Clinical-Diffusion Mismatch Is Associated with Early Neurological Improvement after Late-Window Endovascular Treatment

2021 ◽  
pp. 1-7
Author(s):  
Bum Joon Kim ◽  
Yoojin Lee ◽  
Boseong Kwon ◽  
Jun Young Chang ◽  
Yun Sun Song ◽  
...  
Keyword(s):  
Multivariable Analysis ◽  
National Institutes Of Health ◽  
Lesion Volume ◽  
Diffusion Weighted Image ◽  
Endovascular Thrombectomy ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Window Period ◽  
Score Improvement ◽  
Time Period

<b><i>Background:</i></b> Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are used to select patients for endovascular thrombectomy (EVT) in the late-window period. As CDM well reflects true penumbra, we hypothesized that patients with CDM and PDM would respond better to EVT than those with PDM only at the late-window period. <b><i>Methods:</i></b> Acute ischemic stroke patients who received EVT 6–24 h after stroke onset were included. PDM (perfusion-/diffusion-weighted image (DWI) lesion volume &#x3e;1.8) was used to select candidates for EVT in this time-period in our center. CDM was defined according to the DAWN trial criteria. Response to EVT was compared between patients with and without CDM. Early neurological improvement (ENI) was defined as improvement &#x3e;4 points on National Institutes of Health Stroke Scale (NIHSS) score 1 day after EVT. Multivariable analysis was performed to investigate independent factors associated with ENI. The correlation between DWI lesion volume and NIHSS score was investigated in those with and without CDM. <b><i>Results:</i></b> Among 94 patients enrolled, all patients had PDM and 44 (46.3%) had CDM. Forty-eight patients (51.1%) showed ENI. The prevalence of hypertension, initial NIHSS score, improvement in NIHSS score after EVT, and prevalence of ENI were greater in patients with CDM than those without. ENI was independently associated with onset-to-door time (odds ratio [95% confidence interval]: 0.998 [0.997–1.000]; <i>p</i> = 0.042), complete recanalization (23.912 [2.238–255.489]; <i>p</i> = 0.009), initial NIHSS score (1.180 [1.012–1.377]; <i>p</i> = 0.034), and the presence of CDM (5.160 [1.448–18.386]; <i>p</i> = 0.011). The correlation between DWI lesion volume and initial NIHSS score was strong in patients without CDM (<i>r</i> = 0.731) but only moderate in patients with CDM (<i>r</i> = 0.355). <b><i>Conclusion:</i></b> Patients with both CDM and PDM had a better response to late-window EVT than those with PDM only.

scholarly journals Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1428-1434 ◽  
Author(s):  
Yasir Saleem ◽  
Raul G. Nogueira ◽  
Gabriel M. Rodrigues ◽  
Song Kim ◽  
Vera Sharashidze ◽  
...  
Keyword(s):  
Multivariable Analysis ◽  
National Institutes Of Health ◽  
Neurological Deterioration ◽  
Large Vessel ◽  
Minor Stroke ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Nihss Score ◽  
Acute Neurological Deterioration

Background and Purpose— It is unclear which factors predict acute neurological deterioration in patients with large vessel occlusion and mild symptoms. We aim to evaluate the frequency, timing, and potential predictors of acute neurological deterioration ≥4 National Institutes of Health Stroke Scale (NIHSS) points in medically managed patients with large vessel occlusion and mild presentation. Methods— Single-center retrospective study of patients with consecutive minor stroke (defined as NIHSS score of ≤5 on presentation) and large vessel occlusion from January 2014 to December 2017. Primary outcome was acute neurological deterioration ≥4 NIHSS points during the hospitalization. Secondary outcomes included ΔNIHSS (defined as discharge minus admission NIHSS score). Results— Among 1133 patients with acute minor strokes, 122 (10.6%) had visible occlusions on computed tomography angiography/magnetic resonance angiography. Twenty-four (19.7%) patients had ≥4 points deterioration on NIHSS at a median of 3.6 (1–16) hours from arrival. No clinical or radiological predictors of acute neurological deterioration ≥4 NIHSS points were observed on multivariable analysis. Rescue endovascular thrombectomy was performed more often in the ones with acute neurological deterioration ≥4 NIHSS points compared with patients with no deterioration (54% versus 0%; P <0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%; P <0.01) and a trend toward lower independence rates at discharge (50% versus 70%; P =0.06) compared with the group with no deterioration. In patients with any degree of neurological worsening, patients who underwent rescue thrombectomy were more likely to be independent at discharge (73% versus 38%; P =0.02) and to have a favorable ΔNIHSS (−2 [−3 to 0] versus 0 [−1 to 6]; P =0.05) compared with the ones not offered rescue thrombectomy. Conclusions— Acute neurological deterioration ≥4 NIHSS points was observed in a fifth of patients with large vessel occlusion and mild symptoms, occurred very early in the hospital course, impacted functional outcomes, and could not be predicted by any of the studied clinical and radiological variables. Rescue thrombectomy was associated with improved clinical outcomes at discharge in patients with neurological deterioration.

