Unfavorable neurological outcome in diabetic patients with acute ischemic stroke is associated with incomplete recanalization after intravenous thrombolysis

2015 ◽  
Vol 8 (4) ◽  
pp. 342-346 ◽  
Author(s):  
Huan Tang ◽  
Sheng Zhang ◽  
Shenqiang Yan ◽  
David S Liebeskind ◽  
Jianzhong Sun ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Neurological Outcome ◽  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
Diabetic Patients ◽  
Vessel Occlusion ◽  
Neurological Outcomes ◽  
New Diagnosis ◽  
The Impact

ObjectiveTo assess the impact of diabetes on neurological outcome and recanalization in acute ischemic stroke (AIS) after intravenous thrombolysis (IVT).MethodsClinical data of 419 consecutive patients with AIS who received IVT between June 2009 and April 2014. Based on the medical history and new diagnosis, the patients were divided into groups with and without diabetes. Neurological outcomes at 24 h, 7 days and 3 months after IVT were evaluated. Favorable outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score decrease ≥4 points from baseline or 0 at 24 h, NIHSS decrease ≥8 points or 0 at day 7, or modified Rankin scale ≤1 at 3 months after IVT. Recanalization on non-invasive imaging was evaluated in patients with large vessel occlusion (LVO) according to thrombolysis in myocardial infarction grades.ResultsAmong 419 patients, 98 (23.4%) had diabetes. Multivariable analyses showed that comorbidity of diabetes was an independent predictor of unfavorable outcome at 24 h (OR=0.534, 95% CI 0.316 to 0.903, p=0.019), at day 7 (OR=0.382, 95% CI 0.220 to 0.665, p=0.001), and at 3 months (OR=0.464, 95% CI 0.266 to 0.808, p=0.007). In patients with LVO, diabetes was an independent predictor of incomplete recanalization 24 h after IVT (OR=0.268, 95% CI 0.075 to 0.955, p=0.042).ConclusionsDiabetic patients with AIS had unfavorable neurological outcome, potentially linked to incomplete recanalization after IVT.

Abstract TP21: Is Presence of Diabetes Mellitus a Key Prognostic Factor among Patients Receiving Endovascular Treatment for Acute Ischemic Stroke?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Seong-Joon Lee ◽  
Yang-Ha Hwang ◽  
Ji Man Hong ◽  
Jin Wook Choi ◽  
Dong-Hun Kang ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Logistic Regression ◽  
Regression Analysis ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Logistic Regression Analysis ◽  
Multiple Logistic Regression Analysis ◽  
Univariate Analysis ◽  
Intravenous Thrombolysis ◽  
The Impact

Introduction: Given the recent positive endovascular therapy trials for acute ischemic stroke (AIS), this therapeutic strategy is now being increasingly incorporated into routine clinical practice. Identifying prognostic factors among AIS patients receiving endovascular revascularization treatments (ERT) in the real world could be important for clinicians and patients. While the impact of diabetes mellitus (DM) on IV thrombolytic outcomes after AIS has been extensively investigated, there is a paucity of data assessing effects of DM on ERT outcomes after AIS. We evaluated the impact of comorbid DM on ERT for AIS. Methods: From Jan 2011 to Feb 2016, patients with AIS who underwent ERT for cervicocephalic occlusions were consecutively enrolled into the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention - Korean Retrospective (ASIAN KR) registry from 3 hospitals. Patients were excluded if onset to puncture time over 8 hours, in-hospital stroke, or unavailable 3-month mRS. DM was diagnosed if a patient had the history, or hemoglobin A1c on admission was over 6.5. Univariate analysis was performed to compare the characteristics between DM and non-DM population. Multiple logistic regression analysis was used to validate the effect of comorbid DM on 3 month outcomes. Results: Of 721 patients, 667 (93%) were finally included, with 233 DM patients and 434 non-DM patients. In the univariate analysis, comorbidity with hypertension (71.2% vs. 58.3%, p=0.001) and dyslipidemia (36.7% vs. 26.7%, p=0.012) were more frequent in the DM population. Periprocedural factors such as target vessels, intravenous thrombolysis, and final reperfusion grades did not differ. Good outcomes with mRS 0-2 were less frequent in the DM population (43.3% vs. 53.7%, p=0.011). In the logistic regression analysis adjusting age, male sex, initial NIHSS, premorbid mRS, hypertension history, atrial fibrillation, intravenous thrombolysis, onset to puncture time and successful reperfusion, DM was an independent predictor of poor outcomes (mRS 3-6; 1.933, 1.274-2.933, p=0.002). Conclusion: In patients receiving ERT for AIS due to cervicocephalic artery occlusions, the presence of DM as a comorbidity confers greater odds of a poor functional outcome.

