Internal Cerebral Vein Asymmetry on Follow-up Brain Computed Tomography after Intravenous Thrombolysis in Acute Anterior Circulation Ischemic Stroke Is Associated with Poor Outcome

Background- Significant numbers of acute ischemic stroke (AIS) patients recover with timely-administered intravenous tissue plasminogen activator (IV-TPA). However, rates and extent of recovery remain variable. Considering scarce and costly resources, early identification of reliable predictors for functional outcomes is important for planning rehabilitation strategies. We hypothesized that venous drainage would be impaired on the side of cerebral hypoperfusion due to acute occlusion of internal carotid or middle cerebral artery. The 2 internal cerebral veins (ICV) drain the deep parts of hemispheres and run backward to form great cerebral vein. Since ICVs are consistently seen on CT angiography (CTA), parallel and run very close to each other, even minor asymmetry in their filling can be easily diagnosed. ICV asymmetry in pre-TPA CTA can change in patients achieving arterial recanalization, rendering it less useful for predicting the long-term outcomes. Thus, we aimed at evaluating whether the presence of ICV asymmetry on follow-up CTA can predict the final outcome. Methods- Data from consecutive AIS patients treated with IV-TPA, in a standardized protocol, from Jan2007 to March2010 were included in a prospective registry at our tertiary center. In this study, we excluded posterior circulation strokes. Significant proportion AIS patients undergo CTA on day 2 after IV-TPA to assess the status of arterial patency. ICV asymmetry was assessed by 2 independent stroke neurologists/ neuroradiologists, blinded to patient data or outcomes. Functional outcomes were assessed by modified Rankin Scale (mRS) at 3-months, dichotomized as good outcome (mRS 0-1) and poor outcome (mRS 2-6). Data were analyzed for the early predictors of function outcome. Results- Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). Hypertension was the commonest vascular risk factor in 144 (76%) while 63 (33%) patients suffered from atrial fibrillation (AF). Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. ICV asymmetry could be assessed only in 103 (45.5%) patients on their follow up CTA films. Admission NIHSS score (OR1.08;95%CI 1.001-1.157,p=0.048) and ICV asymmetry on follow-up CT scan (OR 23.9;95%CI 5.15-63.99,p <0.0001) were associated with poor outcome at 3-months. Conclusion- Presence of the asymmetry of internal cerebral veins on the follow up CT angiography in acute ischemic stroke patients treated with IV-TPA can be used as an early predictor of poor functional outcome.

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Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results.

10.21203/rs.2.482/v1 ◽

2019 ◽

Author(s):

Massimo Gamba ◽

Nicola Gilberti ◽

Enrico Premi ◽

Angelo Costa ◽

Michele Frigerio ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Safety Profile ◽

Infarct Volume ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage

Abstract Background and Purpose endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients is still unclear. The present study aims to test whether IVT plus ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS by LVO. Methods we performed a single center retrospective observational study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. The patients were divided in 2 groups based on the treatment they received: CoT and, if IVT contraindicated, direct ET. We compared functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up infarct volume (EFIV) (for recanalized patients only) as well as safety profile, defined as symptomatic intracerebral hemorrhage (sICH) and 3-month mortality, between groups. Results 145 subjects were included in the study, 70 in direct ET group and 75 in CoT group. Patients who received CoT presented more frequently a functional independence at 3-months follow-up compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P<0.001. mRS score 0-2: 67.1% vs 37.3%; P<0.001), higher first-pass success rate (62.7% vs 38.6%, P<0.05), higher recanalization rate (84.3% vs 65.3%; P=0.009) and, in recanalized subjects, smaller EFIV (16.4ml vs 62.3ml; P=0.003). The safety profile was similar for the 2 groups. In multivariable regression analysis, low baseline NIHSS score (P<0.05), vessel recanalization (P=0.05) and CoT (P=0.03) were indipendent predictors of 3-month favorable outcome. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

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Eosinophil-to-Neutrophil Ratio Predicts Poor Prognosis of Acute Ischemic Stroke Patients Treated With Intravenous Thrombolysis

Frontiers in Neurology ◽

10.3389/fneur.2021.665827 ◽

2021 ◽

Vol 12 ◽

Author(s):

Haoye Cai ◽

Honghao Huang ◽

Chenguang Yang ◽

Junli Ren ◽

Jianing Wang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Inflammatory Marker ◽

