Abstract 2674: DWI Reversal is associated with Small Infarct Volume and Early Reperfusion in Patients with TIA and Minor Stroke. Data from VISION and CATCH study groups

Introduction: One-third of patients with TIA and minor ischemic stroke (MIS) have evidence of ischemic penumbra, defined as hypoperfused regions that have not been irreversibly damaged. Diffusion weighted Imaging (DWI) lesions are thought to represent irreversibly damaged tissue. DWI reversal therefore has implications in accurate estimation of penumbra. We aimed to determine the rate of DWI reversal in this population. Methods: Patients with TIA/MIS (NIH Stroke Scale ≤ 3) were prospectively enrolled and imaged within 24 hours of symptom onset as part of two prospective imaging cohorts. Patients were included if their baseline modified Rankin scale (mRS) score was ≤1. All patients were followed clinically for 3 months and had a repeat MRI either at day 30 or 90. Baseline diffusion and perfusion lesions and follow-up FLAIR final infarct volumes were measured. Results: 418 patients were included; 55.5% had DWI lesions and 37% had PWI (Tmax+2s delay) deficits at baseline. A total of 337 (81%) patients had follow-up imaging. DWI reversal occurred in 22/192 (11.5%) of patients who had a diffusion lesion at baseline. The median time from symptom onset to follow-up imaging was not significantly different between those with or without DWI reversal (78.6 days, IQR=33.3 vs. 79.7 days, IQR= 59.4, p=0.65). The median DWI lesion volume was significantly smaller in those with reversal (0.27ml, IQR=0.75 ml) compared to those who did not reverse (1.45 ml, IQR=3.8 ml, p<0.001). Patients with concurrent perfusion deficits (Tmax+2s) were significantly less likely to have DWI reversal (6%) compared to those without evidence of tissue hypoperfusion (20%; p=0.003). DWI reversal occurred in 4% of patients with penumbral patterns ((Tmax+2s)-DWI) and 18% of those without penumbra (p=0.003).Severity of hypoperfusion defined as greater prolongation of Tmax (+2,+4, +6, +8s) did not affect the likelihood of DWI reversal (linear trend p=0.147). No patient with DWI reversal had a mRS of ≥2 at 90 day, compared to 19% of those with evidence of infarction on follow-up imaging (p= 0.02). Conclusion: DWI reversal is common in patients with TIA/MIS and is more likely to occur in those with smaller baseline lesions without concurrent tissue hypoperfusion. DWI reversal therefore should not have a significant effect on the accuracy of penumbra definition. These data suggest early reperfusion is correlated with DWI reversal and better clinical outcome as measured by mRS.

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Abstract WP47: Reperfusion Following Ischemic Stroke is Associated with Reduced Brain Edema

Stroke ◽

10.1161/str.48.suppl_1.wp47 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Hannah J Irvine ◽

Thomas W Battey ◽

Ann-Christin Ostwaldt ◽

Bruce C Campbell ◽

Stephen M Davis ◽

...

Keyword(s):

