3, 81.3%, χ 2 =14.035, P =0.003). Multivariable logistic regression showed that lower age (odds ratio, 0.932, P =0.017), onset-to-tissue plasminogen activator time (odds ratio, 0.980, P =0.005) and TOR (odds ratio, 8.764, P =0.031) were associated with favorable functional outcome. Conclusions: The proportion of TOR achieved by mTICI score of 2b was significantly lower than mTICI score of 2c and mTICI score of 3. TOR was associated with favorable functional outcome, and the degree of reperfusion was more strongly correlated with outcomes than the mTICI scores.

Efficacy and Safety of Adherence to dl-3-n-Butylphthalide Treatment in Patients With Non-disabling Minor Stroke and TIA—Analysis From a Nationwide, Multicenter Registry

Background: Dl-3-n-Butylphthalide (NBP) has the potential to improve clinical outcomes in acute ischemic stroke patients by improving collateral circulation. We aimed to evaluate the efficacy and safety of NBP in patients with non-disabling minor ischemic stroke and transient ischemic attack (TIA).Methods: The BRIDGE (the observation study on clinical effectiveness of NBP on patients with non-disabling ischemic cerebrovascular disease) is a prospective registry to monitor the efficacy and safety of NBP therapy in acute non-disabling ischemic stroke or high-risk TIA. Non-disabling minor ischemic stroke patients within 48 h were enrolled across 51 stroke centers in China. We divided patients into NBP compliance or non-compliance groups according to their adherence to NBP. The primary outcome was the favorable functional outcome at 90 days, defined as a modified Rankin scale (mRS) &lt;2.Results: Between 10th October 2016 and 25th June 2019, 3,118 patients were included in this analysis. In multivariable analysis, after adjusting for common risk factors and demographic factors, NBP-compliance group has a higher proportion of favorable functional outcome (92.1 vs. 87.4%, adjusted odds ratio 2.00, 95% confidence interval, 1.50–2.65), and a higher stroke recurrence rate (2.40 vs. 0.31%, adjusted odds ratio 8.86, 95% confidence interval, 3.37–23.30) than the NBP-non-compliance group. There was no significant difference in death and intracranial hemorrhage rate between the two groups. In subgroup analysis, patients with National Institutes of Health Stroke Scale (NIHSS) scores from 3 to 5 who complied to NBP therapy had a higher rate of favorable functional outcomes than the NBP-non-compliance group. [89.8 vs. 76.8%, adjusted odds ratio 2.54 (1.64–3.93), adjusted interaction P = 0.001].Conclusion: In non-disabling minor ischemic stroke or TIA patients, compliance with NBP therapy led to better 90-day functional outcomes despite a higher risk of recurrence, and this effect seems to be stronger in patients with NIHSS scores of 3–5. Further large randomized, double-blind controlled studies to analyse the association between NBP and functional outcome is warranted in the coming future.

Posttreatment Ischemic Lesion Evolution Is Associated With Reduced Favorable Functional Outcome in Patients With Stroke

Background and Purpose: Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association. Methods: We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associated P <0.10) in univariate analysis with favorable functional outcome, defined as modified Rankin Scale score of ≤2. Interaction analysis was performed to evaluate the influence of successful recanalization, defined as modified Arterial Occlusion Lesion score of 3 points, on this association. Results: Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10–45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66–0.86; per 10 mL of lesion evolution; P <0.01) and adjusted odds ratio: 0.85 (95% CI, 0.72–0.97; per 10 mL of lesion evolution; P =0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77–1.36]; P =0.94). Conclusions: In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.

Beyond Functional Impairment: Redefining Favorable Outcome in Patients with Subarachnoid Hemorrhage