Abstract P488: The Impact of First Pass Effect on Acute Ischemic Stroke Clinical Outcomes: Why We Need to Continue to Improve Mechanical Thrombectomy?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Mahmoud Dibas ◽  
Amr Ehab El-Qushayri ◽  
Sherief Ghozy ◽  
Adam A Dmytriw ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Improved Outcomes ◽  
First Pass ◽  
The Impact

Background: Mechanical thrombectomy (MT) has significantly improved outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). The first-pass effect (FPE), defined as achieving complete reperfusion (mTICI3/2c) with a single pass, was reported to be associated with higher functional independence rates following EVT and has been emphasized as an important procedural target. We compared MT outcomes in patients who achieved FPE to those who did not in a real world large database. Method: A retrospective analysis of LVO pts who underwent MT from a single center prospectively collected database. Patients were stratified into those who achieved FPE and non-FPE. The primary outcome (discharge and 90 day mRS 0-2) and safety (sICH, mortality and neuro-worsening) were compared between the two groups. Results: Of 580 pts, 261 (45%) achieved FPE and 319 (55%) were non-FPE. Mean age was (70 vs 71, p=0.051) and mean initial NIHSS (16 vs 17, p=0.23) and IV tPA rates (37% bs 36%, p=0.9) were similar between the two groups. Other baseline characteristics were similar. Non-FPE pts required more stenting (15% vs 25%, p=0.003), and angioplasty (19% vs 29%, p=0.01). The FPE group had significantly more instances of discharge (33% vs 17%, p<0.001), and 90-day mRS score 0-2 (29% vs 20%, p<0.001), respectively. Additionally, the FPE group had a significant lower mean discharge NIHSS score (12 vs 17, p<0.001). FPE group had better safety outcomes with lower mortality (14.2% vs 21.6%, p=0.03), sICH (5.7% vs 13.5, p=0.004), and neurological worsening (71.3% vs 78.4%, p=0.02), compared to the non-FPE group. Conclusion: Patients with first pass complete or near complete reperfusion with MT had higher functional independence rates, reduced mortality, symptomatic hemorrhage and neurological worsening. Improvement in MT devices and techniques is vital to increase first pass effect and improve clinical outcomes.

Abstract WP25: The Impact of Body Mass Index on Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Stephanie Chen ◽  
David McCarthy ◽  
Vasu Saini ◽  
Marie Brunet ◽  
Eric Peterson ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Body Mass ◽  
Linear Correlation ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Normal Weight ◽  
Vessel Occlusion ◽  
The Impact

