scholarly journals Hyperglycemia during Ischemia Rapidly Accelerates Brain Damage in Stroke Patients Treated with tPA

2007 ◽  
Vol 27 (9) ◽  
pp. 1616-1622 ◽  
Author(s):  
Marc Ribo ◽  
Carlos A Molina ◽  
Pilar Delgado ◽  
Marta Rubiera ◽  
Raquel Delgado-Mederos ◽  
...  
Keyword(s):  
Brain Damage ◽  
Independent Predictor ◽  
Characteristic Curve ◽  
Artery Occlusion ◽  
National Institutes Of Health ◽  
Occlusion Time ◽  
Poor Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Lesion Extension

To evaluate impact of glucose burden on diffusion-weighted imaging (DWI)-lesion evolution according to ischemia duration in stroke. We studied 47 patients with transcranial Doppler (TCD)-documented artery occlusion treated with intravenous tissue plasminogen activator. Hyperglycemia (HG) was defined as glucose > 140 mg/dL. A subcutaneous device continuously monitored glucose during 24 h. Magnetic resonance imaging was performed pretreatment (1) and at 24 to 36 h (2) in 30 patients. We measured initial PWI lesion (PW1) and DWI growth: DW2–DW1 (DWg). Serial TCD during 24 h determined occlusion time (OT). National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and 48 h. Poor short-term clinical course defined as <50% recovery of initial NIHSS. Baseline NIHSS was 18. On admission 10 patients (21.3%) were hyperglycemic and presented similar NIHSS, DW1, and PW1 lesion extension as those without HG. During monitoring 24 patients (51%) had HG, 21 (45%) of them during OT (median OT 12 h). Median 48 h-NIHSS was 10; 15 patients presented poor outcome. 48 h-NIHSS was higher in patients with HG during OT (15 versus 3; P < 0.001). Patients with favorable outcome had shorter OT (8.4 versus 17.4 h; P < 0.001). However, the only independent predictor of poor outcome was HG during OT (OR: 20.3; 95% CI: 3.77 to 108.8; P < 0.001). At 24 h mean DWg was 52 cm3. A receiver operating characteristic curve identified DWg > 14 cm3 best predictor of poor outcome (sensitivity, 85.7%; specificity, 75%). Total OT ( P = 0.007) and HG during OT ( P = 0.01) showed the strongest correlation with DWg. DWI lesion grew 2.7 times faster in patients with HG than without HG during OT (1.73 versus 4.63 cm3/h of occlusion; P = 0.07). In a regression model the only independent predictor of DWg was HG during OT (OR: 10.83; 95% CI: 1.96 to 59.83; P = 0.006). Hyperglycemia, especially during OT, has a powerful deleterious effect after stroke accelerating brain damage.

Abstract 2808: The Prognosis of Intravenous Thrombolysis with Alteplase Relate to Site of Cerebral Artery Occlusion

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Takao Kanzawa ◽  
Ban Mihara ◽  
Tomo horikoshi
Keyword(s):  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
National Institutes Of Health ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Cerebral Artery Occlusion ◽  
Mean Time ◽  
Time Form ◽  
Iv Tpa