<b><i>Background:</i></b> For outcome assessment in patients surviving subarachnoid hemorrhage (SAH), the modified Rankin scale (mRS) represents the mostly established outcome tool, whereas other dimensions of outcome such as mood disorders and impairments in social life remain unattended so far. <b><i>Objective:</i></b> The aim of our study was to correlate 12-month functional and subjective health outcomes in SAH survivors. <b><i>Methods:</i></b> All SAH patients treated over a 5-year period received outcome assessment at 12 months, including functional scores (mRS and Barthel Index [BI]), subjective health measurement (EQ-5D), and whether they returned to work. Analyses – including utility-weighted mRS – were conducted to detect associations and correlations among different outcome measures, especially in patients achieving good functional outcome (i.e., mRS 0-2) at 12 months. <b><i>Results:</i></b> Of 351 SAH survivors, 287 (81.2%) achieved favorable functional outcome at 12 months. Contrary to the BI, the EQ-5D visual analog scale (VAS) showed a strong association with different mRS grades, accentuated in patients with favorable functional outcome. Despite favorable functional outcome, patients reported a high rate of impairments in activities (24.0%), pain (33.4%), and anxiety/depression (42.5%). Further, multivariable analysis revealed (i) impairments in activities (odds ratio [OR] [95% confidence interval {CI}]: 0.872 [0.817–0.930]), (ii) presence of depression or anxiety (OR [95% CI]: 0.836 [0.760–0.920]), and (iii) return to work (OR [95% CI]: 1.102 [0.1.013–1.198]) to be independently associated with self-reported subjective health. <b><i>Conclusion:</i></b> Established stroke scores mainly focusing on functional outcomes do poorly reflect the high rate of subjective impairments reported in SAH survivors, specifically in those achieving good functional outcome. Further studies are needed to investigate whether psychoeducational approaches aiming at improving coping mechanisms and perceived self-efficacy may result in higher subjective health in these patients.

Comparison of Risk Factors, Safety, and Efficacy Outcomes of Mechanical Thrombectomy in Posterior vs. Anterior Circulation Large Vessel Occlusion

Background and Purpose: It is believed that stroke occurring due to posterior circulation large vessel occlusion (PCLVO) and that occurring due to anterior circulation large vessel occlusion (ACLVO) differ in terms of their pathophysiology and the outcome of their acute management in relation to endovascular mechanical thrombectomy (MT). Limited sample size and few randomized controlled trials (RCTs) with respect to PCLVO make the safety and efficacy of MT, which has been confirmed in ACLVO, difficult to assess in the posterior circulation. We therefore conducted a meta-analysis to study to which extent MT in PCLVO differs from ACLVO.Materials and Methods: We searched the databases PubMed, Cochrane, and EMBASE for studies published between 2010 and January 2021, with information on risk factors, safety, and efficacy outcomes of MT in PCLVO vs. ACLVO and conducted a systematic review and meta-analysis; we compared baseline characteristics, reperfusion treatment profiles [including rates of intravenous thrombolysis (IVT) and onset-to-IVT and onset-to-groin puncture times], recanalization success [Thrombolysis In Cerebral Infarction scale (TICI) 2b/3], symptomatic intracranial hemorrhage (sICH), and favorable functional outcome [modified Rankin Score (mRS) 0–2] and mortality at 90 days.Results: Sixteen studies with MT PCLVO (1,172 patients) and ACLVO (7,726 patients) were obtained from the search. The pooled estimates showed higher baseline National Institutes of Health Stroke Scale (NIHSS) score (SMD 0.32, 95% CI 0.15–0.48) in the PCLVO group. PCLVO patients received less often IVT (OR 0.65, 95% CI 0.53–0.79). Onset-to-IVT time (SMD 0.86, 95% CI 0.45–1.26) and onset-to-groin puncture time (SMD 0.59, 95% CI 0.33–0.85) were longer in the PCLVO group. The likelihood of obtaining successful recanalization and favorable functional outcome at 90 days was comparable between the two groups. PCLVO was, however, associated with less sICH (OR 0.56, 95% CI 0.37–0.85) but higher mortality (OR 1.92, 95% CI 1.46–2.53).Conclusions: This meta-analysis indicates that MT in PCLVO may be comparably efficient in obtaining successful recanalization and 90 day favorable functional outcome just as in ACLVO. Less sICH in MT-treated PCLVO patients might be the result of the lower IVT rate in this group. Higher baseline NIHSS and longer onset-to-IVT and onset-to-groin puncture times may have contributed to a higher 90 day mortality in PCLVO patients.

Abstract P31: Intravenous Thrombolysis And Short-term Functional Outcome In Minor Stroke: Observational Study.