Pre-Admission CHADS2 and CHA2DS2-VASc Scores on Early Neurological Worsening

2021 ◽  
pp. 1-8
Author(s):  
Ki-Woong Nam ◽  
Chi Kyung Kim ◽  
Sungwook Yu ◽  
Jong-Won Chung ◽  
Oh Young Bang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Stroke Risk ◽  
Multivariable Analysis ◽  
National Institutes Of Health ◽  
Risk Scores ◽  
Stroke Patients ◽  
Nihss Score ◽  
Early Neurological Deterioration ◽  
Close Relationship ◽  
The Relationship

<b><i>Background:</i></b> Stroke risk scores (CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc) not only predict the risk of stroke in atrial fibrillation (AF) patients, but have also been associated with prognosis after stroke. <b><i>Objective:</i></b> The aim of this study was to evaluate the relationship between stroke risk scores and early neurological deterioration (END) in ischemic stroke patients with AF. <b><i>Methods:</i></b> We included consecutive ischemic stroke patients with AF admitted between January 2013 and December 2015. CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores were calculated using the established scoring system. END was defined as an increase ≥2 on the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 on the motor NIHSS score within the first 72 h of admission. <b><i>Results:</i></b> A total of 2,099 ischemic stroke patients with AF were included. In multivariable analysis, CHA<sub>2</sub>DS<sub>2</sub>-VASc score (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.04–1.31) was significantly associated with END after adjusting for confounders. Initial NIHSS score, use of anticoagulants, and intracranial atherosclerosis (ICAS) were also found to be closely associated with END, independent of the CHA<sub>2</sub>DS<sub>2</sub>-VASc score. Multivariable analysis stratified by the presence of ICAS demonstrated that both CHA<sub>2</sub>DS<sub>2</sub>-VASc (aOR = 1.20, 95% CI = 1.04–1.38) and CHADS<sub>2</sub> scores (aOR = 1.24, 95% CI = 1.01–1.52) were closely related to END in only patients with ICAS. In patients without ICAS, neither of the risk scores were associated with END. <b><i>Conclusions:</i></b> High CHA<sub>2</sub>DS<sub>2</sub>-VASc score was associated with END in ischemic stroke patients with AF. This close relationship is more pronounced in patients with ICAS.

Management of tandem occlusion stroke with endovascular therapy

2012 ◽  
Vol 32 (5) ◽  
pp. E16 ◽  
Author(s):  
Haitham Dababneh ◽  
Waldo R. Guerrero ◽  
Anna Khanna ◽  
Brian L. Hoh ◽  
J Mocco
Keyword(s):  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
National Institutes Of Health ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Point Reduction ◽  
Mca Occlusion ◽  
Tandem Occlusion ◽  
Multimodality Approach ◽  
Extracranial Ica

Object Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant internal carotid artery (ICA) occlusion, and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. The authors report their experience with acute ischemic stroke patients who suffered tandem ICA/MCA (TIM) occlusions and underwent intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy. Methods In a retrospective analysis of their stroke database (2008–2011), the authors identified 2 patients with TIM occlusion treated with intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy. They examined early neurological improvement defined by a greater than 10-point reduction of National Institutes of Health Stroke Scale (NIHSS) score and an improved modified Rankin Scale (mRS) score at 60 days. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2 or 3 was also evaluated. Results In both patients a TICI score of 2b or 3 was achieved, signifying successful recanalization. In addition, both patients had a reduction in the NIHSS score by greater than 10 points and an mRS score of 0 at 60 days. Conclusions Tandem occlusions of the cervical ICA and MCA may be successfully treated using the multimodality approach of intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy.

scholarly journals Clinical-CT mismatch defined NIHSS ≥ 8 and CT-ASPECTS ≥ 9 as a reliable marker of candidacy for intravenous thrombolytic therapy in acute ischemic stroke