Ischemic Stroke ◽

Brain Edema ◽

Infarct Volume ◽

Brain Magnetic Resonance Imaging ◽

Lesion Volume ◽

Stroke Patients ◽

Early Reperfusion ◽

Echoplanar Imaging ◽

Swelling Volume

Introduction: Revascularization is a robust therapy for acute ischemic stroke, but animal studies suggest that reperfusion edema may attenuate its beneficial effects. In stroke patients, early reperfusion consistently reduces infarct volume and improves long-term functional outcome, but there is little clinical data available regarding reperfusion edema. We sought to elucidate the relationship between reperfusion and brain edema in a patient cohort of moderate to severe stroke. Methods: Seventy-one patients enrolled in the Echoplanar Imaging Thrombolysis Evaluation Trial (EPITHET) with serial brain magnetic resonance imaging and perfusion-weighted imaging (PWI) were analyzed. Reperfusion percentage was calculated based on the difference in PWI lesion volume at baseline and follow-up (day 3-5). Midline shift (MLS) was measured on the day 3-5 fluid attenuated inversion recovery (FLAIR) sequence. Swelling volume and infarct growth volume were assessed using region-of-interest analysis on the baseline and follow-up DWI scans based on our prior methods. Results: Greater percentage of reperfusion was associated with less MLS (Spearman ρ = -0.46; P <0.0001) and reduced swelling volume (Spearman ρ = -0.56; P <0.0001). In multivariate analysis, reperfusion was an independent predictor of less MLS ( P <0.006) and decreased swelling volume ( P <0.0054), after adjusting for age, baseline NIHSS, admission blood glucose, baseline DWI volume, and IV tPA treatment. Conclusions: Reperfusion is associated with reduced brain edema as measured by MLS and swelling volume. While our data do not exclude the possibility of reperfusion edema in certain circumstances, in stroke patients, reperfusion following acute stroke is predominantly linked to less brain swelling.

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Abstract WP44: NIHSS Score Components Predict Infarct Volume in Minor Ischemic Stroke Patients

Stroke ◽

10.1161/str.47.suppl_1.wp44 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Charlotte Herber ◽

Amelia K Boehme ◽

Howard Andrews ◽

Joshua Z Willey ◽

...

Keyword(s):

Ischemic Stroke ◽

Language Disorder ◽

Infarct Volume ◽

Final Diagnosis ◽

Minor Stroke ◽

Lesion Volume ◽

Nihss Score ◽

Therapeutic Implications ◽

Significant Relationships ◽

Minor Ischemic Stroke

Background: Prior studies have shown a correlation between the National Institutes of Health Stroke Scale (NIHSS) score and infarct volume on diffusion weighted imaging (DWI); however data are limited in patients with minor stroke whose treatment is controversial. Our aim is to determine the association between DWI lesion(s) volume and the (1) total NIHSS score and (2) NIHSS components in a population of patients with minor ischemic stroke. Methods: We included all patients with minor stroke (NIHSS 0-5) who were enrolled in the prospective Stroke Warning Information and Faster Treatment (SWIFT) study. All patients were admitted to the hospital with a final diagnosis of stroke. We calculated lesion(s) volume (cm 3 ) on DWI sequence using Medical Image Processing, Analysis, and Visualization (MIPAV, NIH, Version 7.1.1). Based on the distribution of lesion volume, we summarized the explanatory value into median cm 3 . We used non-parametric tests to study the association between the primary outcome, DWI lesion(s) volume, and the predictors (NIHSS score and its components). Results: 894 patients had a discharge diagnosis of ischemic stroke; 709 underwent MRI and 510 were DWI positive. There was a weak graded relationship between NIHSS score and median DWI lesion volume in cm 3 : (NIHSS 0: 7.1, NIHSS 1: 8.0, NIHSS 2: 17.1, NIHSS 3: 11.6, NIHSS 4: 19.0, NIHSS 5: 23.6). We also noted highly significant relationships between lesion volume and certain NIHSS components. Compared to patients without the deficit, the median lesion volume was significantly higher in patients with neglect (105.6 vs. 12.5,p=0.025), language disorder (34.6 vs. 11.9,p<0.001), and visual field deficits (185.6 vs. 11.6,p<0.001). Other components of the NIHSS were not associated with lesion volume. Conclusion: In patients with minor stroke, the nature of the neurological deficit improves prediction of infarct volume when added to the total NIHSS score. This may lead to clinical and therapeutic implications.

