Intravenous Thrombolysis Is Associated with Less Disabling Stroke and Lower Mortality in Multiple-Pass Endovascular Thrombectomy

2021 ◽  
pp. 1-6
Author(s):  
Christopher Blair ◽  
Leon Edwards ◽  
Cecilia Cappelen-Smith ◽  
Dennis Cordato ◽  
Andrew Cheung ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Additional Benefit ◽  
Modified Rankin Scale ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Multiple Pass ◽  
First Pass

<b><i>Background and Purpose:</i></b> The benefit of bridging intravenous thrombolysis (IVT) in acute ischaemic stroke patients eligible for endovascular thrombectomy (EVT) is unclear. This may be particularly relevant where reperfusion is achieved with multiple thrombectomy passes. We aimed to determine the benefit of bridging IVT in first and multiple-pass patients undergoing EVT ≤6 h from stroke onset to groin puncture. <b><i>Methods:</i></b> We compared 90-day modified Rankin Scale (mRS) outcomes in 187 consecutive patients with large vessel occlusions (LVOs) of the anterior cerebral circulation who underwent EVT ≤6 h from symptom onset and who achieved modified thrombolysis in cerebral ischaemia (mTICI) 2c/3 reperfusion with the first pass to those patients who required multiple passes to achieve reperfusion. The effect of bridging IVT on outcomes was examined. <b><i>Results:</i></b> Significantly more first-pass patients had favourable (mRS 0–2) 90-day outcomes (68 vs. 42%, <i>p</i> = 0.001). Multivariate analysis showed an association between first-pass reperfusion and favourable outcomes (OR 2.25; 95% CI 1.08–4.68; <i>p</i> = 0.03). IVT provided no additional benefit in first-pass patients (OR 1.17; CI 0.42–3.20; <i>p</i> = 0.76); however, in multiple-pass patients, it reduced the risk of disabling stroke (mRS ≥4) (OR 0.30; CI 0.10–0.88; <i>p</i> = 0.02) and mortality (OR 0.07; CI 0.01–0.36; <i>p</i> = 0.002) at 90 days. <b><i>Conclusion:</i></b> Bridging IVT may benefit patients with anterior circulation stroke with LVO who qualify for EVT and who require multiple passes to achieve reperfusion.

Abstract TP28: Intravenous Thrombolysis is Associated With Better Functional Outcomes in Endovascular Thrombectomy Patients Requiring Multiple-Passes to Achieve Reperfusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Blair ◽  
Cecilia Cappelen-Smith ◽  
Dennis Cordato ◽  
Leon Edwards ◽  
Amer Mitchelle ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Independent Effect ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Multiple Pass ◽  
First Pass

Introduction: In patients with anterior circulation stroke with large vessel occlusion (LVO), recent data suggest that successful reperfusion (mTICI≥2b) after a single device pass results in more favourable functional outcomes in comparison to patients requiring multiple passes. It is unclear if this effect represents an epiphenomenon or a true independent effect. Methods: A prospectively maintained database of EVT was interrogated for patients presenting with anterior circulation LVO with onset to groin puncture times of ≤ 6 hours from January 2016 to March 2019. Three-month functional outcomes were compared between first-pass reperfusion and multiple-pass reperfusion patients using logistic regression. Results: A total of 169 patients were identified (mean age 71 yrs, 44% female, median NIHSS 17, intravenous thrombolysis (IVT) in 47%). Successful reperfusion (mTICI≥2b) was achieved with the first-pass (FP) in 80 patients (47%) and multiple-passes (MP) in 89 patients (53%). First pass patients had better outcomes when compared to MP patients (mRS 0-2 71% vs 31%, p < 0.001). No difference in functional outcomes was seen between FP patients who received IVT and those that did not (mRS 0-2 68% vs 75%, p = 0.459). Multiple-pass patients who received IVT achieved higher rates of functional independence than those who did not (mRS 0-2 40% vs 27%, p = 0.035). Conclusion: Intravenous thrombolysis may improve functional recovery in EVT patients requiring multiple-passes to achieve reperfusion. Prospective studies should be considered.