Background: Identification of predictive factors for favorable functional outcome after acute ischemic stroke is crucial. 1 Minor stroke (MS) is the most common exclusion criteria for intravenous thrombolysis and up to 30% of patients with MS will have a poor functional outcome at 3 months. 2 Objective: We reported the frequency of intravenous thrombolysis in the setting of minor stroke in the population of study and tried to identify clinical factors associated with favorable functional outcomes among these patients. Methods: Fifty-one consecutive patients with acute MS were selected (National Institute of Health Stroke Scale of 5 or less). Functional outcome was assessed using the modified Rankin scale (mRS) at 3 months after index event. Descriptive analysis through frequency and central tendency measures were applied and exact Fisher’s test was used for analysis of categorical variables and logistic regression analysis to determine the impact of independent factors related to functional outcome. Results: 60.8% of patients were males. Hypertension (43.1%) was the most frequent risk factor identified among these patients follow by diabetes (37.5%) and smoking (31.4%). 46.5% of patients presented in the <4.5 hours window for IV thrombolysis of these 4.7% presented within the first hour of symptom onset and only 11.8% were treated with rtPA. None of these patients had intracerebral hemorrhage (ICH). Small vessel disease was the most common cause of MS (37.2%) and no cause was identified in 13.7% of patients after evaluation. Favorable outcome (mRS 0 - 2) was observed in 88.2% of patients and one patient died after recurrence of stroke two weeks after MS. Male sex and time from symptom onset to the emergency department > 24 hours were associated with poor functional outcome (mRS 3 - 6) ( p 0.029 and p 0.014 respectively) without reaching statistical significance in the multivariate analysis. Conclusions: Most patients with MS had a favorable functional outcome (mRS 0 - 2) notwithstanding the low rate of IV thrombolysis compared with other study populations without increasing the risk of ICH in this group of patients. 3 A tendency towards poor functional outcome for male sex and time from symptom onset to the emergency department > 24 hours was observed

Female Stroke

Background and Purpose: Men and women are differently affected by acute ischemic stroke (AIS) in many aspects. Prior studies on sex disparities were limited by moderate sample sizes, varying years of data acquisition, and inconsistent inclusions of covariates leading to controversial findings. We aimed to analyze sex differences in AIS severity, treatments, and early outcome and to systematically evaluate the effect of important covariates in a large German stroke registry. Methods: Analyses were based on the Stroke Registry of Northwestern Germany from 2000 to 2018. We focused on admission-stroke severity and disability, acute recanalization treatment, and early stroke outcomes. Potential sex divergences were investigated via odds ratio (OR) using logistic regression models. Covariates were introduced in 3 steps: (1) base models (age and admission year), (2) partially adjusted models (additionally corrected for acute stroke severity and recanalization treatment), (3) fully adjusted models (additionally adjusted for onset-to-admission time interval, prestroke functional status, comorbidities, and stroke cause). Models were separately fitted for the periods 2000 to 2009 and 2010 to 2018. Results: Data from 761 106 patients with AIS were included. In fully adjusted models, there were no sex differences with respect to treatment with intravenous thrombolysis (2000–2009: OR, 0.99 [95% CI, 0.94–1.03]; 2010–2018: OR, 1.0 [0.98–1.02]), but women were more likely to receive intraarterial therapy (2010–2018: OR, 1.12 [1.08–1.15]). Despite higher disability on admission (2000–2009: OR, 1.10 [1.07–1.13]; 2010–2018: OR, 1.09 [1.07–1.10]), female patients were more likely to be discharged with a favorable functional outcome (2003–2009: OR, 1.05 [1.02–1.09]; 2010–2018: OR, 1.05 [1.04–1.07]) and experienced lower in-hospital mortality (2000–2009: OR, 0.92 [0.86–0.97]; 2010–2018: OR, 0.91 [0.88–0.93]). Conclusions: Female patients with AIS have a higher chance of receiving intraarterial treatment that cannot be explained by clinical characteristics, such as age, premorbid disability, stroke severity, or cause. Women have a more favorable in-hospital recovery than men because their higher disability upon admission was followed by a lower in-hospital mortality and a higher likelihood of favorable functional outcome at discharge after adjustment for covariates.