Background: Obesity is an established risk factor for acute ischemic stroke (AIS), but its impact on clinical outcomes and mortality after AIS remains controversial. In this study, we evaluate the association of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS). Methods: We reviewed our prospective MT database for LVOS between 2015 and 2018. BMI was analyzed as a continuous and categorical variable with underweight BMI <18.5, normal BMI 18.5-24.9, overweight BMI 25-29.9, and obese BMI>30. Multivariate analysis was used to determine predictors of outcome. Results: 335 patients underwent MT with 7 (2.1%) patients classified as underweight, 107 (31.9%) normal, 141 (42.1%) overweight, and 80 (23.9%) obese. Compared to normal weight (reference), obese patients had higher rates of hypertension and hyperlipidemia, while underweight patients had higher rates of previous stroke and presentation NIHSS. The time from symptom onset to puncture, procedural techniques, and reperfusion success (>TICI 2b) was not significantly different between BMI categories. There was a significant inverse linear correlation between BMI and symptomatic hemorrhagic. In patients with successful reperfusion (>TICI 2b), there was also a significant bell-shaped relationship between BMI and functional independence (mRS < 3) with both low and high BMIs associated with worse outcomes. In patients without post-procedural symptomatic hemorrhage, there was a significant linear correlation between BMI and inpatient mortality. Conclusion: In LVOS patients treated with MT, BMI is inversely related with post-procedural symptomatic hemorrhage. Yet in those whom reperfusion is achieved, both lower and higher than normal BMI were associated with worse functional outcomes. Thus, the obesity paradox does not appear to pertain to mechanical thrombectomy, although larger prospective studies are necessary.

Management of acute ischemic stroke

BMJ ◽  
2020 ◽  
pp. l6983 ◽  
Author(s):  
Michael S Phipps ◽  
Carolyn A Cronin
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Time ◽  
Recurrent Stroke ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Developed Countries ◽  
Future Research ◽  
The Impact

ABSTRACT Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

scholarly journals Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1616-1619 ◽  
Author(s):  
James Beharry ◽  
Michael J. Waters ◽  
Roy Drew ◽  
John N. Fink ◽  
Duncan Wilson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Scale Score ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

scholarly journals The Association of Neutrophil-Lymphocyte Ratio, Platelet-Lymphocyte Ratio and Lymphocyte-Monocyte Ratio With Post-Thrombolysis Early Neurological Outcomes in Patients With Acute Ischemic Stroke

2020 ◽  
Author(s):  
Pengyu Gong ◽  
Yukai Liu ◽  
Yachi Gong ◽  
Gang Chen ◽  
Xiaohao Zhang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Characteristic Curve ◽  
Intravenous Thrombolysis ◽  
Nihss Score ◽  
Neutrophil Lymphocyte Ratio ◽  
Lymphocyte Ratio ◽  
Neurological Outcomes ◽  
Platelet Lymphocyte Ratio ◽  
Cell Counts

Abstract Background and Purpose: To investigate the association of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) with post-thrombolysis early neurological outcomes including early neurological improvement (ENI) and early neurological deterioration (END) in patients with acute ischemic stroke (AIS).Methods: AIS patients undergoing intravenous thrombolysis were enrolled from April 2016 to September 2019. Blood cell counts were sampled before thrombolysis. Post-thrombolysis END was defined as National Institutes of Health Stroke Scale (NIHSS) score increase of ≥4 within 24 hours after thrombolysis. Post-thrombolysis ENI was defined as NIHSS score decrease of ≥4 or complete recovery within 24 hours. Multivariable logistic regression analyses were performed to explore the relationship of NLR, PLR and LMR to post-thrombolysis END and ENI. We also used receiver operating characteristic curve analysis to assess the discriminative ability of three ratios in predicting END and ENI.Results: Among 1060 recruited patients, a total of 193 (18.2%) were diagnosed with ENI and 398 (37.5%) were diagnosed with END. Multivariable logistic models indicated that NLR (odds ratio [OR], 1.652; 95% confidence interval [CI] 1.510-1.807, P=0.001) and PLR (OR, 1.015; 95% CI 1.012-1.018, P=0.001) were independent factors for post-thrombolysis END. Moreover, NLR (OR, 0.686; 95% CI 0.631-0.745, P=0.001), PLR (OR, 0.997; 95% CI 0.994-0.999, P=0.006) and LMR (OR, 1.170; 95% CI 1.043-1.313, P=0.008) served as independent factors for post-thrombolysis ENI. Area under curve (AUC) of NLR, PLR and LMR to discriminate END were 0.763, 0.703 and 0.551, respectively. AUC of NLR, PLR and LMR to discriminate ENI were 0.695, 0.530 and 0.547, respectively.Conclusions: NLR and PLR were associated with and may predict post-thrombolysis END. NLR, PLR and LMR were related to post-thrombolysis ENI.