Purpose: The objective of this study was to determine whether the arterial obstruction site is predictive of clinical outcomes in patients receiving intravenous tissue plasminogen activator (IV tPA). Methods: In a retrospective analysis of our stroke database between Nov. 2005 and May. 2011, we identified 91 consecutive patients who were treated with IV tPA within 3 hours after symptom onset of a stroke in the distribution of a documented ICA, proximal M1, distal M1, or M2/M3 occlusion by Magnetic resonance angiography. We analyzed the rate of favorable outcomes at 3 months (modified Rankin Scale 0 or 1) at various occlusion sites, and determined predictors of favorable outcomes. Results: 91 consecutive patients were treated (mean age, 71 +/- 11 yr; 40.9% were women). Median baseline National Institutes of Health Stroke Scale score (NIHSS) was 10 (range, 4 to 32) and mean time form onset to IV tPA was 128+/- 33 minutes. Favorable outcomes were achieved in 55.6% and significantly correlated with age, basal NIHSS and MRI ASPECT score. Based on the occlusion site, M2/M3 occlusion had an OR of 6.4 for favorable outcomes (83.7%, 95% CI: 2.2 to 19.2, P 0.0006), whereas the odds for proximal M1 occlusion was 0.163 (25.9%, 95% CI: 0.059 to 0.447, P 0.0004), ICA occlusion was 0.378 (23.0%, 95% CI: 0.138 to 1.036, P 0.01). After adjusting for age, sex, baseline NIHSS, and MRI ASPECT score, M2/M3 occlusion occlusion were an independent predictor to achieve favorable outcomes (OR: 9.203, 95% CI: 1.896 to 45.443, P 0.006). Conclusions: Clinical outcome in IV tPA depends on the site of occlusion. This is important to make reasonable decisions for identifying which patients benefit in IV tPA and combined IV tPA/ interventional approach.

Abstract WP61: Volumetric DWI Malignant Profile Assessment in Acute Ischemic Patients With Reperfusion Therapy.

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Shinichi Wada ◽  
Kazutaka Sonoda ◽  
Sohei Yoshimura ◽  
Shoichiro Sato ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Reperfusion Therapy ◽  
National Institutes Of Health ◽  
Roc Curve Analysis ◽  
Poor Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Magnetic Resonance Imaging Mri ◽  
Poor Outcomes ◽  
Iv Tpa

Background: The efficacy of endovascular therapy (EVT) in acute stroke has been established but the imaging criteria have not yet been assessed. Malignant profile is a magnetic resonance imaging (MRI) pattern that is associated with poor outcomes. We estimated this profile by volumetrically assessing diffusion weighted image (DWI) in patients treated with reperfusion therapy including intravenous tissue plasminogen activator (IV tPA) and endovascular therapy (EVT). Methods: Acute anterior ischemic stroke patients with baseline DWI before reperfusion therapy were included. Outcome was assessed by modified Rankin Scale (mRS) at discharge. DWI volume was measured by semi-automated software.Receiver operating characteristic (ROC) curve analysis was performed to identify optimal DWI volumes with poor outcome (mRS 5-6). Results: Total of 96 patients (43% women, mean age 72±13 years) were included in this study. Median (interquartile range: IQR) National Institutes of Health Stroke Scale was 9 (5-12) and median onset to MRI time was 108.5 (70-217) minutes. Median DWI volume was 4.4 (1.3-17) mL for overall patients. Median onset to IV tPA time for 60 (63%) patients were 120 (65-177) minutes. Median onset to puncture time for 36 (38%) EVT-treated patients was 208 (121.0-474.3) minutes; 29 of these 36 patients (81%) had Thrombolysis in Cerebral Infarction (TICI) score of 2B/3. Median discharge mRS was 2 (1-3) for overall and 6 cases (6%) had mRS 5-6. ROC analysis determined DWI volume with poor outcome as 49.5 mL (92.2% specificity and 50% sensitivity, AUC 0.75, p<0.001). Conclusion: Our study suggests the optimal volume of the malignant profile on DWI was approximately 50mL in reperfusion therapy eligible patients. Clinical outcome of patients exceeding the cutoff volume were very poor. The imaging criteria for reperfusion therapy including EVT should be well considered to achieve better outcomes.

scholarly journals Initial Stroke Severity Is the Major Outcome Predictor for Patients Who Do Not Receive Intravenous Thrombolysis due to Mild or Rapidly Improving Symptoms

2011 ◽  
Vol 2011 ◽  
pp. 1-3 ◽  
Author(s):  
Mu-Chien Sun ◽  
Tien-Bao Lai
Keyword(s):  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
National Institutes Of Health ◽  
Unfavorable Outcome ◽  
Stroke Severity ◽  
Outcome Predictor ◽  
Nihss Score ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Favorable Group