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Abstract TP438: Japanese versus Non-Japanese Patients With Transient Ischemic Attack or Minor Stroke: Five-Year Risk of Stroke and Vascular Events

Stroke ◽

10.1161/str.51.suppl_1.tp438 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shinichiro Uchiyama ◽

Takao Hoshino ◽

Hugo Charles ◽

Kenji Kamiyama ◽

Taizen Nakase ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Transient Ischemic Attack ◽

Japanese Patients ◽

Minor Stroke ◽

Stroke Recurrence ◽

Large Artery ◽

Vascular Events ◽

Minor Ischemic Stroke ◽

Ischemic Attack

Background: We have reported 5-year risk of stroke and vascular events after a transient ischemic attack (TIA) or minor ischemic stroke in patients enrolled into the TIAregistry.org, which was an international multicenter-cooperative, prospective registry (N Engl J Med 2018;378:2182-90). We conducted subanalysis on the 5-year follow-up data of Japanese patients in comparison with non-Japanese patients. Methods: The patients were classified into two groups on ethnicity, Japanese (n=345) and non-Japanese (n=3502), and their 5-year event rates were compared. We also determined predictors of five-year stroke in both groups. Results: Death from vascular cause (0.9% vs 2.7%, HR 0.28, 95% CI 0.09-0.89, p=0.031) and death from any cause (7.8% vs 9.9%, HR 0.67, 95% CI 0.45-0.99, p=0.045) were fewer in Japanese patients than in non-Japanese patients, while stroke (13.9% vs 7.2%, HR 1.78, 95% CI 1.31-2.43, p<0.001) and intracranial hemorrhage (3.2% vs 0.8%, HR 3.61. 95% CI 1.78-7.30, p<0.001) were more common in Japanese than non-Japanese patients during five-year follow-up period. Caplan-Meyer curves at five-years showed that the rates of stroke was also significantly higher in Japanese than non-Japanese patients (log-rank test, p=0.001). Predictors for stroke recurrence at five years were large artery atherosclerosis (HR 1.81, 95% CI 1.31-2.52, p<0.001), cardioembolism (HR 1.71, 95% CI 1.18-2.47, p=0.004), multiple acute infarction (HR 1.77, 95% CI 1.27-2.45, p<0.001) and ABCD 2 score 6 or 7 (HR 1.96, 95% CI 1.38-2.78, p<0.001) in non-Japanese patients, although only large artery atherosclerosis (HR 3.28, 95% CI 1.13-9.54, p=0.029) was a predictor for stroke recurrence in Japanese patients. Conclusions: Recurrence of stroke and intracranial hemorrhage were more prevalent in Japanese than non-Japanese patients. Large artery atherosclerosis was a predictor for stroke recurrence not only in non-Japanese patients but also in Japanese patients.

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Abstract 19483: Assessment of Outcome in Patients With Acute Minor Ischemic Stroke Treated With Intravenous TPA

Circulation ◽

10.1161/circ.130.suppl_2.19483 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Sameer Sharma ◽

Umair Afzal ◽

Mubashir Pervez ◽

Rochele Clark ◽

Julius G Latorre ◽

...

Keyword(s):

Acute Stroke ◽

Small Sample Size ◽

Intervention Group ◽

Small Sample ◽

Minor Stroke ◽

Good Outcome ◽

Minor Ischemic Stroke ◽

Significant Difference ◽

Iv Tpa

Introduction: Minor acute stroke (NIHSS≤4) within 4.5 hours from symptom onset is a common reason for withholding intravenous (iv) Thrombolysis (TPA), due to potential risk of major bleeding with such treatment and assumed good outcome without intervention. This subgroup of patients was excluded from the landmark NINDS iv tPA trial as per the prespecified protocol and also from various recent clinical trials involving acute stroke. In a recent study of patients with Rapid Improving symptoms and Minor stroke who did not receive IV tPA, 28.3% could not be discharged home and 28.5% could not ambulate independently at the time of discharge (Smith et al 2011). The efficacy of iv TPA in Minor stroke has not been previously studied. Method: Retrospective review of consecutive patients with Minor stroke (NIHSS ≤4) arriving within 4.5 hours between January 2009-July 2013 was done. Outcome in patients who received IV TPA was compared with patients who did not receive any IV tPA. Good outcome was defined as mRS ≤2. Results: 186 patients were identified out of which 20 received iv tPA. The baseline median NIHSS was 2 in the non-intervention group vs 3 in the intervention group (p =0.001), more cardioembolic, cryptogenic and lacunar stroke in tPA group (40% vs 35.53%, 20% vs 14.46% and 30% vs 22.89% respectively) there was no other statistically significant difference between the baseline characteristics of the two groups. Median change in NIHSS from admission to discharge was 1 for non-tPA vs 2.5 for tPA(p<0.001) and good outcome at discharge was seen in 80% patients in tPA vs 69.28% in non-tpa group (p =0.321). 8-12 week follow up data was available for 100 patients (12 tPA patients). Mean mRS was 1.34 in non-tPA vs 1 in tPA group (p=0.430) Conclusion: Acute intervention in Minor stroke appears to be safe. We did not find any statistically significant difference in clinical outcome between the two groups; this is likely due to small sample size, short follow-up period, and other confounding factors that we cannot fully account for in a retrospective study. A prospective randomized control study is warranted to clearly delineate the effect of iv TPA in patients with Minor stroke.