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

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.

Abstract TP62: Frequency, Characteristics, and Outcomes of Acute Ischemic Stroke Patients With “Total Mismatch” on Penumbral Imaging Before Reperfusion Therapy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Hai Jui CHU ◽  
David Liebeskind ◽  
Yannan Yu ◽  
Bryan Yoo ◽  
Latisha Sharma ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Frequency Characteristics ◽  
Lesion Volume ◽  
Therapy Outcomes ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Penumbral Imaging ◽  
Acute Cerebral Ischemia

Background: When penumbral imaging shows “total mismatch” (large perfusion lesion and no irreversibly infarcted core), the entirety of jeopardized brain is still salvageable and the benefits of reperfusion therapy may be enhanced. The frequency, characteristics, and reperfusion therapy outcomes of total mismatch patients has not been well-characterized. Methods: Analysis of consecutive acute cerebral ischemia patients in anterior circulation undergoing CT or MR penumbral imaging prior to intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT). Patients were classified in four groups: 1) total mismatch (core 0% of perfusion lesion), 2) non-total but substantial mismatch (core 1-20% of perfusion lesion), 3) moderate or no mismatch (core 20-100% of perfusion lesion), and 4) small perfusion lesion (perfusion lesion volume <10 ml). Results: Among 180 patients, pretreatment imaging patterns were: total mismatch 28.9%, substantial mismatch 22.8%, moderate or no mismatch 22.8%, and small perfusion lesion 25.6%. Among total mismatch patients, the Tmax>6 sec perfusion lesion volume was 56.5 ml (IQR 28.3-85.6) and time from last known well to imaging was 89 mins (IQR 65-296). Compared to moderate patients, clinical features of total mismatch patients were: older (76.0 vs 65.9, p=0.006), lower NIHSS (median 12 vs 18, p=0.019), and more cardioembolism (76.9% vs 48.8%, p=0.005). Total mismatch patients more often had CT than MR (65.4% vs 14.6%, p=0.000), less ICA occlusion (15.4% vs 34.1%, p=0.035), and smaller perfusion lesions (median 56.5 vs 82.1 ml, p=0.007). Total mismatch patients were treated with combined IVT+EVT in 32.7%, IVT alone in 26.9%, and EVT alone in 40.4%. Freedom from disability (mRS 0-1) at discharge was more frequent, 35.6% vs 16.2%, p=0.049 and disability levels at day 90 were lower in total mismatch patients, mean mRS 2.7 vs 3.9, p=0.029. Conclusion: Total mismatch is present in one-quarter of patients undergoing reperfusion therapy, more often in older patients with cardioembolism as etiology of stroke. Total mismatch patients have better disability outcomes from reperfusion therapy, but more than half show disability indicating need for more complete reperfusion.

scholarly journals Significant aortic stenosis associated with poorer functional outcomes in patients with acute ischaemic stroke undergoing endovascular therapy

2020 ◽  
Vol 26 (6) ◽  
pp. 793-799
Author(s):  
Nicholas JH Ngiam ◽  
Benjamin YQ Tan ◽  
Ching-Hui Sia ◽  
Bernard PL Chan ◽  
Gopinathan Anil ◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Ischaemic Stroke ◽  
Functional Outcome ◽  
Acute Ischaemic Stroke ◽  
Functional Outcomes ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and aim Bi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke. Methods Consecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm2) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months. Results We identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68–84) vs. 67 (interquartile range 56–75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1–7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation. Conclusion In acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.

scholarly journals Intravenous thrombolysis outcome in posterior vs anterior circulation stroke in a tertiary stroke center in Egypt

2021 ◽  
Vol 57 (1) ◽  
Author(s):  
Nourhan Abdelmohsen Taha ◽  
Hala El Khawas ◽  
Mohamed Amir Tork ◽  
Tamer M. Roushdy
Keyword(s):  
Intravenous Thrombolysis ◽  
Posterior Circulation ◽  
University Hospitals ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Time Points ◽  
Posterior Circulation Stroke ◽  
First Line Therapy ◽  
Insignificant Difference ◽  
Stroke Center