Intravenous tissue plasminogen activator thrombolysis for stroke is still under use. A substantial proportion of excluded patients for mild or improving symptoms are dependent at discharge. We prospectively recruited 49 patients who did not receive thrombolysis because of mild or improving symptoms. 32 had favorable outcome (mRS ≤ 2) and 17 had unfavorable outcome (mRS > 2) at discharge. Comparisons were made between the two groups. Age was older (72.5 ± 10.0 versus 64.7 ± 13.2 years, P = 0.037), and initial National Institutes of Health Stroke Scale (NIHSS) score (5.7 ± 4.0 versus 2.2 ± 2.1, P < 0.001) was higher in the unfavorable group. Diastolic blood pressure was higher in the favorable group (98 ± 15 versus 86 ± 18  mmHg; P = 0.018). Atrial fibrillation (3.1 versus 23.5%; P = 0.043) and ipsilateral artery stenosis (21.9 versus 58.8%; P = 0.012) were more frequently found in the unfavorable group. Percentage of patients excluded from thrombolysis due to improving symptoms was higher in the unfavorable group (40.6 versus 82.4%; P = 0.005). Initial NIHSS score, but not other factors, was identified by logistic regression analysis as a major independent predictor for unfavorable outcome (OR 1.44; 95%CI, 1.03–2.02).

scholarly journals Comparison of outcome of patients with acute minor ischaemic stroke treated with intravenous t-PA, DAPT or aspirin

2020 ◽  
pp. svn-2019-000319
Author(s):  
Peng Wang ◽  
Mengyuan Zhou ◽  
Yuesong Pan ◽  
Xia Meng ◽  
Xingquan Zhao ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
National Institutes Of Health ◽  
Minor Stroke ◽  
Post Hoc Analysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Ischemic Attack ◽  
Post Hoc

BackgroundWhether to treat minor stroke with intravenous tissue plasminogen activator (t-PA) treatment or antiplatelet therapy is a dilemma. Our study aimed to explore whether intravenous t-PA treatment, dual antiplatelet therapy (DAPT) and aspirin have different efficacies on outcomes in patients with minor stroke.MethodsA post hoc analysis of patients with acute minor stroke treated with intravenous t-PA within 4.5 hours from a nationwide multicentric electronic medical record and patients with acute minor stroke treated with DAPT and aspirin from the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack Database. Minor stroke was defined by a score of 0–3 on the National Institutes of Health Stroke Scale at randomisation. Favourable functional outcome (defined as modified Rankin Scale (mRS) score of 0–1 or 0–2 at 3 months).ResultsCompared with those treated with intravenous t-PA, no significant association with 3-month favourable functional outcome (defined as mRS score of 0–1) was found neither in patients treated with aspirin (87.8% vs 89.4%; OR, 0.83; 95% CI, 0.46 to 1.50; p=0.53) nor those treated with DAPT (87.4% vs 89.4%; OR, 0.84; 95% CI, 0.46 to 1.52; p=0.56). Similar results were observed for the favourable functional outcome defined as mRS score of 0–2 at 3 months.ConclusionsIn our study, no significant advantage of intravenous t-PA over DAPT or aspirin was found. Due to insufficient sample size, our study is probably unable to draw such a conclusion that that intravenous t-PA was superior or non-superior to DAPT.

scholarly journals Treating ischaemic stroke with intravenous tPA beyond 4.5 hours under the guidance of a MRI DWI/T2WI mismatch was safe and effective

2019 ◽  
Vol 4 (1) ◽  
pp. 8-13 ◽  
Author(s):  
Qing-ke Bai ◽  
Zhen-guo Zhao ◽  
Lian-jun Lu ◽  
Jian Shen ◽  
Jian-ying Zhang ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Contrast Material ◽  
Final Analysis ◽  
National Institutes Of Health ◽  
Haemorrhagic Transformation ◽  
Intravenous Tissue Plasminogen Activator ◽  
Hyperintense Signal ◽  
Rapid Sequence ◽  
Tissue Plasminogen ◽  
Sequence Study