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The association between telomere length and ischemic stroke risk and phenotype

Scientific Reports ◽

10.1038/s41598-021-90435-9 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Ezgi Yetim ◽

Mehmet Akif Topcuoglu ◽

Nuket Yurur Kutlay ◽

Ajlan Tukun ◽

Kader K. Oguz ◽

...

Keyword(s):

Ischemic Stroke ◽

Telomere Length ◽

Infarct Volume ◽

Chronological Age ◽

Biological Aging ◽

Lesion Volume ◽

Blood Leukocytes ◽

Scale Scores ◽

Time Of Admission

AbstractThe chronological age of a person is a key determinant of etiology and prognosis in the setting of ischemic stroke. Telomere length, an indicator of biological aging, progressively shortens with every cell cycle. Herein, we determined telomere length from peripheral blood leukocytes by Southern blot analyses in a prospective cohort of ischemic stroke patients (n = 163) and equal number of non-stroke controls and evaluated its association with various ischemic stroke features including etiology, severity, and outcome. A shorter telomere length (i.e. lowest quartile; ≤ 5.5 kb) was significantly associated with ischemic stroke (OR 2.95, 95% CI 1.70–5.13). This significant relationship persisted for all stroke etiologies, except for other rare causes of stroke. No significant association was present between admission lesion volume and telomere length; however, patients with shorter telomeres had higher admission National Institutes of Health Stroke Scale scores when adjusted for chronological age, risk factors, etiology, and infarct volume (p = 0.046). On the other hand, chronological age, but not telomere length, was associated with unfavorable outcome (modified Rankin scale > 2) and mortality at 90 days follow-up. The association between shorter telomere length and more severe clinical phenotype at the time of admission, might reflect reduced resilience of cerebral tissue to ischemia as part of biological aging.

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Neutrophil counts, neutrophil ratio, and new stroke in minor ischemic stroke or TIA

Neurology ◽

10.1212/wnl.0000000000005554 ◽

2018 ◽

Vol 90 (21) ◽

pp. e1870-e1878 ◽

Cited By ~ 11

Author(s):

Bihong Zhu ◽

Yuesong Pan ◽

Jing Jing ◽

Xia Meng ◽

Xingquan Zhao ◽

...

Keyword(s):

