Intravenous thrombolysis in ischaemic stroke secondary to cervical artery dissection: safe but not effective?

This chapter considers the effects of neurological conditions in the pregnant patient. This includes epilepsy, the use of antiepileptic drugs and any contraindications and problems for the fetus, and the management of seizures both pre- and postnatally. Ischaemic stroke, intracranial and subarachnoid haemorrhage, cervical artery dissection, moyamoya, headaches, migraine, and neonatal effects of myasthenia gravis are all discussed, along with management strategies. Inherited and acquired neuropathies are also covered, along with other neurological conditions.

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Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke – Results from the SWISS registry

European Stroke Journal ◽

10.1177/2396987317748545 ◽

2018 ◽

Vol 3 (1) ◽

pp. 47-56 ◽

Cited By ~ 10

Author(s):

Christopher Traenka ◽

Simon Jung ◽

Jan Gralla ◽

Rebekka Kurmann ◽

Christoph Stippich ◽

...

Keyword(s):

Confidence Interval ◽

Endovascular Therapy ◽

Odds Ratio ◽

Intracranial Haemorrhage ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Bridging Therapy ◽

Cervical Artery

Introduction In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications. Materials and methods In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0–1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel–Haenszel model. Results Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9–11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00–14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38–2.44]) among endovascular therapy patients and intravenous thrombolysis patients. Discussion and Conclusion In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which – given the limitation of our sample size – does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.

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Impact of a comprehensive stroke centre on the care of patients with acute ischaemic stroke due to cervical artery dissection

Neurología (English Edition) ◽

10.1016/j.nrleng.2014.01.004 ◽

2015 ◽

Vol 30 (6) ◽

pp. 331-338 ◽

Cited By ~ 1

Author(s):

M. Almendrote ◽

M. Millán ◽

L.A. Prats ◽

N. Pérez de la Ossa ◽

E. López-Cancio ◽

...

Keyword(s):

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Cervical Artery ◽

Stroke Centre

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Efficacy and safety of endovascular treatment in acute ischemic stroke due to cervical artery dissection: A 15-year consecutive case series

International Journal of Stroke ◽

10.1177/1747493018823161 ◽

2019 ◽

Vol 14 (4) ◽

pp. 381-389 ◽

Cited By ~ 4

Author(s):

Francisco Bernardo ◽

Stefania Nannoni ◽

Davide Strambo ◽

Francesco Puccinelli ◽

Guillaume Saliou ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Intravenous Thrombolysis ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Cervical Artery ◽

Symptomatic Intracranial Hemorrhage ◽

Favorable Clinical Outcome

Background Limited observational data are available on endovascular treatment in acute ischemic stroke due to cervical artery dissection. Three studies comparing endovascular treatment with standard medical therapy or intravenous thrombolysis in cervical artery dissection-related acute ischemic stroke did not demonstrate superiority of endovascular treatment. Efficacy and the choice of endovascular treatment technique in this setting remain to be established. Aims To assess the potential efficacy and safety of endovascular treatment compared to intravenous thrombolysis alone or to no revascularization treatment in our center. Methods We selected all consecutive patients with cervical artery dissection-related acute ischemic stroke and intracranial occlusion from the Acute STroke Registry and Analysis of Lausanne between 2003 and 2017. We compared clinical and neuroimaging data of patients treated by endovascular treatment versus patients receiving intravenous thrombolysis or patients without revascularization treatment. Safety analysis included symptomatic intracranial hemorrhage, major radiological hemorrhages (parenchymal hematoma 1, parenchymal hematoma 2, and subarachnoid hemorrhage) and mortality within seven days. We assessed favorable clinical outcome (modified Rankin Scale 0-2) at three months using a binary logistic regression model. Results Of the 109 patients included, 24 had endovascular treatment, 38 received intravenous thrombolysis alone, and 47 had no revascularization treatment. Endovascular treatment patients had a higher rate of recanalization at 24 h. Major radiological hemorrhages occurred more often in endovascular treatment patients (all with bridging therapy) than in patients without revascularization treatment (p = 0.026), with no differences in symptomatic intracranial hemorrhage or mortality within seven days. Favorable clinical outcome at three months did not differ between groups (endovascular treatment versus intravenous thrombolysis p = 0.407; endovascular treatment versus no revascularization treatment p = 0.580). Conclusions In this single-center cohort of cervical artery dissection-related acute ischemic stroke with intracranial occlusion, endovascular treatment with prior intravenous thrombolysis may increase the risk of major radiological but not symptomatic intracranial hemorrhage. Despite the lack of clear superiority in our cohort, endovascular treatment should currently not be withheld in these patients.

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Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012421 ◽

2016 ◽

Vol 9 (7) ◽

pp. 654-658 ◽

Cited By ~ 14

Author(s):

Judd Jensen ◽

Kristin Salottolo ◽

Donald Frei ◽

David Loy ◽

Kathryn McCarthy ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Therapeutic Option ◽

Intravenous Thrombolysis ◽

Target Population ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Symptomatic Intracerebral Hemorrhage ◽

Cervical Artery ◽

Procedural Complications

ObjectiveThe safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT.DesignDemographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ2 tests and multivariate logistic regression.ResultsThere were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34).ConclusionsIAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

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