Baseline Neutrophil Counts and Neutrophil Ratio May Predict a Poor Clinical Outcome in Minor Stroke Patients with intravenous Thrombolysis

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis

The Neuroradiology Journal ◽

10.1177/19714009211009112 ◽

2021 ◽

pp. 197140092110091

Author(s):

Hanna Styczen ◽

Matthias Gawlitza ◽

Nuran Abdullayev ◽

Alex Brehm ◽

Carmen Serna-Candel ◽

...

Keyword(s):

Clinical Outcome ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Intracranial Haemorrhage ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

Background Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience. Methods A retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010–September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded. Results In total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up. Conclusion Mechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.

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Elevated urea level is associated with poor clinical outcome and increased mortality post intravenous tissue plasminogen activator in stroke patients

Journal of the Neurological Sciences ◽

10.1016/j.jns.2013.06.030 ◽

2013 ◽

Vol 332 (1-2) ◽

pp. 110-115 ◽

Cited By ~ 10

Author(s):

Yan Zhang ◽

Leonid Churilov ◽

Atte Meretoja ◽

Sarah Teo ◽

Stephen M Davis ◽

...

Keyword(s):

Clinical Outcome ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Stroke Patients ◽

Poor Clinical Outcome ◽

Urea Level ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen

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Abstract TP66: Single Slice Maximal Lesion Diameter Predicts Malignant Pattern of Diffusion Lesions in Acute Ischemic Stroke

Stroke ◽

10.1161/str.47.suppl_1.tp66 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Anke Wouters ◽

Patrick Dupont ◽

Anna Kufner ◽

Robin Lemmens ◽

Vincent Thijs

Keyword(s):

Clinical Outcome ◽

Intravenous Thrombolysis ◽

Volumetric Analysis ◽

Maximum Diameter ◽

Lesion Volume ◽

Imaging Data ◽

Poor Clinical Outcome ◽

Lesion Diameter ◽

Single Slice ◽

Lesion Extension

Introduction: Recent endovascular trials excluded patients with large ischemic cores on diffusion-weighted imaging (DWI) or perfusion CT using automated volumetric analysis. Hypothesis: We investigated whether the largest diameter of the DWI lesion measured on a single slice could accurately predict large ischemic cores, as defined by automated volumetric analysis; such findings could result in a simple tool for predicting clinical outcome. Methods: Magnetic resonance imaging data from the multicenter AXIS 2-trial were used. Patients were included within 9h of symptom onset and received intravenous thrombolysis if eligible. The maximum diameter of the diffusion lesion was measured on the slice with the largest lesion extension. Maximum diameters on a single slice were compared with the volumes of > 50 ml, >70ml and >100ml determined by standard volumetric analysis. We also assessed whether and for which threshold, largest lesion diameter was a predictor of poor clinical outcome defined as modified ranking scale (mRS) 5 or 6. Results: A total of 304 patients were included of which 50 (16%) presented with a carotid occlusion. 96 (32%) patients had a DWI-volume of more than 50 ml, 63 (21%) more than 70ml and 46 (15%) more than 100ml. A diameter of respectively 5.5, 6.5 and 7 cm on a single slice with the largest lesion extension was the best predictor of a DWI lesion volume of more than 50 (sensitivity (sens) 97%, specificity (spec) 80%), 70 (sens 95%, spec 83%) and 100ml (sens 100%, spec 85%). The maximum diameter was a reasonable predictor of poor clinical outcome with an AUC of 0.76 (95%CI: 0.68-0.83). The optimal cut off point was found to be 5.5 cm (sens 71%, spec 67%). Conclusion: Measuring the maximum lesion diameter on a single slice on DWI identifies patients with large ischemic cores with a high sensitivity and specificity. This finding can be useful in clinical practice and for future clinical trials where rapid and uniform decision making to exclude patients with a malignant profile from endovascular therapy is essential.