Ischemic Stroke ◽

Minor Stroke ◽

Minor Ischemic Stroke ◽

Cerebrovascular Events ◽

Increased Risk ◽

Risk Patients ◽

Composite Events ◽

A Minor ◽

Derived Data

ObjectiveEvidence about whether neutrophil counts or neutrophil ratio is associated with new stroke is scant. The aim of this study is to assess the association of neutrophil counts or neutrophil ratio with a new stroke in patients with minor stroke or TIA.MethodsWe derived data from the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events trial. Patients with a minor stroke or TIA were categorized into 4 groups according to the quartile of neutrophil counts or neutrophil ratio. The primary outcome was a new stroke (ischemic or hemorrhagic), and secondary outcomes included a new composite vascular event (stroke, myocardial infarction, or death resulting from cardiovascular causes) and ischemic stroke during the 90-day follow-up. We assessed the association between neutrophil counts, neutrophil ratio, and risk of new stroke.ResultsA total of 4,854 participants were enrolled, among whom 495 had new strokes at 90 days. Compared with the first quartile, the second, third, and fourth quartiles of neutrophil counts were associated with increased risk of new stroke (adjusted hazard ratio 1.40 [95% confidence interval (CI) 1.05–1.87], 1.55 [95% CI 1.17–2.05], and 1.69 [95% CI 1.28–2.23], respectively, p for trend <0.001). Similar results were observed for the endpoint of composite events and ischemic stroke. Parallel results were found for neutrophil ratio.ConclusionHigh levels of both neutrophil counts and neutrophil ratio were associated with an increased risk of new stroke, composite events, and ischemic stroke in patients with a minor ischemic stroke or TIA.

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Abstract WP56: The Hypoperfusion Intensity Ratio is a Poor Discriminator of Infarct Growth in Fully Reperfused Patients

Stroke ◽

10.1161/str.51.suppl_1.wp56 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Krishnan Ravindran ◽

Mehdi Bouslama ◽

Gabriel Rodrigues ◽

Diogo Haussen ◽

Leonardo Pisani ◽

...

Keyword(s):

Intensity Ratio ◽

Infarct Volume ◽

Treatment Decision ◽

Lesion Volume ◽

Treatment Decision Making ◽

Fast Progression ◽

The Difference ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Purpose: The hypoperfusion intensity ratio (HIR) is a perfusion-weighted imaging parameter defined as the ratio of Tmax>10 seconds : Tmax>6 seconds volume and is believed to be reflective of collateral strength and consequently influence infarct growth. We sought to assess the utility of the HIR in predicting infarct growth in patients undergoing thrombectomy at a comprehensive stroke center (CSC). Methods: Consecutive acute ischemic stroke patients transferred to our CSC from 09/2010-11/2018 were identified and included if the following criteria were met: 1)computed tomography perfusion (CTP) imaging enabling assessment of baseline ischemic core volume and HIR 2) follow-up neuroimaging for assessment of final infarct volumes and 3)modified Thrombolysis In Cerebral Infarction scale (mTICI) 2c status or greater post-thrombectomy. Infarct growth rate (IGR) was calculated as the difference between infarct volume on follow-up imaging and the acute DWI lesion volume, divided by time from CTP to reperfusion in hours. Results: 461 patients (median age, 64 [55-75] years, median baseline NIHSS, 16 [12-21]) were eligible for this analysis. HIR poorly correlated with IGR (Spearman’s rho=0.001, p=0.89). An HIR cut-off of 0.5 was not able to discriminate ‘fast progressors’ (IGR>5 mL/hr) (AUC 0.42, sensitivity 40%, specificity 51%), or IGR at thresholds of either 2.5 or 10 mL/hr (AUC 0.44 and 0.49 respectively, with 95% confidence intervals [0.35-0.52] and [0.41-0.57], respectively). Similarly, an HIR of 0.5 only weakly distinguished ‘fast progression’ in patients reperfused beyond 120 min from imaging and patients with early CTP (last known well to CTP<6 hrs) (AUC 0.59, sensitivity 43%, specificity 68% and AUC 0.50, sensitivity 45%, specificity 55%). On multiple regression analysis, HIR was not predictive of infarct growth (regression equation=18.09+8.48x, F=2.46, p=0.11, R 2 =0.13) but was predictive of ‘fast progression’ (OR 0.22, 95% CI [0.09-0.60], p=0.003, pseudo-R 2 =0.16). Conclusions: Though predictive of fast progression, the HIR is a poor discriminator of infarct growth in successfully reperfused thrombectomy patients who undergo perfusion imaging at a CSC, and thus should not be factored into treatment decision-making.

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Abstract 1122‐000120: Clinical and Neuroperfusion Predictors of Functional Outcome and Final Infarct Volume in Posterior Circulation Stroke

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000120 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Rami Fakih ◽

Mudassir Farooqui ◽

Andres Dajles ◽

Juan Suarez‐Vivanco ◽

Milagros Galecio Castillo ◽

...