scholarly journals Circulating cytokines and growth factors in acute cerebral large vessel occlusion - association with success of endovascular treatment

2021 ◽  
Author(s):  
Gerrit M Grosse ◽  
Christopher Werlein ◽  
Nicole Blume ◽  
Omar Abu-Fares ◽  
Friedrich Goetz ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Growth Factors ◽  
Growth Factor ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Efficient Treatment ◽  
Circulating Cytokines

Mechanical thrombectomy (MT) is a highly efficient treatment in patients with acute ischemic stroke due to large vessel occlusion (LVO). However, in a relevant proportion of LVO, no sufficient recanalization can be achieved. The composition of cerebral thrombi is highly heterogeneous and may constitute a relevant factor for insufficient reperfusion. We hypothesized that circulating cytokines and growth factors involved in thrombo-inflammation and platelet activation may be associated with reperfusion status and thrombus composition in patients undergoing MT. An according biomarker panel was measured in plasma specimens taken prior to MT and at a seven-day follow-up. Reperfusion status was categorized into sufficient or insufficient. Composition of retrieved thrombi was histologically analyzed. Differences of baseline biomarker-concentrations between insufficient and sufficient reperfusion were highest for interferon (IFN)-γ, epidermal growth factor (EGF), platelet derived growth factor (PDGF)-AB/BB, and interferon-γ induced protein 10 (IP-10/CXCL10). After applying correction for multiple comparisons and logistic regression analysis adjusting for stroke etiology, intravenous thrombolysis and vascular risk factors, PDGF-AB/BB was identified as an independent predictor of reperfusion status (odds ratio: 0.403 (95%-CI: 0.199–0.819). Histological analysis revealed that the majority of thrombi had a mixed composition. In conclusion, this study provides first evidence that cytokines and growth factors are potential effectors in patients undergoing MT for the treatment of acute ischemic stroke.

Abstract 3799: Baseline Total Cholesterol Levels and Risk of Developing Brain Edema after Intravenous Thrombolysis in Acute Ischemic Stroke Patients

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Svetlana Lorenzano ◽  
Niaz Ahmed ◽  
Karen L Furie ◽  
Nils Wahlgren ◽  
Danilo Toni
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Brain Edema ◽  
Independent Predictor ◽  
Plasma Cholesterol ◽  
Intravenous Thrombolysis ◽  
Time Interval ◽  
Blood Brain Barrier Disruption ◽  
Cholesterol Levels ◽  
Lower Baseline