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Collateral Circulation Predicts the Size of the Infarct Core and the Proportion of Salvageable Penumbra in Hyperacute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Cerebrovascular Diseases ◽

10.1159/000439064 ◽

2015 ◽

Vol 40 (3-4) ◽

pp. 182-190 ◽

Cited By ~ 18

Author(s):

Harri Rusanen ◽

Jukka T. Saarinen ◽

Niko Sillanpää

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Collateral Circulation ◽

Cerebral Blood Volume ◽

Treatment Time ◽

Ct Perfusion ◽

Mean Transit Time ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

The Impact

Background: We studied the impact of collateral circulation on CT perfusion (CTP) parametric maps and the amount of salvaged brain tissue, the imaging and clinical outcome at 24 h and at 3 months in a retrospective acute (<3 h) stroke cohort (105 patients) with anterior circulation thrombus treated with intravenous thrombolysis. Methods: Baseline clinical and imaging information were collected and groups with different collateral scores (CS) were compared. Binary logistic regression analyses using good CS (CS ≥2) as the dependent variable were calculated. Results: CTP Alberta Stroke Program Early CT Score (ASPECTS) was successfully assessed in 58 cases. Thirty patients displayed good CS. Poor CS were associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (15 vs. 7, p = 0.005) and at 24 h (10 vs. 3, p = 0.003) after intravenous thrombolysis. Good CS were associated with a longer mean onset-to-treatment time (141 vs. 121 min, p = 0.009) and time to CTP (102 vs. 87 min, p = 0.047), better cerebral blood volume (CBV) ASPECTS (9 vs. 6, p < 0.001), better mean transit time (MTT) ASPECTS (6 vs. 3, p < 0.001), better noncontrast CT (NCCT) ASPECTS (10 vs. 8, p < 0.001) at arrival and with favorable clinical outcome at 3 months (modified Rankin Scale ≤2, p = 0.002). The fraction of penumbra that was salvageable at arrival and salvaged at 24 h was higher with better CS (p < 0.001 and p = 0.035, respectively). In multivariate analysis, time from the onset of symptoms to imaging (p = 0.037, OR 1.04 per minute, 95% CI 1.00-1.08) and CBV ASPECTS (p = 0.001, OR 2.11 per ASPECTS point, 95% CI 1.33-3.34) predicted good CS. In similar multivariable models, MTT ASPECTS (p = 0.04, OR 1.46 per ASPECTS point, 95% CI 1.02-2.10) and NCCT ASPECTS predicted good CS (p = 0.003, OR 4.38 per CT ASPECTS point, 95% CI 1.66-11.55) along with longer time from the onset of symptoms to imaging (p = 0.045, OR 1.03 per minute, 95% CI 1.00-1.06 and p = 0.02, OR 1.05 per minute, 95% CI 1.00-1.09, respectively). CBV ASPECTS had a larger area under the receiver operating characteristic curve for good CS (0.837) than NCCT ASPECTS (0.802) or MTT ASPECTS (0.752) at arrival. Conclusions: Favorable CBV ASPECTS, NCCT ASPECTS and MTT ASPECTS are associated with good CS along with more salvageable tissue and longer time from the onset of symptoms to imaging in ischemic stroke patients treated with intravenous thrombolysis.

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Abstract TP26: The Outcome of Patients With Tandem Occlusion Remains Poor Despite Mechanical Thrombectomy

Stroke ◽

10.1161/str.47.suppl_1.tp26 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Robert Fahed ◽

Hocine Redjem ◽

Raphaël Blanc ◽

Julien Labreuche ◽

Stanislas Smajda ◽

...