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0251077
Author(s):  
Hung-Ming Wu ◽  
I-Hui Lee ◽  
Chao-Bao Luo ◽  
Chih-Ping Chung ◽  
Yung-Yang Lin
Keyword(s):  
Thrombolytic Therapy ◽  
Intravenous Thrombolysis ◽  
Incidence Rates ◽  
Favorable Outcome ◽  
Stroke Severity ◽  
Lesion Volume ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Early Neurological Deterioration ◽  
Reliable Marker

Background Clinical-diffusion mismatch between stroke severity and diffusion-weighted imaging lesion volume seems to identify stroke patients with penumbra. However, urgent magnetic resonance imaging is sometimes inaccessible or contraindicated. Thus, we hypothesized that using brain computed tomography (CT) to determine a baseline “clinical-CT mismatch” may also predict the responses to thrombolytic therapy. Methods Brain CT lesions were measured using the Alberta Stroke Program Early CT Score (ASPECTS). A total of 104 patients were included: 79 patients with a baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 8 and a CT-ASPECTS ≥ 9 who were defined as clinical-CT mismatch-positive (P group) and 25 patients with an NIHSS score ≥ 8 and a CT-ASPECTS < 9 who were defined as clinical-CT mismatch-negative (the N group). We compared their clinical outcomes, including early neurological improvement (ENI), early neurological deterioration (END), delta NIHSS score (admission NIHSS—baseline NIHSS score), symptomatic intracranial hemorrhage (sICH), mortality, and favorable outcome at 3 months. Results Patients in the P group had a greater proportion of favorable outcome at 3 months (p = 0.032) and more frequent ENI (p = 0.038) and a greater delta NIHSS score (p = 0.001), as well as a lower proportion of END (p = 0.004) than those in the N group patients. There were no significant differences in the incidence rates of sICH and mortality between the two groups. Conclusions Clinical-CT mismatch may be able to predict which patients would benefit from intravenous thrombolysis.

scholarly journals Non-atrial fibrillation was associated with early neurological improvement after intravenous thrombolysis with rt-PA in patients with acute ischemic stroke

2019 ◽  
Author(s):  
Jie Liu ◽  
Jiaqi Huang ◽  
Huimin Xu ◽  
Haibin Dai
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Time ◽  
Independent Predictor ◽  
Multivariable Analysis ◽  
Laboratory Data ◽  
Intravenous Thrombolysis ◽  
Nihss Score ◽  
Neurological Improvement

Abstract Background To investigate the factors associated with early neurological improvement of intravenous recombinant tissue plasminogen activator (rt-PA) treatment to acute ischemic stroke (AIS) within 4.5 hours of onset. Methods Demographics onset to treatment time, risk factors, and clinical and laboratory data of 209 AIS patients undergoing intravenous rt-PA therapy at the Second Affiliated Hospital, Zhejiang University School of Medicine between January 2013 and August 2016 were retrospectively analyzed. The National Institute of Health Stroke Scale (NIHSS) score was recorded before thrombolytic therapy, 24 h after the treatment and 7 d after the treatment to evaluate the recovery of neurological function. A multivariate logistic regression analysis was performed to assess the outcomes. Results Of the 209 AIS patients treated by intravenous thrombolysis with rt-PA. Low-density lipoprotein (LDL) levels were significantly lower (P < 0.05) in patients with early neurological improvement. The multivariable analysis showed that non-atrial fibrillation (AF) was independently associated with early neurological improvement at 24 h and 7 d after thrombolysis. Onset to treatment time was an independent predictor (P < 0.05) for early neurological improvement at 7 d after thrombolysis. The NIHSS score and diastolic blood pressure on admission were associated with symptomatic intracerebral hemorrhagic (sICH) transformation. Conclusions Non-AF was independently associated with early neurological improvement after intravenous thrombolysis in AIS patients, but non-AF was not associated with the occurrence of sICH. Onset to treatment time was an independent predictor of early neurological improvement at 7 d after thrombolysis in AIS patients.