Abstract Background Intravenous thrombolysis (IVT) with alteplase is the first-line therapy for acute ischemic anterior and posterior circulation strokes (ACS and PCS). Knowledge about safety and efficacy of IVT in posterior circulation stroke is deficient as most of the Egyptian studies either assessed IVT outcome in comparison to conservative therapy or its outcome in anterior circulation stroke only. Therefore, our aim was to compare the relative frequency and outcome after intravenous thrombolysis in anterior versus posterior circulation stroke patients presenting to stroke centers of Ain Shams University hospitals (ASUH). Results A total of 238 anterior circulation stroke and 61 posterior circulation strokes were enrolled, onset-to-door and door-to-needle time were statistically insignificant. NIHSS showed comparable difference at all time points despite higher scores along anterior circulation stroke; 90-day modified Rankin Scale (mRS) showed significant improvement in both groups from mRS >2 to ≤2 with a better percentage along posterior circulation stroke patients. There was insignificant difference for either incidence of death or intracranial hemorrhage (ICH) between the two groups. Conclusion IVT significantly reduced NIHSS for both anterior and posterior circulation stroke along different studied time points. Meanwhile, a higher percentage of patients with posterior circulation stroke had a better mRS outcome at 90 days.

scholarly journals In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

2020 ◽  
Author(s):  
Juha-Pekka Pienimäki ◽  
Jyrki Ollikainen ◽  
Niko Sillanpää ◽  
Sara Protto
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ordinal Logistic Regression Analysis ◽  
Stroke Center

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.

Obesity in acute ischaemic stroke patients treated with intravenous thrombolysis therapy

2021 ◽  
pp. 1-8
Author(s):  
Hongmin Li ◽  
Suliman Khan ◽  
Rabeea Siddique ◽  
Qian Bai ◽  
Yang Liu ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Thrombolysis Therapy

scholarly journals Switch Strategy from Direct Aspiration First Pass Technique to Solumbra Improves Technical Outcome in Endovascularly Treated Stroke

2021 ◽  
Vol 18 (5) ◽  
pp. 2670
Author(s):  
Enrico Pampana ◽  
Sebastiano Fabiano ◽  
Gianluca De Rubeis ◽  
Luca Bertaccini ◽  
Alessandro Stasolla ◽  
...  
Keyword(s):  
Added Value ◽  
Stroke Patients ◽  
First Line ◽  
Anterior Circulation ◽  
First Pass ◽  
Procedural Time ◽  
The Mean ◽  
The Difference ◽  
Number Of Passes ◽  
Switch Strategy

Background: The major endovascular mechanic thrombectomy (MT) techniques are: Stent-Retriever (SR), aspiration first pass technique (ADAPT) and Solumbra (Aspiration + SR), which are interchangeable (defined as switching strategy (SS)). The purpose of this study is to report the added value of switching from ADAPT to Solumbra in unsuccessful revascularization stroke patients. Methods: This is a retrospective, single center, pragmatic, cohort study. From December 2017 to November 2019, 935 consecutive patients were admitted to the Stroke Unit and 176/935 (18.8%) were eligible for MT. In 135/176 (76.7%) patients, ADAPT was used as the first-line strategy. SS was defined as the difference between first technique adopted and the final technique. Revascularization was evaluated with modified Thrombolysis In Cerebral Infarction (TICI) with success defined as mTICI ≥ 2b. Procedural time (PT) and time to reperfusion (TTR) were recorded. Results: Stroke involved: Anterior circulation in 121/135 (89.6%) patients and posterior circulation in 14/135 (10.4%) patients. ADAPT was the most common first-line technique vs. both SR and Solumbra (135/176 (76.7%) vs. 10/176 (5.7%) vs. 31/176 (17.6%), respectively). In 28/135 (20.7%) patients, the mTICI was ≤ 2a requiring switch to Solumbra. The vessel’s diameter positively predicted SS result (odd ratio (OR) 1.12, confidence of interval (CI) 95% 1.03–1.22; p = 0.006). The mean number of passes before SS was 2.0 ± 1.2. ADAPT to Solumbra improved successful revascularization by 13.3% (107/135 (79.3%) vs. 125/135 (92.6%)). PT was superior for SS comparing with ADAPT (71.1 min (CI 95% 53.2–109.0) vs. 40.0 min (CI 95% 35.0–45.2); p = 0.0004), although, TTR was similar (324.1 min (CI 95% 311.4–387.0) vs. 311.4 min (CI 95% 285.5–338.7); p = 0.23). Conclusion: Successful revascularization was improved by 13.3% after switching form ADAPT to Solumbra (final mTICI ≥ 2b was 92.6%). Vessel’s diameter positively predicted recourse to SS.