Keyword(s):

Stroke Volume ◽

Functional Outcome ◽

Patient Selection ◽

Infarct Volume ◽

Brain Mri ◽

Posterior Circulation ◽

Accurate Estimation ◽

Vessel Occlusion ◽

Posterior Circulation Stroke

Introduction : Computed tomography perfusion (CTP) is considered standard of care in patient selection for mechanical thrombectomy (MT) in anterior circulation large vessel occlusion (LVO) ischemic strokes presenting after 6 hours from symptom onset. Its role in triaging patients is uncertain in posterior circulation stroke. The aim of this study is to assess the value of the admission CTP sequences in predicting clinical and radiological outcomes in posterior circulation LVO. Methods : We performed a retrospective cohort study of a prospectively maintained stroke database of patients who were diagnosed with a posterior circulation LVO and underwent MT. We included patients with a CTP on arrival and follow‐up imaging (brain MRI or CT) after MT. Baseline clinical as well as CTP parameters (cerebral blood flow [CBF]; cerebellar blood volume [CBV]; time at maximum intensity [Tmax]) at different thresholds were estimated using post‐processing RAPID software. Final stroke volume was quantified on follow‐up imaging using the DWI sequence or plain CT. Good functional outcome was defined as using the mRS of 0–2 at 90 days. Results : Out of 81 patients with posterior circulation LVO who underwent MT, 23 had CTP on arrival along with follow‐up brain imaging (16 had MRI, and 7 had CT) and were included in the final analysis. Lower age, BMI, NIHSS on arrival, and faster time to reperfusion were significantly associated with better mRS at 90 days (p<0.05). Tmax>6 (p = 0.08) and Tmax>8 (0.057) seconds trended towards predicting good mRS at 90 days. None of the CTP parameters showed a predictive value for final stroke volume on follow‐up imaging. Conclusions : Age, NIHSS on arrival, and time to reperfusion were superior to neuroperfusion parameters in predicting good mRS at 90 days in patients who underwent MT in posterior circulation LVO. Since CTP might have limitations in the posterior fossa for accurate estimation of ischemic volumes, plain CT or acute MRI brain may represent a diagnostic tool for patient selection in posterior circulation strokes at this moment.

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Abstract 52: Results of DEFUSE 2: Imaging Endpoints

Stroke ◽

10.1161/str.43.suppl_1.a52 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Gregory W Albers ◽

Matus Straka ◽

Stephanie Kemp ◽

Michael Mlynash ◽

Tudor G Jovin ◽

...

Keyword(s):