Glycated hemoglobin (HbA1c) and outcome following endovascular thrombectomy for ischemic stroke

2019 ◽  
Vol 12 (1) ◽  
pp. 30-32 ◽  
Author(s):  
William K Diprose ◽  
Michael T M Wang ◽  
Andrew McFetridge ◽  
James Sutcliffe ◽  
P Alan Barber
Keyword(s):  
Ischemic Stroke ◽  
Glycated Hemoglobin ◽  
Multiple Logistic Regression Analysis ◽  
Functional Independence ◽  
Endovascular Thrombectomy ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Glucose Levels ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Hba1c Levels

BackgroundIn ischemic stroke, increased glycated hemoglobin (HbA1c) and glucose levels are associated with worse outcome following thrombolysis, and possibly, endovascular thrombectomy.ObjectiveTo evaluate the association between admission HbA1c and glucose levels and outcome following endovascular thrombectomy.MethodsConsecutive patients treated with endovascular thrombectomy with admission HbA1c and glucose levels were included. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0–2 at 3 months. Secondary outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3), early neurological improvement (reduction in National Institutes of Health Stroke Scale (NIHSS) score ≥8 points, or NIHSS score of 0–1 at 24 hours), symptomatic intracerebral hemorrhage (sICH), and mortality at 3 months.Results223 patients (136 (61%) men; mean±SD age 64.5±14.6) were included. The median (IQR) HbA1c and glucose were 39 (36-45) mmol/mol and 6.9 (5.8–8.4) mmol/L, respectively. Multiple logistic regression analysis demonstrated that increasing HbA1c levels (per 10 mmol/mol) were associated with reduced functional independence (OR=0.76; 95% CI 0.60–0.96; p=0.02), increased sICH (OR=1.33; 95% CI 1.03 to 1.71; p=0.03), and increased mortality (OR=1.26; 95% CI 1.01 to 1.57; p=0.04). There were no significant associations between glucose levels and outcome measures (all p>0.05).ConclusionsHbA1c levels are an independent predictor of worse outcome following endovascular thrombectomy. The addition of HbA1c to decision-support tools for endovascular thrombectomy should be evaluated in future studies.

Abstract TP59: Clinical Course and Radiological Outcome of Mild Stroke Patients Treated and not Treated with Thrombolysis

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Xabier Urra ◽  
Helena Ariño ◽  
Sergi Amaro ◽  
Víctor Obach ◽  
Alvaro Cervera ◽  
...  
Keyword(s):  
Repeated Measures ◽  
Clinical Course ◽  
Past History ◽  
Infarct Volume ◽  
Clinical Severity ◽  
Lesion Volume ◽  
Radiological Outcome ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Mild Stroke

Background: Around 30% of patients with acute stroke are excluded from thrombolysis because of mild or improving symptoms, but some of these patients don’t achieve a good recovery. We compared the clinical and radiological course in a cohort of 239 patients with mild stroke treated and not treated with thrombolysis in the same institution. Methods: We studied all patients with ischemic stroke admitted within 6 hours of symptom-onset with previous mRS≤1 and mild symptoms (NIHSS≤5) at arrival or during initial evaluation. We compared the baseline characteristics, clinical course (NIHSS), radiological outcome (final DWI lesion volume), incidence of symptomatic intracranial hemorrhage (sICH) and favourable 3-month outcome (mRS≤1) of patients treated with thrombolysis (123 tPA only and 9 endovascular interventions) or not treated (n=107). Results: Treated patients had greater clinical severity at presentation and after imaging and arrived to the hospital faster than not treated patients. In a general linear model of repeated measures, their course was significantly different (p=0.03) and thrombolised patients improved more during hospitalization. Patients with significant neurological improvement (NIHSS score>1) had more severe strokes at presentation but similar outcome, and were more often treated with tPA (p<0.001). Infarct volume was significantly correlated with NIHSS score especially at day 1. Despite the differences in the initial clinical severity, final infarct volume was similar in treated and not treated patients. The rate of sICH was similar in both groups. Outcome at 3-months was associated to past history of stroke, glucose levels and deterioration during hospital stay. On multivariate analysis, thrombolysis remained associated to neurological improvement (OR 4.34;p<0.001) and was non-significantly associated to greater chances of good functional outcome at 3-months (OR 2.38;p=0.099). Conclusions: In patients with mild stroke thrombolysis was safe and was associated to better neurological course. Overall, these results suggest that patients presenting with mild symptoms do benefit from thrombolysis.

