scholarly journals Repeated Intravenous Thrombolysis in Patients with Recurrent Ischemic Stroke in the Vertebrobasilar Territory

2021 ◽  
pp. 510-514
Author(s):  
David Černík ◽  
Dušan Ospalík ◽  
Daniel Šaňák ◽  
Filip Cihlář
Keyword(s):  
Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Anterior Circulation ◽  
Poor Outcome ◽  
Vertebrobasilar Stroke ◽  
Therapeutic Time Window

Acute ischemic vertebrobasilar stroke (AIVBS) is usually associated with poor outcome and prognosis and in case of basilar artery occlusion (BAO) with high mortality. Intravenous thrombolysis (IVT), as a standard recanalization therapy of acute ischemic stroke (IS) within first 4.5 h, can be administrated beyond this therapeutic time window in case of symptomatic BAO. Repeated IVT is generally contraindicated in case of early recurrent IS, despite a risk of poor outcome or death after recurrent IS. The aim was to present 2 cases of repeated IVT for recurrent AIVBS and discuss specific situations where repeated IVT may be considered. Up to now, repeated IVT has been reported only in recurrent stroke in anterior circulation.

scholarly journals Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 49-55
Author(s):  
Huong Bich Thi Nguyen ◽  
Thang Huy Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Large Artery ◽  
Limited Information ◽  
Anterior Circulation ◽  
Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

Abstract 3286: Persistently Reduced Venous Drainage After Intravenous Thrombolysis is Associated With Poor outcome in Acute Anterior Circulation Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Leonard L Yeo ◽  
Ben Wakerley ◽  
Liang Shen ◽  
Aftab Ahmad ◽  
Kay W Ng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Venous Drainage ◽  
Cerebral Veins ◽  
Poor Functional Outcome ◽  
Anterior Circulation ◽  
Poor Outcome ◽  
Internal Cerebral Veins ◽  
Iv Tpa

Background- Significant numbers of acute ischemic stroke (AIS) patients recover with timely-administered intravenous tissue plasminogen activator (IV-TPA). However, rates and extent of recovery remain variable. Considering scarce and costly resources, early identification of reliable predictors for functional outcomes is important for planning rehabilitation strategies. We hypothesized that venous drainage would be impaired on the side of cerebral hypoperfusion due to acute occlusion of internal carotid or middle cerebral artery. The 2 internal cerebral veins (ICV) drain the deep parts of hemispheres and run backward to form great cerebral vein. Since ICVs are consistently seen on CT angiography (CTA), parallel and run very close to each other, even minor asymmetry in their filling can be easily diagnosed. ICV asymmetry in pre-TPA CTA can change in patients achieving arterial recanalization, rendering it less useful for predicting the long-term outcomes. Thus, we aimed at evaluating whether the presence of ICV asymmetry on follow-up CTA can predict the final outcome. Methods- Data from consecutive AIS patients treated with IV-TPA, in a standardized protocol, from Jan2007 to March2010 were included in a prospective registry at our tertiary center. In this study, we excluded posterior circulation strokes. Significant proportion AIS patients undergo CTA on day 2 after IV-TPA to assess the status of arterial patency. ICV asymmetry was assessed by 2 independent stroke neurologists/ neuroradiologists, blinded to patient data or outcomes. Functional outcomes were assessed by modified Rankin Scale (mRS) at 3-months, dichotomized as good outcome (mRS 0-1) and poor outcome (mRS 2-6). Data were analyzed for the early predictors of function outcome. Results- Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). Hypertension was the commonest vascular risk factor in 144 (76%) while 63 (33%) patients suffered from atrial fibrillation (AF). Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. ICV asymmetry could be assessed only in 103 (45.5%) patients on their follow up CTA films. Admission NIHSS score (OR1.08;95%CI 1.001-1.157,p=0.048) and ICV asymmetry on follow-up CT scan (OR 23.9;95%CI 5.15-63.99,p <0.0001) were associated with poor outcome at 3-months. Conclusion- Presence of the asymmetry of internal cerebral veins on the follow up CT angiography in acute ischemic stroke patients treated with IV-TPA can be used as an early predictor of poor functional outcome.