Intravenous Thrombolysis ◽

Poor Outcome ◽

Risk Of Mortality ◽

Lower Baseline ◽

To Come ◽

Lost To Follow Up

Background and Purpose: The eosinophil-to-neutrophil ratio (ENR) was recently reported as a novel inflammatory marker in acute ischemic stroke (AIS). However, few studies reported the predictive value of ENR in AIS patients, especially for those with intravenous thrombolysis.Methods: Two hundred sixty-six AIS patients receiving intravenous thrombolysis were retrospectively recruited in this study and followed up for 3 months and 1 year. The Modified Rankin Scale (mRS) and the time of death were recorded. Poor outcome was defined as mRS 3–6. After excluding patients who were lost to follow-up, the remaining 250 patients were included in the 3-month prognosis analysis and the remaining 223 patients were included in the 1-year prognosis analysis.Results: ENR levels in the patients were lower than those in the healthy controls. The optimal cutoff values for the ability of ENR × 102 to predict 3-month poor outcome were 0.74 with 67.8% sensitivity and 77.3% specificity. Patients with ENR × 102 ≥ 0.74 have a lower baseline National Institutes of Health Stroke Scale (NIHSS) score (median: 7 vs. 11, p < 0.001). After multivariate adjustment, patients with ENR × 102 ≥ 0.74 were more likely to come to a better 3-month outcome (OR = 0.163; 95% CI, 0.076–0.348, p < 0.001). At the 1-year follow-up, the patients with ENR × 102 ≥ 0.74 showed a lower risk of mortality (HR = 0.314; 95% CI, 0.135–0.731; p = 0.007).Conclusions: A lower ENR is independently associated with a 3-month poor outcome and a 3-month and 1-year mortality in AIS patients treated with intravenous thrombolysis.

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Repeated Intravenous Thrombolysis in Patients with Recurrent Ischemic Stroke in the Vertebrobasilar Territory

Case Reports in Neurology ◽

10.1159/000518193 ◽

2021 ◽

pp. 510-514

Author(s):

David Černík ◽

Dušan Ospalík ◽

Daniel Šaňák ◽

Filip Cihlář

Keyword(s):

Ischemic Stroke ◽

Time Window ◽

Recurrent Stroke ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation ◽

Poor Outcome ◽

Vertebrobasilar Stroke ◽

Therapeutic Time Window

Acute ischemic vertebrobasilar stroke (AIVBS) is usually associated with poor outcome and prognosis and in case of basilar artery occlusion (BAO) with high mortality. Intravenous thrombolysis (IVT), as a standard recanalization therapy of acute ischemic stroke (IS) within first 4.5 h, can be administrated beyond this therapeutic time window in case of symptomatic BAO. Repeated IVT is generally contraindicated in case of early recurrent IS, despite a risk of poor outcome or death after recurrent IS. The aim was to present 2 cases of repeated IVT for recurrent AIVBS and discuss specific situations where repeated IVT may be considered. Up to now, repeated IVT has been reported only in recurrent stroke in anterior circulation.

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Pathophysiology of acute middle cerebral artery infarct by multimodal computed tomography: A pilot study in Thai patients

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.143196 ◽

2015 ◽

Vol 6 (01) ◽

pp. 059-064 ◽

Cited By ~ 1

Author(s):

Pornpatr A. Dharmasaroja ◽

Arvemas Watcharakorn ◽

Utairat Chaumrattanakul

Keyword(s):

Computed Tomography ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Anterior Circulation ◽

Severe Stroke ◽

Middle Cerebral Artery Infarct ◽

Multimodal Ct

ABSTRACTMultimodal computed tomography, including non-contrast computed tomography (CT), computed tomography perfusion (CTP) and computed tomography angiography (CTA), has been increasingly used. Aims: The purpose of this study was to study pathophysiology of acute middle cerebral artery infarct using multimodal CT and to evaluate the safety and feasibility of this method in our center. Materials and Methods: Patients who had moderate to severe stroke (NIHSS score > 10), suspected of anterior circulation infarct and presented within 4 hours after stroke onset were prospectively included. Multimodal CTs, using low-osmolar contrast agents, were performed in all patients. Results: Twenty-two patients were included. Mean NIHSS was 16. All patients received intravenous thrombolysis. Favorable outcome was found in nine patients (41%). CTP was unable to identify ischemic lesions in three patients with small subcortical infarct. Most patients (82%) with large middle cerebral artery infarct still had some salvageable brain (penumbra) which partly recovered in a follow-up imaging. Eleven patients (50%) had major artery occlusion. Two patients had creatinine rising within 72 hours. Conclusions: Multimodal CT does provide information about status of major artery and the volume of salvageable/infarct brain tissue and is safely and easily applicable in our center.