PurposeClinical trials have provided evidence that treating patients with acute ischaemic stroke (AIS) beyond 4.5 hours was feasible. Among them using MRI diffusion-weighted imaging/fluid attenuation inversion response (DWI/FLAIR) mismatch to guide intravenous tissue plasminogen activator (tPA) was successful. Our study explored the outcome and safety of using DWI/T2-weighted imaging (T2WI) mismatch to guide intravenous tPA therapy for patients with AIS between 4.5 hours and 12 hours of onset.MethodThis was a retrospective study. Records of 1462 AIS patients with the time of onset of <12 hours were reviewed. Those had MRI rapid sequence study and had hyperintense signal on DWI but normal T2WI and received intravenous tPA up to 12 hours of onset were included in the analysis. Their demographics, risk factors, post-tPA complications, National Institutes of Health Stroke Scale (NIHSS) scores and outcome were recorded and analyse. χ2 was used to compare the intergroup variables. SAS was used to perform statistical calculation. A p<0.05 was considered statistically significant.ResultsOf 1462 identified, 601 (41%) patients were entered into the final analysis. Among them, 327 (54%) had intravenous tPA within 4.5 hours of onset and 274 (46%) were treated between 4.5–12 hours. After intravenous tPA, 426 cases (71%) had >4 pints of improvement on NIHSS score within 24 hours. Postintravenous tPA, 32 (5.32%) cases had haemorrhagic transformation. 26 (4.33%) were asymptomatic ICH and 4 (0.67%) died. At 90 days, 523 (87%) achieved a modified Rankin scale of 0–2.ConclusionUsing MRI DWI/T2WI mismatch to identify patients with AIS for intravenous tPA between 4.5 hours and 12 hours was safe and effective. The outcome was similar to those used DWI/PWI or DWI/FLAIR mismatch as the screening tool. However, obtaining DWI/T2WI was faster and avoided the need of contrast material.

What predicts poor outcome after successful thrombectomy in early time window?

2021 ◽  
pp. neurintsurg-2021-017946
Author(s):  
Jean-Marc Olivot ◽  
Jeremy J Heit ◽  
Mikael Mazighi ◽  
Nicolas Raposo ◽  
Jean François Albucher ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Time Window ◽  
Independent Predictor ◽  
Early Time ◽  
National Institutes Of Health ◽  
Multivariable Logistic Regression Analysis ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Poor Outcome

BackgroundHalf of the patients with large vessel occlusion (LVO)-related acute ischemic stroke (AIS) who undergo endovascular reperfusion are dead or dependent at 3 months. We hypothesize that in addition to established prognostic factors, baseline imaging profile predicts outcome among reperfusers.MethodsConsecutive patients receiving endovascular treatment (EVT) within 6 hours after onset with Thrombolysis In Cerebral Infarction (TICI) 2b, 2c and 3 revascularization were included. Poor outcome was defined by a modified Rankin scale (mRS) 3–6 at 90 days. No mismatch (NoMM) profile was defined as a mismatch (MM) ratio ≤1.2 and/or a volume <10 mL on pretreatment imaging.Results187 patients were included, and 81 (43%) had a poor outcome. Median delay from stroke onset to the end of EVT was 259 min (IQR 209–340). After multivariable logistic regression analysis, older age (OR 1.26, 95% CI 1.06 to 1.5; p=0.01), higher National Institutes of Health Stroke Scale (NIHSS) (OR 1.15, 95% CI 1.06 to 1.25; p<0.0001), internal carotid artery (ICA) occlusion (OR 3.02, 95% CI 1.2 to 8.0; p=0.021), and NoMM (OR 4.87, 95% CI 1.09 to 22.8; p=0.004) were associated with poor outcome. In addition, post-EVT hemorrhage (OR 3.64, 95% CI 1.5 to 9.1; p=0.04) was also associated with poor outcome.ConclusionsThe absence of a penumbra defined by a NoMM profile on baseline imaging appears to be an independent predictor of poor outcome after reperfusion. Strategies aiming to preserve the penumbra may be encouraged to improve these patients’ outcomes.

