Acute Ischemic Stroke Evaluation and Treatment

2021 ◽  
pp. 410-416
Author(s):  
Eugene L. Scharf
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Neuronal Death ◽  
Clinical Management ◽  
Correct Diagnosis ◽  
Collateral Flow ◽  
Early Symptom ◽  
Symptom Recognition ◽  
Short Time ◽  
Neurologic Emergency

Acute ischemic stroke is a neurologic emergency where an estimated 2 million neurons a minute are lost secondary to ischemia. Treatments of acute stroke are directed at early revascularization of the occluded vessel and to preserve neuronal death and improve collateral flow. Treatments are time sensitive, an aspect that places great importance on early symptom recognition, correct diagnosis, and clinical management. In acute ischemic stroke, in short, “time is brain.”

scholarly journals Impact of Early Blood Pressure Lowering in Patients Presenting with Acute Ischemic Stroke

2021 ◽  
Vol 23 (6) ◽  
Author(s):  
A. Maud ◽  
G. J. Rodriguez ◽  
A. Vellipuram ◽  
F. Sheriff ◽  
M. Ghatali ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Negative Impact ◽  
Systemic Blood Pressure ◽  
Hemodynamic Response ◽  
Collateral Flow ◽  
Early Management ◽  
Ischemic Tissue

Abstract Purpose of Review In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. Recent Findings Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Summary Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.

Abstract TP476: White Matter Hyperintensity Burden is Associated With Poor Collateral Flow and Worse Outcomes in an Acute Ischemic Stroke Cohort

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Rami-James Assadi ◽  
Hongyu An ◽  
Yasheng Chen ◽  
Andria Ford ◽  
Jin-Moo Lee
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Pearson Correlation ◽  
Stroke Onset ◽  
White Matter Hyperintensity ◽  
Flow Index ◽  
Acute Ischemia ◽  
Collateral Flow ◽  
Core Volume

Introduction: White matter hyperintensity volume (WMHv), a quantitative neuroimaging biomarker of cerebral small vessel disease (CSVD), is associated worse outcomes after ischemic stroke. In this study, we hypothesized that worse outcomes in CSVD patients were due to poor collateral flow during acute ischemia. Methods: 47 patients with acute ischemic stroke (AIS) were prospectively enrolled in this study. Serial MRIs were performed at 3 hours and 30 days after stroke onset. 3-hour FLAIR images were used to determine WMHv, after manually delineating lesions with MIPAV. An index of collateral flow (delayed perfusion to the penumbra) was determined by subtracting core volume (volume of tissue with ADC<600) from the volume of brain tissue with Tmax>2. Patient’s NIHSS was scored at 3 hours and 30 days after stroke onset and the difference was calculated (ΔNIHSS). Log-transformed WMHv was correlated to ΔNIHSS and the collateral flow index, using Pearson correlation. Results: Mean age = 63.9 years (SD 13.5); 37% female; median 3-hour NIHSS = 13 (IQR 6.5-20); median change in NIHSS between 3h and 30d = 4 (IQR: 0-7); median core volume = 13cm3 (IQR 4.3-35.6); median WMHv = 1.257cm3 (IQR 641-3595). WMHv was associated with reduced improvement in ΔNIHSS (R=-0.42, ρ=0.005). Furthermore, WMHv demonstrated a trend for association with poor collateral flow (R=-0.28, ρ=0.062). In this dataset, we will explore the relationship between WMHv and other tissue-based metrics of collateral flow, including the hypoperfusion intensity ratio (HIR) and the cerebral blood volume ratio (rCBV). Conclusions: Our study confirms that patients with CSVD have worse outcomes after AIS. The data also raise the possibility that these worse outcomes in CSVD patients may be mediated by compromised collateral flow in the setting of acute ischemia.

scholarly journals Fingolimod enhances the efficacy of delayed alteplase administration in acute ischemic stroke by promoting anterograde reperfusion and retrograde collateral flow

2018 ◽  
Vol 84 (5) ◽  
pp. 717-728 ◽  
Author(s):  
De‐Cai Tian ◽  
Kaibin Shi ◽  
Zilong Zhu ◽  
Jia Yao ◽  
Xiaoxia Yang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Collateral Flow

Abstract WMP24: CT Angiography Collateral Gradient Mapping: Validation of a Novel Imaging Technique in Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Elijah Agbayani ◽  
Graham W Woolf ◽  
Baixue Jia ◽  
Nerses Sanossian ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
3D Reconstruction ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Quantitative Data ◽  
Single Phase ◽  
Imaging Technique ◽  
Collateral Flow ◽  
Gradient Mapping ◽  
Flow Gradients