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Abstract TP51: Decreased Internal Cerebral Vein Filling - A New Radiographic Sign of Acute Ischemic Stroke

Stroke ◽

10.1161/str.44.suppl_1.atp51 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Evgenia Klourfeld ◽

Apurva Patel ◽

Karim Mohamed ◽

Albert Y Jin

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Vein ◽

Venous Outflow ◽

Anterior Circulation ◽

Ischemic Lesion ◽

Internal Cerebral Vein ◽

Radiology Reports ◽

Radiographic Sign ◽

Arterial Lesions

INTRODUCTION: CT signs of acute ischemic stroke focus on parenchymal and arterial lesions. Little is known about venous changes. The aim of this study was to determine the value of decreased deep venous outflow as a predictor of acute ischemic stroke. METHODS: Multimodal CT findings of 182 patients presenting for acute stroke evaluation within 4.5 hours of symptom onset were retrospectively reviewed for evidence of deep venous outflow changes. Interhemispheric symmetry of internal cerebral vein (ICV) opacification on CT angiogram was assessed by 3 raters. Discharge diagnosis, neurological assessment details, and radiographic data were extracted from electronic hospital records, and radiology reports. RESULTS: Of 182 patients included in the study, 46 showed diminished ICV opacification (dICV) on the side of the expected ischemic lesion. Anterior circulation stroke was diagnosed in 87% of dICV cases, but in only 31% of subjects with ICV symmetry (sICV), suggesting a strong correlation of dICV with ipsilateral anterior circulation infarction (P<0.0001). Patients with dICV presented with greater neurologic impairment (NIHSS 14±1.0 vs. 6±0.8, P<0.0001), proximal arterial lesions, and lower ASPECTS (8±0.3 vs. 9±0.2, P=0.0022). In 48 patients who had a CT perfusion scan at the time of initial evaluation (dICV N=20 vs. sICV N=28), dICV was associated with larger perfusion defects: mean transit time ASPECTS 3±0.7 vs. 8±0.3 (P<0.0001), cerebral blood flow ASPECTS 3±0.8 vs. 8±0.5 (P<0.0001), and cerebral blood volume ASPECTS 7±0.7 vs. 9±0.2 (P=0.006). The sensitivity, specificity, and positive predictive value of dICV for anterior circulation stroke were 48%, 94%, and 87% respectively. Inter-rater agreement was very good with a free marginal kappa of 0.75. CONCLUSION: Decreased ICV may be a useful radiographic sign of ipsilateral acute ischemic stroke and a marker of a large cerebral territory at risk of infarction. Prospective studies are needed to help validate this finding, and its role in predicting stroke outcomes.

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Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results.

10.21203/rs.2.482/v2 ◽

2019 ◽

Author(s):

Massimo Gamba ◽

Nicola Gilberti ◽

Enrico Premi ◽

Angelo Costa ◽

Michele Frigerio ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Safety Profile ◽

Infarct Volume ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage

Abstract Background and Purpose endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients is still unclear. The present study aims to test whether IVT plus ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS by LVO. Methods we performed a single center retrospective observational study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. The patients were divided in 2 groups based on the treatment they received: CoT and, if IVT contraindicated, direct ET. We compared functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up infarct volume (EFIV) (for recanalized patients only) as well as safety profile, defined as symptomatic intracerebral hemorrhage (sICH) and 3-month mortality, between groups. Results 145 subjects were included in the study, 70 in direct ET group and 75 in CoT group. Patients who received CoT presented more frequently a functional independence at 3-months follow-up compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P<0.001. mRS score 0-2: 67.1% vs 37.3%; P<0.001), higher first-pass success rate (62.7% vs 38.6%, P<0.05), higher recanalization rate (84.3% vs 65.3%; P=0.009) and, in recanalized subjects, smaller EFIV (16.4ml vs 62.3ml; P=0.003). The safety profile was similar for the 2 groups. In multivariable regression analysis, low baseline NIHSS score (P<0.05), vessel recanalization (P=0.05) and CoT (P=0.03) were indipendent predictors of 3-month favorable outcome. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

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Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x20982395 ◽

2021 ◽

pp. 0271678X2098239

Author(s):

Adam E Goldman-Yassen ◽

Matus Straka ◽

Michael Uhouse ◽

Seena Dehkharghani

Keyword(s):

Ischemic Stroke ◽

Selection Criteria ◽

Arterial Input Function ◽

Anatomic Variation ◽

Input Function ◽

Posterior Circulation ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Perfusion Time

The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.