Keyword(s):

Clinical Outcome ◽

Endovascular Treatment ◽

Intravenous Thrombolysis ◽

Poor Clinical Outcome ◽

Good Clinical Outcome ◽

Intravenous Tissue Plasminogen Activator ◽

Tandem Occlusion ◽

Treatment Data ◽

Research Gap

Introduction: Ischemic strokes with tandem occlusions are associated with a poor prognosis. Recent studies demonstrating the effectiveness of endovascular treatment for large vessel occlusions have shown less impressive results in patients with tandem occlusions than in those with isolated intracranial occlusions. Besides, the indications and effects of ICA stenting remain unclear. Hypothesis: To determine the factors associated with favorable outcome at 3-month in this subtype of AIS. Methods: From a prospectively gathered registry, we analyzed the data of 70 consecutive patients who underwent mechanical endovascular treatment for acute stroke with tandem occlusions from November 2011 to August 2014. Clinical (including demographics, NIHSS, and stroke etiology), imaging (including DWI-ASPECTS), and endovascular treatment data were assessed and reviewed in consensus by two observers. Good clinical outcome was defined as a modified Rankin Scale (mRS) of ≤2 at 3-month follow-up. The mRS at 3 months follow-up was available in 67 patients. Results: At 3-month follow-up, 33 of 67 (49.3%) patients had a good clinical outcome and 34 (50.8%) had a poor clinical outcome, including 9 deaths (13.4%). Lower NIHSS (initial, at day 1, and at discharge) and successful recanalization (TICI 2b-3) were associated with a good clinical outcome (P<0.05). There were no statistically significant differences between patients with a good or poor clinical outcome in terms of intravenous tissue plasminogen activator use, delay between symptom onset and recanalization, and endovascular technique, including the ICA stenting. Conclusions: Despite the recent randomized control trials demonstrating the effectiveness of thrombectomy, there is still a research gap about tandem occlusions. This subtype of stroke, which usually responds poorly to intravenous thrombolysis, is also difficult to treat by endovascular means.

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Renal Impairment Is Associated with Intracerebral Hemorrhage after Mechanical Thrombectomy in Vertebrobasilar Stroke

Cerebrovascular Diseases ◽

10.1159/000497070 ◽

2019 ◽

Vol 47 (1-2) ◽

pp. 48-56 ◽

Cited By ~ 7

Author(s):

Mona Laible ◽

Ekkehart Jenetzky ◽

Markus A. Möhlenbruch ◽

Ulf Neuberger ◽

Martin Bendszus ◽

...

Keyword(s):

Clinical Outcome ◽

Intracerebral Hemorrhage ◽

Mechanical Thrombectomy ◽

Posterior Circulation ◽

Stroke Severity ◽

Stroke Patients ◽

Poor Clinical Outcome ◽

Treatment Results ◽

Risk Of Mortality ◽

Vertebrobasilar Stroke

Background and Purpose: Renal dysfunction (RD) is overall associated with unfavorable functional outcome and higher risk of mortality after acute ischemic stroke. Associations between RD and outcome in patients with acute vertebrobasilar stroke treated with thrombectomy have not been evaluated so far. Materials and Methods: Consecutive patients with vertebrobasilar stroke treated with mechanical thrombectomy between October 2010 and July 2017 at our center were analyzed. RD was defined as glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 at admission. Endpoints were (I) poor clinical outcome (modified Rankin Scale > 2) at 3 months, (II) 3-month mortality, and (III) intracerebral hemorrhage (ICH) after treatment. Results: Overall, 106 patients were included. Median age was 73.0 years (interquartile range 62.0–80.0), and RD was present in 20.8%. Multivariate analysis revealed that RD was associated with a higher risk for any ICH (OR 3.54; 95% CI 1.09–11.49; p = 0.035). Stroke severity at onset predicted poor clinical outcome (OR 1.08; 95% CI 1.03–1.14; p = 0.003). Neither low GFR nor any ICH, but stroke severity (OR 1.08; 95% CI 1.03–1.14; p = 0.002) and poor recanalization results (OR 11.38; 95% CI 2.01–64.41; p = 0.006) were associated with a higher risk for mortality. Conclusions: Patients with RD and acute vertebrobasilar stroke should be thoroughly monitored to prevent ICH after thrombectomy. Our results support performing mechanical thrombectomy in acute stroke patients with large vessel occlusions of the posterior circulation, irrespective of their renal function.

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