scholarly journals A leap forward in the endovascular management of acute basilar artery occlusion since the appearance of stent retrievers: a single-center comparative study

2017 ◽  
Vol 126 (5) ◽  
pp. 1578-1584 ◽  
Author(s):  
Robert Fahed ◽  
Federico Di Maria ◽  
Charlotte Rosso ◽  
Nader Sourour ◽  
Vincent Degos ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Basilar Artery ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Endovascular Management ◽  
Anterior Circulation ◽  
The Impact

OBJECTIVEContrary to acute ischemic stroke involving the anterior circulation, no randomized trial has yet demonstrated the safety and effectiveness of endovascular management in acute basilar artery occlusion (BAO). Recently developed thrombectomy devices, such as stentrievers and aspiration systems, have helped in improving the endovascular management of acute ischemic stroke. The authors sought to assess the impact of these devices in the endovascular treatment of acute BAO.METHODSA retrospective analysis of 34 consecutive patients treated in Pitié-Salpêtrière Hospital for acute BAO was carried out. All patients had undergone an endovascular procedure. In addition to the global results in terms of safety and effectiveness (recanalization rate and 3-month clinical outcome based on the modified Rankin Scale [mRS]), the authors aimed to determine if the patients treated with the most recently developed devices (i.e., the Solitaire stentriever or the ADAPT catheter) had better angiographic and clinical outcomes than those treated with older endovascular strategies.RESULTSThe overall successful recanalization rate (thrombolysis in cerebral infarction score 2b–3) was 50% (17 of 34 patients). A good clinical outcome (mRS score 0–2 at 3-month follow-up) was achieved in 11 (32.3%) of 34 patients. The mortality rate at 3-month follow-up was 29.4% (10 of 34 patients). Patients treated with the Solitaire stentriever and the ADAPT catheter had a higher recanalization rate (12 [92.3%] of 13 patients vs 5 [23.8%] of 21 patients, p = 0.0002) and a shorter mean (± SD) procedure duration (88 ± 31 minutes vs 126 ± 58 minutes, p = 0.04) than patients treated with older devices.CONCLUSIONSThe latest devices have improved the effectiveness of mechanical thrombectomy in acute BAO. Their use in further studies may help demonstrate a benefit in the endovascular management of acute BAO.

scholarly journals ENDOVASCULARAPPROACHES TOACUTE ISCHEMIC STROKE- INDIAN PERSPECTIVE

2020 ◽  
Vol 7 (3) ◽  
pp. 7-14
Author(s):  
Pramod Dhonde ◽  
N. Kadam
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Review Literature ◽  
Large Artery ◽  
Stroke Event ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Indian Perspective

Aim: To review literature about endovascular approaches to acute ischemic stroke and provide Indian perspective about managing these cases. Brief Summary: In acute ischemic stroke cases, intravenous thrombolysis (IVT) with altepase within 4.5 hours has been the standard of care. Due to certain limitations of IVT, in pooled patientlevel data from 5 trials (HERMES [Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials], which included the 5 trials MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA), mechanical thrombectomy (MT) is indicated for patients with acute ischemic stroke due to a large artery occlusion (LVO) in the anterior circulation who can be treated within 24 hours of the time last known to be well (ie, at neurologic baseline), regardless of whether they received intravenous alteplase for the same ischemic stroke event. The maximum benefit can be achieved within 6 hours of onset of symptoms. There are studies suggesting the benefit of MT in posterior circulation stroke as well as in distal arteries. We are going to review the methodology of endovascular techniques in brief alongwith Indian perspective on feasibility of this treatment approach in AIS. Conclusion: Mechnicalthrombectomy is certainly an effective modality of treatment in large vessel occlusion in anterior circulation within 24 hours. More awareness regarding the approach in India, can reduce the stroke morbidity and mortality in many of the cases in future