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Abstract WP78: Intracranial Calcification is Predictive for Hemorrhage Transformation and Prognosis After Intravenous Thrombolysis

Stroke ◽

10.1161/str.51.suppl_1.wp78 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Yao Yu ◽

Fu-Liang Zhang ◽

Yin-Meng Qu ◽

Hong-Wei Zhou ◽

Zhenni Guo ◽

...

Keyword(s):

Ischemic Stroke ◽

Poor Prognosis ◽

Intravenous Thrombolysis ◽

Major Complication ◽

Third Party ◽

Intracranial Calcification ◽

Stroke Patients ◽

Anterior Circulation ◽

Cerebrovascular Function ◽

Lesion Side

Introduction: Hemorrhage transformation is the major complication of intravenous thrombolysis, which can deteriorate the prognosis of ischemic stroke patients. Calcification is widely used as an imaging indicator of atherosclerotic burden and cerebrovascular function. The relationship between intracranial calcification and hemorrhage transformation has not been fully explained. Here, we aimed to identify and quantify calcification in the main cerebral vessels to investigate the correlations between quantitative calcification parameters, hemorrhage transformation, and prognosis. Methods: Acute noncardiogenic ischemic stroke patients with anterior circulation who received intravenous thrombolysis therapy in the First Hospital of Jilin University from July 2015 to June 2017 were retrospectively consecutively included. All the patients included underwent a baseline CT before intravenous thrombolysis and a follow-up CT at 24 hours. A third-party software, ITK-SNAP, was used for segmentation and measurement of the calcification volume. A vascular non-bone component with a CT value >130 HU was judged to be calcified. The criterion for poor prognosis was an mRS score > 2 at 3 months. Results: A total of 146 patients were included, among which 128 patients were identified to have calcification. Twenty-one patients developed hemorrhage transformation. The risk of hemorrhage transformation in the extreme group of calcification volume on the lesion side was 10.018 times that of the none to mild groups (OR=10.018, 95% CI: 1.030-97.396). Sixty-one patients had poor prognosis. The risk of poor prognosis increased by 54.7% for each additional calcified vessel (OR=1.547, 95% CI: 1.038-2.305). Conclusions: High calcification volume burden on the lesion side is associated with hemorrhage transformation after intravenous thrombolysis. The higher the number of calcified vessels, the greater is the risk of poor prognosis.

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Heterogeneity between proximal and distal aspects of occlusive thrombi on pretreatment imaging in acute ischemic stroke

The Neuroradiology Journal ◽

10.1177/19714009211049713 ◽

2021 ◽

pp. 197140092110497

Author(s):

Tetsuya Hashimoto ◽

Takenobu Kunieda ◽

Tristan Honda ◽

Fabien Scalzo ◽

Latisha K Sharma ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Region Of Interest ◽

Hounsfield Unit ◽

Distal Segment ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

The Difference

Background The potential heterogeneity in occlusive thrombi caused by in situ propagation by secondary thrombosis after embolic occlusion could obscure the characteristics of original thrombi, preventing the clarification of a specific thrombus signature for the etiology of ischemic stroke. We aimed to investigate the heterogeneity of occlusive thrombi by pretreatment imaging. Methods Among consecutive stroke patients with acute embolic anterior circulation large vessel occlusion treated with thrombectomy, we retrospectively reviewed 104 patients with visible occlusive thrombi on pretreatment non-contrast computed tomography admitted from January 2015 to December 2018. A region of interest was set on the whole thrombus on non-contrast computed tomography under the guidance of computed tomography angiography. The region of interest was divided equally into the proximal and distal segments and the difference in Hounsfield unit densities between the two segments was calculated. Results Hounsfield unit density in the proximal segment was higher than that in the distal segment (mean difference 4.45; p < 0.001), regardless of stroke subtypes. On multivariate analysis, thrombus length was positively correlated (β = 0.25; p < 0.001) and time from last-known-well to imaging was inversely correlated (β = −0.0041; p = 0.002) with the difference in Hounsfield unit densities between the proximal and distal segments. Conclusions The difference in density between the proximal and distal segments increased as thrombi became longer and decreased as thrombi became older after embolic occlusion. This time/length-dependent thrombus heterogeneity between the two segments is suggestive of secondary thrombosis initially occurring on the proximal side of the occlusion.

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