Objectives: There is evidence that low plasma cholesterol levels(CLs) are among the factors that contribute to blood brain barrier disruption in acute ischemic stroke, leading to hemorrhagic transformation.The aim of this was to evaluate the association between baseline CLs and the development of brain edema (BE)after i.v. thrombolysis in AIS. Methods: We analyzed all the data of AIS patients treated with i.v. rt-PA in Italy from 2003 to 2009 included in the international internet-based SITS-ISTR.The presence and severity of the BE was assessed on 22-36 hour and 7-day neuroimaging as mild, moderate and severe.Total CLs were obtained within 24 hours from symptom onset.Univariate and multivariate analyses were performed. Results: Overall, 4194 patients were included,of which 2577/4194 (61.4%) had data on baseline CLs.We analyzed CLs based on quartiles:≤164 mg/dl,≤191 mg/dl,≤221 mg/dl and >221 mg/dl. 1126/3782 (29.8%) developed BE within 22-36 hours of symptom onset,397 of 1015 (39.1%) at 7 days. In 103 cases (25.9%)BE developed between 36 hours and 7 days.Of 1126 patients with both 22-36 hour and 7-day neuroimaging, 89 (7.9%)had a BE worsening and 21 (1.9%)an improvement.Compared to those without BE,patients with BE were more likely to be dependent before stroke (p=0.031),have AF (p<0.0001),have early ischemic signs on baseline CT,higher prevalence of cardioembolic and large vessel mechanism,more SICH per NINDS definition,(p<0.0001).BE+ subjects had higher baseline median NIHSS(17 vs 11,p<0.0001), blood glucose levels (BGLs)(p=0.001) and DBP(p=0.044).Patients with BE had a worse outcome in terms of 3-month mRS>2 (72.5 vs 35.3%) and death (25.8 vs 6.7%) (p<0.0001).Subjects with BE were less likely to have a history of dyslipidemia (p=0.009).Independent predictors of BE developing within 22-36 hours were baseline NIHSS(OR1.104,95%CI 1.085-1.124,p<0.0001), BGLs(OR1.003,95%CI 1.001-1.005, p=0.014), onset-to-door time interval (OR1.002,95%CI 1.000-1.005,p=0.017), early ischemic signs on baseline CT (OR1.797,95%CI 1.127-2.867,p 0.014).NIHSS was confirmed as the strongest independent predictor for the presence of BE at the 7-day neuroimaging and for moderate and severe BE. BGLs was the only independent predictor of BE worsening (OR1.007,95%CI 1.000-1.014,p=0.05).Lower baseline CLs, in particular values <164 mg/dl,were independent predictors of BE improvement (OR3.758,95%IC 1.299-10.869,p=0.015)whereas higher values (>221 mg/dl) were independent predictors of severe BE at the 7-day neuroimaging (OR2.020,95%CI 1.044-3.94,p=0.037). Conclusions: Our study did not show an independent association between lower baseline total CLs and the risk of BE developing after i.v. thrombolysis in AIS. More studies are necessary to address this issue, particularly considering also the LDL-CLs and the use of statins at stroke onset and during the hospital stay.

A study on relationship of Hounsfield Units value on non-contrast computer tomography and recanalization of intravenous thrombolysis

2021 ◽  
Vol 18 ◽  
Author(s):  
Zhen Wang ◽  
Kangping Song ◽  
Wei Xu ◽  
Guohua He ◽  
Tieqiao Feng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Characteristics ◽  
Intravenous Thrombolysis ◽  
Imaging Features ◽  
Hounsfield Units ◽  
Vessel Occlusion ◽  
Mean Values ◽  
Intravenous Alteplase ◽  
Relationship Of

Objective: To determine whether the administration of intravenous alteplase would be beneficial or futile to patients with acute ischemic stroke caused by large vessel occlusion (LVO) before endovascular treatment (EVT), we conducted this study to determine the relationship between Hounsfield units (HU) in non-contrast computed tomography (NCCT) and recanalization by alteplase. Methods: We performed a retrospective analysis of patients with acute ischemic stroke caused by LVO received intravenous thrombolysis (IVT) or followed by EVT at our center during November 2016 and October 2020. The clinical characteristics and imaging features of patients who achieved recanalization after IVT, and those who did not, were compared. Results: Forty-three eligible patients were enrolled; 12 achieved recanalization by IVT. Baseline clinical characteristics did not differ between patients of the recanalization and non-recanalization groups. HU in the NCCT were estimated and statistically significant maximum and mean values of the ipsilateral middle cerebral artery (MCA) were found between the groups (P< 0.05). The results hint that patients in the non-recanalization group have a higher rHU and δHU value of the ipsilateral MCA compared with recanalization group (P< 0.05). With regards the receiver operator characteristic (ROC) curve, we demonstrated that a high HU value of the ipsilateral MCA could be a predictor for non-recanalization by IVT. Conclusion: Patients suffering LVO stroke are less likely to obtain recanalization by IVT with a high HU value of the ipsilateral MCA. It is feasible to screen patients with LVO using HU for direct EVT.

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