Background: CT angiography (CTA) is routinely acquired in acute ischemic stroke, providing data on extent of collaterals yet current techniques compromise either spatial or temporal resolution. We developed and validated a novel imaging technique from standard or single-phase CTA to discriminate both the spatial and temporal blood flow features in leptomeningeal collaterals. Methods: Consecutive acute ischemic stroke patient data, including single-phase CTA (sCTA) followed immediately by digital subtraction angiography (DSA), in the setting of ICA or proximal MCA occlusions were analyzed. Three-dimensional (3D) reconstruction and surface mapping of collateral flow gradients on sCTA was performed. Quantitative output of flow gradients in individual collateral vessels was correlated with DSA ASITN collateral grade. Results: 75 consecutive cases of acute stroke due to ICA or proximal MCA occlusion were analyzed with contemporaneous sCTA and DSA. Automatic post-processing of collateral gradient maps and generation of quantitative data output followed 3D reconstruction and segmentation of sCTA. sCTA collateral gradient mapping was feasible in all cases, compared to limitations in availability of DSA collateral grades. Poor collateral status on DSA (ASITN 0-1) was evident as limited extent and color-mapped gradients on sCTA. In contrast, sCTA gradient mapping provided more detailed distinction between subjects of intermediate or partial DSA collaterals (ASITN 2) and also amongst complete, but delayed DSA collaterals (ASITN 3). sCTA gradient mapping provided quantitative data on the delay of collateral flow in individual cortical vessels. Conclusions: CTA collateral gradient mapping can routinely provide detailed data on both the extent and delay of collaterals, using standard sCTA acquisition. This novel imaging technique may provide key information to distinguish the wide variability of ASITN grades 2-3, most commonly encountered in acute stroke.

Capillary Index Score Derived from Computed Tomography Angiography as An Indicator of Collateral Flow after Acute Ischemic Stroke

2019 ◽  
Author(s):  
Shang Kai ◽  
Xiaoxing Zhang ◽  
Yuehua Li
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Treatment Strategies ◽  
Artery Occlusion ◽  
Index Score ◽  
Collateral Flow ◽  
Imaging Data ◽  
Flow Group ◽  
Cerebral Artery Occlusion

Abstract Background The capillary index score (CIS) determined from DSA is used to evaluate cerebral collateral flow in acute ischemic stroke (AIS) caused by cerebral artery occlusion. Our aim was to determine the reliability of CIS calculated from MIP-CTA images as an alternative to DSA-based CIS, as CTA is less invasive and less expensive. Methods Clinical and imaging data of 40 patients with AIS caused by cerebral artery occlusion within 6 h from symptom onset were collected. CIS was calculated from CTA and DSA images. Patients were classified into the favorable collateral flow group if CIS was ≥2 (fCIS), and into the poor collateral flow group if CIS was <2 (pCIS). Agreement between the methods was evaluated using the Kappa test. Logistic regression was performed to explore the relationship between CTA-based CIS and clinical outcomes. Results The two methods had high consistency (Kappa = 0.72), and the diagnostic accuracy of CTA for CIS classification was 87.5%. The decrease in the NIHSS score at discharge was not significantly different between the fCIS and pCIS groups according to CTA (p = 0.156), while the 90-day mRS was higher in the pCIS group (p = 0.04). High CTA-based CIS and low blood glucose at admission were significantly correlated with good outcome. Conclusion CIS calculated using CTA is as reliable as DSA-based CIS for assessing collateral flow in AIS, and is also a good predictor of clinical outcome. This index could be useful for guiding patient selection and treatment strategies for AIS.

scholarly journals Prevention of the collapse of pial collaterals by remote ischemic perconditioning during acute ischemic stroke

2016 ◽  
Vol 37 (8) ◽  
pp. 3001-3014 ◽  
Author(s):  
Junqiang Ma ◽  
Yonglie Ma ◽  
Bin Dong ◽  
Mischa V Bandet ◽  
Ashfaq Shuaib ◽  
...  
Keyword(s):  
Blood Flow ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Laser Speckle ◽  
Laser Scanning Microscopy ◽  
Collateral Flow ◽  
Contrast Imaging ◽  
Peripheral Ischemia ◽  
Remote Ischemic Perconditioning

Collateral circulation is a key variable determining prognosis and response to recanalization therapy during acute ischemic stroke. Remote ischemic perconditioning (RIPerC) involves inducing peripheral ischemia (typically in the limbs) during stroke and may reduce perfusion deficits and brain damage due to cerebral ischemia. In this study, we directly investigated pial collateral flow augmentation due to RIPerC during distal middle cerebral artery occlusion (MCAo) in rats. Blood flow through pial collaterals between the anterior cerebral artery (ACA) and the MCA was assessed in male Sprague Dawley rats using in vivo laser speckle contrast imaging (LSCI) and two photon laser scanning microscopy (TPLSM) during distal MCAo. LSCI and TPLSM revealed that RIPerC augmented collateral flow into distal MCA segments. Notably, while control rats exhibited an initial dilation followed by a progressive narrowing of pial arterioles 60 to 150-min post-MCAo (constricting to 80–90% of post-MCAo peak diameter), this constriction was prevented or reversed by RIPerC (such that vessel diameters increased to 105–110% of post-MCAo, pre-RIPerC diameter). RIPerC significantly reduced early ischemic damage measured 6 h after stroke onset. Thus, prevention of collateral collapse via RIPerC is neuroprotective and may facilitate other protective or recanalization therapies by improving blood flow in penumbral tissue.

Using Standard First-Pass Perfusion Computed Tomographic Data to Evaluate Collateral Flow in Acute Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (4) ◽  
pp. 961-967 ◽  
Author(s):  
Hui Chen ◽  
Bing Wu ◽  
Nan Liu ◽  
Max Wintermark ◽  
Zihua Su ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Collateral Flow ◽  
Computed Tomographic ◽  
Pass Perfusion ◽  
First Pass ◽  
Tomographic Data ◽  
First Pass Perfusion
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