Republished: A novel route of revascularization in basilar artery occlusion and review of the literature

2015 ◽  
Vol 8 (7) ◽  
pp. e25-e25 ◽  
Author(s):  
Alejandro Morales ◽  
Phillip Vaughan Parry ◽  
Ashutosh Jadhav ◽  
Tudor Jovin
Keyword(s):  
Basilar Artery ◽  
Mechanical Thrombectomy ◽  
Antiplatelet Agents ◽  
Artery Occlusion ◽  
Direct Access ◽  
Basilar Artery Occlusion ◽  
Review Of The Literature ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Angioplasty And Stenting

Ischemia of the basilar artery is one of the most devastating types of arterial occlusive disease. Despite treatment of basilar artery occlusions (BAO) with intravenous tissue plasminogen activator, antiplatelet agents, intra-arterial therapy or a combination, fatality rates remain high. Aggressive recanalization with mechanical thrombectomy is therefore often necessary to preserve life. When direct access to the basilar trunk is not possible, exploration of chronically occluded vessels through collaterals with angioplasty and stenting creates access for manual aspiration. We describe the first report of retrograde vertebral artery (VA) revascularization using thyrocervical collaterals for anterograde mechanical aspiration of a BAO followed by stenting of the chronically occluded VA origin. Our novel retrograde–anterograde approach resulted in resolution of the patient's clinical stroke syndrome.

scholarly journals Enrollment bias: frequency and impact on patient selection in endovascular stroke trials

2015 ◽  
Vol 8 (4) ◽  
pp. 353-359 ◽  
Author(s):  
Sunil A Sheth ◽  
Jeffrey L Saver ◽  
Sidney Starkman ◽  
Ileana D Grunberg ◽  
Judy Guzy ◽  
...  
Keyword(s):  
First Generation ◽  
National Institutes Of Health ◽  
Stroke Therapy ◽  
Tertiary Referral Center ◽  
Prognostic Features ◽  
Intravenous Tissue Plasminogen Activator ◽  
Acute Cerebral Ischemia ◽  
Tissue Plasminogen ◽  
Scale Scores ◽  
Angiographic Data

BackgroundSelection bias may have affected enrollment in first generation endovascular stroke trials. We investigate, evaluate, and quantify such bias for these trials at our institution.MethodsDemographic, clinical, imaging, and angiographic data were prospectively collected on a consecutive cohort of patients with acute ischemic stroke who were enrolled in formal trials of endovascular stroke therapy (EST) or received EST in clinical practice outside of a randomized trial for acute cerebral ischemia at a single tertiary referral center from September 2004 to December 2012.ResultsAmong patients considered appropriate for EST in practice, 47% were eligible for trials, with rates for individual trials ranging from 17% to 70%. Compared with trial ineligible patients treated with EST, trial eligible patients were younger (67 vs 74 years; p<0.05), more often treated with intravenous tissue plasminogen activator (53% vs 34%; p<0.01), and had shorter last known well to puncture times (328 vs 367 min; p<0.05). Focusing on the largest trial with a non-interventional control arm, compared with trial eligible patients treated with EST outside the trial, enrolled patients presented later (274 vs 163 min; p<0.001), had higher National Institutes of Health Stroke Scale scores (20 vs 17; p<0.05), and larger strokes (diffusion weighted imaging volumes 49 vs 18; p<0.001).ConclusionsThe majority of patients felt suitable for EST at our institution were excluded from recent trials. Formal entry criteria succeeded in selecting patients with better prognostic features, although many of these patients were treated outside of trials. Acknowledging and mitigating these biases will be crucial to ongoing investigations.

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