Predictors for Mortality after Mechanical Thrombectomy of Acute Basilar Artery Occlusion

2018 ◽  
Vol 45 (1-2) ◽  
pp. 61-67 ◽  
Author(s):  
Benjamin Gory ◽  
Mikael Mazighi ◽  
Julien Labreuche ◽  
Raphael Blanc ◽  
Michel Piotin ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Basilar Artery ◽  
Strong Predictor ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Stroke Patients ◽  
Clinical Registry ◽  
Intermediate Outcomes ◽  
Antithrombotic Medication

Background: Modern endovascular thrombectomy (MET), using stent retrievers or large-bore distal aspiration catheters in stroke patients with acute basilar artery occlusion (BAO), is routinely performed to date. However, more than 35% of BAO patients treated with MET die within 90 days despite high recanalization rates. The purpose of this study is to investigate the parameters associated with 90-day mortality in patients with BAO after MET. Methods: We analyzed 117 consecutive BAO patients included in the Endovascular Treatment in Ischemic Stroke prospective clinical registry of consecutive acute ischemic stroke patients treated with MET (60 patients [51.3%] treated with a stent retriever as first-line technique) between March 2010 and April 2017. Successful recanalization was defined as modified thrombolysis In cerebral infarction scores 2b-3 at the end of MET, and mortality was defined as modified Rankin Scale 6 at 90 days. Associations of baseline characteristics (patient and treatment characteristics) and intermediate outcomes (recanalization, complications) with 90-day mortality were investigated in univariate and multivariate analyses. Results: Overall successful recanalization rate was 79.5, and 41.9% (95% CI 32.8–51.0%) of patients died within 90 days after MET. Patients with successful recanalization had a lower mortality rate (32.9 vs. 74.4%; p < 0.001). Failure of successful recanalization was an independent predictor of mortality (OR 5.1; 95% CI 1.34–19.33). In multivariate analysis, age ≥60 years (OR 6.37; 95% CI 1.74–23.31), admission National Institute of Health Stroke Scale (NIHSS) ≥13 (OR 4.62; 95% CI 1.42–15.03), lower posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS; OR 1.71; 95% CI 1.19–2.44), use of antithrombotic medication prior to stroke onset (OR 3.38; 95% CI 1.03–11.08), absence of intravenous thrombolysis (OR 3.36; 95% CI 1.12–10.03), and angioplasty/stenting of the basilar artery (OR 4.71; 95% CI 1.34–16.54) were independent predictors for mortality after MET. Conclusions: Failure of successful recanalization was a strong predictor for mortality. In the setting of recanalization, age, admission NIHSS, pc-ASPECTS, absence of intravenous thrombolysis, and angioplasty/stenting of the basilar artery were also independent predictors for mortality after MET of BAO patients.

scholarly journals IV-Thrombolysis in Ischemic Stroke With Unknown Time of Onset—Safety and Outcomes in Posterior vs. Anterior Circulation Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Kosmas Macha ◽  
Philip Hoelter ◽  
Gabriela Siedler ◽  
Ruihao Wang ◽  
Michael Knott ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Time Window ◽  
Statistical Significance ◽  
Intravenous Thrombolysis ◽  
Mortality Rates ◽  
Extended Time ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Hemorrhagic Complications ◽  
Patient Groups