Clinical Response ◽

Endovascular Therapy ◽

Infarct Volume ◽

Reperfusion Therapy ◽

Early Reperfusion ◽

Lesion Growth ◽

Favorable Clinical Response ◽

Multi Center Study ◽

Automated Software

Background: The aim of DEFUSE 2 is to determine if predefined MRI profiles predict clinical and imaging outcomes following endovascular reperfusion therapy. Methods: This prospective, NIH funded, multi-center study enrolled consecutive acute stroke patients in whom an MRI scan could be obtained immediately prior to intra-arterial therapy. A follow-up MRI was performed within 12 hrs of completion of the procedure and again at 5 days. PWI and DWI lesion volumes were determined using a fully automated software program (RAPID). Lesion growth (infarct volume on 5 day FLAIR - baseline DWI volume) was compared for patients with and without the Target mismatch profile based on whether early reperfusion occurred. The Target mismatch profile was defined as PWI(Tmax>6s) / DWI >1.8, DWI <70 mL and PWI(Tmax>10s) <100 mL. Early reperfusion was defined as a >50% reduction in PWI volume following the procedure. The incidence and extent of DWI reversal was assessed and the fate of PWI lesions that were not reperfused was determined. Favorable clinical response was defined as an improvement in NIHSS ≥8 or 0-1 at 30 days. Results: This abstract represents a preliminary analysis of 71 of 101 patients who were treated with endovascular therapy (final results to be presented). Among the 54 patients with Target mismatch, early reperfusion was achieved in 70% and was associated with less infarct growth (relative median growth 210% vs. 450%, p=0.01) and a higher rate of favorable clinical response (OR=5.4; 95%CI 1.5-19.2). In patients without the Target mismatch profile (N= 13) early reperfusion was not associated with a reduction in infarct growth (relative median growth was 220% in both reperfusers and non-reperfusers; p=0.94) or an increased rate of favorable clinical response (OR=0.1; 95%CI 0.004-2.2). 96% of all voxels that were DWI positive at baseline were incorporated into the final infarct (assessed on the co-registered 5 day FLAIR); only 3 of 71 patients had FLAIR volumes that were smaller than the baseline DWI lesion (mean difference 3 mL). 80% of the voxels that had a PWI lesion (Tmax>6s) on the post-procedure scan were incorporated into the final infarct. The correlation between the union of the baseline DWI + early follow-up PWI lesion and the 5 day FLAIR volume was high (r=0.84; p< 0.0001). In 82% of the patients, the day 5 FLAIR volume was as at least as large as the union of the baseline DWI + early follow-up PWI lesion. Conclusion: Patients with the Target mismatch profile who achieve early reperfusion following intra-arterial therapy have less infarct growth and more favorable clinical outcomes. In contrast, no benefit of reperfusion was evident for non-Target mismatch patients. Baseline DWI lesions are virtually always fully incorporated into the final infarct volume, regardless of reperfusion. Tissue that remains hypoperfused (Tmax >6s) following endovascular therapy reliably progresses to infarction.

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Early Dabigatran Treatment After Transient Ischemic Attack and Minor Ischemic Stroke Does Not Result in Hemorrhagic Transformation

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2020.84 ◽

2020 ◽

Vol 47 (5) ◽

pp. 604-611

Author(s):

Anas Alrohimi ◽

Kelvin Ng ◽

Dar Dowlatshahi ◽

Brian Buck ◽

Grant Stotts ◽

...

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Infarct Volume ◽

Hemorrhagic Transformation ◽

Minor Stroke ◽

Optimal Timing ◽

Minor Ischemic Stroke ◽

Pre Treatment ◽

Ischemic Attack ◽

Ischemic Events

ABSTRACT:Objectives:The optimal timing of anticoagulation after ischemic stroke in atrial fibrillation (AF) patients is unknown. Our aim was to demonstrate the feasibility and safety of initiating dabigatran therapy within 14 days of transient ischemic attack (TIA) or minor stroke in AF patients.Patients and Methods:A prospective, multi-center registry (NCT02415855) in patients with AF treated with dabigatran within 14 days of acute ischemic stroke/TIA (National Institutes of Health Stroke Scale (NIHSS) ≤ 3) onset. Baseline and follow-up computed tomography (CT) scans were assessed for hemorrhagic transformation (HT) and graded by using European Cooperative Acute Stroke Study criteria.Results:One hundred and one patients, with a mean age of 72.4 ± 11.5 years, were enrolled. Median infarct volume was 0 ml. Median time from index event onset to dabigatran initiation was 2 days, and median baseline NIHSS was 1. Pre-treatment HT was present in seven patients. No patients developed symptomatic HT. On the day 7 CT scan, HT was present in six patients (one progressing from baseline hemorrhagic infarction type 1). Infarct volume was a predictor of incident HT (odds ratio = 1.063 [1.020–1.107], p < 0.003). All six (100%) patients with new/progressive HT were functionally independent (modified Rankin Scale (mRS) = 0–2) at 30 days, which was similar to those without HT (90%, p = 0.422). Recurrent ischemic events occurred within 30 days in four patients, two of which were associated with severe disability and death (mRS 5 and 6, respectively).Conclusion:Early dabigatran treatment did not precipitate symptomatic HT after minor stroke. Asymptomatic HT was associated with larger baseline infarct volumes. Early recurrent ischemic events may be clinically more important.

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