Eloquence-based reperfusion scoring and its ability to predict post-thrombectomy disability and functional status

2021 ◽  
pp. 159101992110464
Author(s):  
Elliot Pressman ◽  
Victoria Sands ◽  
Gabriel Flores ◽  
Liwei Chen ◽  
Rahul Mhaskar ◽  
...  
Keyword(s):  
Frontal Lobe ◽  
Functional Outcomes ◽  
Visual Fields ◽  
Predictive Ability ◽  
Occipital Lobe ◽  
Cerebral Infarct ◽  
Modified Rankin Scale ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Post Procedure

Background Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score. Methods Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale. Results One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = −1.60, p = 0.002) and occipital lobe non-reperfusion (MD = −1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = −0.734, p = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = −3.39 to −0.072, p = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = −5.34, 95%CI = −9.52 to −1.18, p = 0.013) and occipital lobe non-reperfusion (MD = −6.35, 95%CI = −10.4 to −2.31, p = 0.002). Odds of achieving modified Rankin Scale of 0–2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090–0.869, p = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153–0.922, p = 0.033). Conclusions Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Abstract WP78: Intracranial Calcification is Predictive for Hemorrhage Transformation and Prognosis After Intravenous Thrombolysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Yao Yu ◽  
Fu-Liang Zhang ◽  
Yin-Meng Qu ◽  
Hong-Wei Zhou ◽  
Zhenni Guo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Poor Prognosis ◽  
Intravenous Thrombolysis ◽  
Major Complication ◽  
Third Party ◽  
Intracranial Calcification ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Cerebrovascular Function ◽  
Lesion Side

Introduction: Hemorrhage transformation is the major complication of intravenous thrombolysis, which can deteriorate the prognosis of ischemic stroke patients. Calcification is widely used as an imaging indicator of atherosclerotic burden and cerebrovascular function. The relationship between intracranial calcification and hemorrhage transformation has not been fully explained. Here, we aimed to identify and quantify calcification in the main cerebral vessels to investigate the correlations between quantitative calcification parameters, hemorrhage transformation, and prognosis. Methods: Acute noncardiogenic ischemic stroke patients with anterior circulation who received intravenous thrombolysis therapy in the First Hospital of Jilin University from July 2015 to June 2017 were retrospectively consecutively included. All the patients included underwent a baseline CT before intravenous thrombolysis and a follow-up CT at 24 hours. A third-party software, ITK-SNAP, was used for segmentation and measurement of the calcification volume. A vascular non-bone component with a CT value >130 HU was judged to be calcified. The criterion for poor prognosis was an mRS score > 2 at 3 months. Results: A total of 146 patients were included, among which 128 patients were identified to have calcification. Twenty-one patients developed hemorrhage transformation. The risk of hemorrhage transformation in the extreme group of calcification volume on the lesion side was 10.018 times that of the none to mild groups (OR=10.018, 95% CI: 1.030-97.396). Sixty-one patients had poor prognosis. The risk of poor prognosis increased by 54.7% for each additional calcified vessel (OR=1.547, 95% CI: 1.038-2.305). Conclusions: High calcification volume burden on the lesion side is associated with hemorrhage transformation after intravenous thrombolysis. The higher the number of calcified vessels, the greater is the risk of poor prognosis.

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