Background: rt-PA for ischemic stroke in the unknown or extended time window beyond the first 4. 5 h after symptom onset is safe and effective for certain patients after selection by multimodal neuroimaging. However, the evidence for this approach comes mainly from patients with anterior circulation stroke (ACS), while the data on posterior circulation stroke (PCS) are scarce.Methods: Ischemic stroke patients treated with IV-thrombolysis in the unknown or extended time window between January 2011 and May 2019 were identified from an institutional registry. The patients were categorized into PCS or ACS based on clinico-radiological findings. We analyzed the hemorrhagic complications, clinical and imaging efficacy outcomes, and mortality rates by comparing the PCS and ACS patient groups. Adjusted outcome analyses were performed after propensity score matching for the relevant factors.Results: Of the 182 patients included, 38 (20.9%) had PCS and 144 (79.1%) had ACS. Symptomatic acute large vessel occlusion (LVO) was present in 123 patients on admission [27 (22.0%) PCS and 96 (78.0%) ACS]. The score on the National Institutes of Health Stroke Scale (NIHSS), the time from last seen normal, and the door-to-needle times were similar in PCS and ACS. In patients with LVO, the NIHSS score was lower [8 (5–15) vs. 14 (9–18), p = 0.005], and infarction visible on follow-up imaging was less common [70.4 vs. 87.5%; aRD, −18.9% (−39.8 to −2.2%)] in the PCS patient group. There was a trend toward a lower risk for intracranial hemorrhage (ICH) following intravenous thrombolysis in PCS vs. ACS, without reaching a statistical significance [5.3 vs. 16.9%; aRD, −10.4% (−20.4 to 4.0%)]. The incidence of symptomatic ICH [according to the ECASS III criteria: 2.6 vs. 3.5%; aRD, −2.9% (−10.3 to 9.2%)], efficacy outcomes, and mortality rates were similar in PCS and ACS patients.Conclusions: In this real-world clinical cohort, the safety and the efficacy of rt-PA for ischemic stroke in the unknown or extended time window did not show relevant differences between PCS and ACS, with a trend toward less hemorrhagic complications in PCS. The findings reconfirm the clinician in the usage of rt-PA beyond the first 4.5 h also in selected patients with PCS.

scholarly journals Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion

2017 ◽  
Vol 6 (3-4) ◽  
pp. 254-262
Author(s):  
Xiongjun He ◽  
Liang Zhang ◽  
Juan Yang ◽  
Hui Zheng ◽  
Kaifeng Li ◽  
...  
Keyword(s):  
Drug Treatment ◽  
Basilar Artery ◽  
Multimodal Therapy ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Average Score ◽  
Parent Artery

Objective: The aim of this study was to evaluate the feasibility and safety of multimodal therapy for patients with non-superacute vertebral basilar artery occlusion. Method: We performed a retrospective analysis of multimodal therapy for patients with vertebral basilar artery occlusion. All patients who were beyond the time window to receive intravenous thrombolysis and who had deterioration of symptoms after drug treatment received small-balloon dilatation of the occlusive artery to estimate vascular occlusion aetiology. Thrombectomy with a Solitaire AB system was applied to the thrombus, and angioplasty with intracranial stents was used to treat stenosis. During the 3-month follow-up, National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores were recorded regularly. Results: We included 12 patients with a mean age of 60.4 (SD: 12.9) years. The average score on the NIHSS was 16.6 (SD: 11.6), and the average time from onset to admission was 95 h (SD: 121). The arteries were recanalized for all patients, but the degree of residual stenosis in the parent artery was 17.5% (SD: 20.1). During the follow-up period, one patient died of pulmonary haemorrhage and infection, and another patient died from haemorrhage related to high perfusion. After 3 months of follow-up, the 10 surviving patients showed an average NIHSS score of 7.9 (SD: 8.7) and an average mRS score below 2 (1.3 ± 1.4). Conclusion: For patients with posterior circulation stroke due to basilar artery or vertebral artery occlusion who present to the hospital 6 h after symptom onset and who exhibit deterioration of symptoms after drug treatment, multimodal recanalization of the occluded artery may be a feasible and safe therapy.

scholarly journals Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome

2021 ◽  
Vol 12 ◽  
pp. 445
Author(s):  
Akinari Yamano ◽  
Yasunobu Nakai ◽  
Kazuki Akutagawa ◽  
Haruki Igarashi ◽  
Kazuaki Tsukada ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Vertebral Artery ◽  
Mechanical Thrombectomy ◽  
Recurrent Stroke ◽  
Recombinant Tissue Plasminogen Activator ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Tissue Plasminogen ◽  
The Right ◽  
Cerebral Artery Occlusion

Background: Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin. Case Description: The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy. Conclusion: Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.

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