EXPRESS: Cerebral microbleeds development after stroke thrombolysis: A secondary analysis of the THAWS randomized clinical trial

2021 ◽  
pp. 174749302110350
Author(s):  
Kaori Miwa ◽  
Masatoshi Koga ◽  
Manabu Inoue ◽  
Sohei Yoshimura ◽  
Makoto Sasaki ◽  
...  
Keyword(s):  
Secondary Analysis ◽  
Intravenous Thrombolysis ◽  
Clinical Impact ◽  
Cerebral Microbleeds ◽  
National Institutes Of Health ◽  
Efficacy And Safety ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Mixed Distribution ◽  
Stroke Thrombolysis

Background and aim: We determined to investigate the incidence and clinical impact of new cerebral microbleeds (CMBs) after intravenous thrombolysis (IVT) in patients with acute stroke. Methods: The THAWS was a multicenter, randomized trial to study the efficacy and safety of IVT with alteplase in patients with wake-up stroke or unknown onset stroke. Prescheduled T2*-weighted imaging assessed CMBs at 3-time points: baseline, 22–36 hours, and 7–14 days. Outcomes included new CMBs development, modified Rankin Scale [mRS] ≥3 at 90 days, and change in the National Institutes of Health Stroke Scale [NIHSS] score from 24 h to 7 days. Results: Of all 131 patients randomized in the THAWS trial, 113 patients (mean 74.3±12.6 years, 50 female, 62 allocated to IVT) were available for analysis. Overall, 46 (41%) had baseline CMBs (15 strictly lobar CMBs, 14 mixed CMBs, and 17 deep CMBs). New CMBs only emerged in the IVT group (7 patients, 11%) within a median of 28.3 h, and did not additionally increase within a median of 7.35 days. In adjusted models, number of CMBs (relative risk [RR]1.30, 95%confidence interval [CI]: 1.17–1.44), mixed distribution (RR 19.2, 95%CI: 3.94–93.7), and CMBs burden ≥5 (RR 44.9, 95%CI: 5.78–349.8) were associated with new CMBs. New CMBs was associated with an increase in NIHSS score (p=0.023). Treatment with alteplase in patients with baseline ≥5 CMBs resulted in a numerical shift toward worse outcomes on ordinal mRS (median [IQR]; 4 [3–4] vs. 0 [0–3]), compared with those with <5 CMBs (common odds ratio 17.1, 95% CI: 0.76 –382.8). The association of baseline ≥5 CMBs with ordinal mRS score differed according to the treatment group (P interaction=0.042). Conclusion: New CMBs developed within 36 h in 11% of the patients after IVT, and they were significantly associated with mixed-distribution and ≥5 CMBs. New CMBs development might impede neurological improvement. Furthermore, CMBs burden might affect the effect of alteplase.

Mechanical thrombectomy using a Solitaire stent retriever in the treatment of pediatric acute ischemic stroke

2019 ◽  
Vol 23 (3) ◽  
pp. 363-368 ◽  
Author(s):  
Bing Zhou ◽  
Xiao-Chuan Wang ◽  
Jun-Yi Xiang ◽  
Ming-Zhao Zhang ◽  
Bo Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Balloon Dilation ◽  
Stent Retriever ◽  
National Institutes Of Health ◽  
Clinical Prognosis ◽  
Nihss Score ◽  
Grade 3

OBJECTIVEMechanical thrombectomy using a Solitaire stent retriever has been widely applied as a safe and effective method in adult acute ischemic stroke (AIS). However, due to the lack of data, the safety and effectiveness of mechanical thrombectomy using a Solitaire stent in pediatric AIS has not yet been verified. The purpose of this study was to explore the safety and effectiveness of mechanical thrombectomy using a Solitaire stent retriever for pediatric AIS.METHODSBetween January 2012 and December 2017, 7 cases of pediatric AIS were treated via mechanical thrombectomy using a Solitaire stent retriever. The clinical practice, imaging, and follow-up results were reviewed, and the data were summarized and analyzed.RESULTSThe ages of the 7 patients ranged from 7 to 14 years with an average age of 11.1 years. The preoperative National Institutes of Health Stroke Scale (NIHSS) scores ranged from 9 to 22 with an average of 15.4 points. A Solitaire stent retriever was used in all patients, averaging 1.7 applications of thrombectomy and combined balloon dilation in 2 cases. Grade 3 on the modified Thrombolysis In Cerebral Infarction scale of recanalization was achieved in 5 cases and grade 2b in 2 cases. Six patients improved and 1 patient died after thrombectomy. The average NIHSS score of the 6 cases was 3.67 at discharge. The average modified Rankin Scale score was 1 at the 3-month follow-up. Subarachnoid hemorrhage after thrombectomy occurred in 1 case and that patient died 3 days postoperatively.CONCLUSIONSThis study shows that mechanical thrombectomy using a Solitaire stent retriever has a high recanalization rate and excellent clinical prognosis in pediatric AIS. The safety of mechanical thrombectomy in pediatric AIS requires more clinical trials for confirmation.

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