Abstract TP32: Endovascular Therapy for Acute Ischemic Stroke Beyond the 6 Hour Window

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Yi Mao ◽  
Sameer Sharma ◽  
Hesham Masoud ◽  
Julius G Latorre
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Current Data ◽  
Posterior Circulation ◽  
Published Data ◽  
Advanced Imaging ◽  
Poor Outcomes ◽  
Mr Clean ◽  
Insight Into

Background: Recent randomized trials demonstrated the efficacy of endovascular therapy (EVT) in managing acute ischemic stroke (AIS), though EVT was initiated <6 hours from time last seen well in nearly all patients, and posterior circulation strokes were excluded. Current data is limited for patients receiving EVT >6 hours, and more so for those with posterior circulation strokes. We aim to assess safety and clinical outcome of EVT in patients presenting >6 hours, with anterior or posterior circulation strokes. Methods: We conducted a retrospective review of patients with AIS receiving EVT >6 hours between 2012-2015, including those with unknown time of onset and wake-up strokes. Outcomes observed include mRS at ≥90 days, rates of recanalization (TICI 2b-3), sICH and mortality. Results: A total of 34 patients were identified presenting with AIS and receiving EVT >6 hours, including 25 anterior and 9 posterior circulation strokes. See Table 1 for comparison with published data from recent EVT trials. Conclusion: Our results are not significantly different from some of the recent trials. MR CLEAN, the only trial that did not employ advanced imaging in patient selection, had similar outcomes. The IV-tPA only groups of recent trials (where data is available) also produced comparable results. It should be noted that the patients in our study all have large vessel occlusions and high NIHSS, are mostly ineligible for tPA, and thus would be expected to have very poor outcomes without treatment. Our data supports the possibility of expanding the EVT window to >6 hours, and with advanced imaging screening, better rates of functional outcome/mortality may still be achieved. DAWN and DEFUSE3 trials currently underway should provide further insight into this subject.

Abstract TMP5: The Smoking-Thrombolysis Paradox in Large Vessel Occlusion Acute Ischemic Stroke Undergoing Endovascular Therapy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mehdi Bouslama ◽  
Leticia C Rebello ◽  
Diogo C Haussen ◽  
Jonathan A Grossberg ◽  
Shannon Doppelheuer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Univariate Analysis ◽  
Tertiary Care ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose: The smoking-thrombolysis paradox has been well described in myocardial infarction. However, its existence in the stroke population remains elusive. In the past decade, several studies have investigated the phenomenon with mixed results. We sought to determine whether clinical outcomes differ between smokers and non-smokers with acute ischemic stroke undergoing endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients who underwent endovascular therapy for acute large vessel occlusion acute ischemic stroke were categorized into current smokers and non-smokers. Baseline characteristics, procedural radiological as well as outcome parameters where compared. Results: A total of 968 patients qualified for the study of which 189 (19.5%) were current smokers. Smokers were younger (60.78±11.95 vs. 66.41±15.05 years, p<0.001), had higher rates of dyslipidemia (49.7% vs 31.7%, p<0.001) and posterior circulation strokes (13.2% vs 7.8%, p=0.02,) and lower rates of atrial fibrillation (21.1% vs 37.9%, p<0.001). There were no statistically significant differences between groups in terms of stroke severity (as assessed by NIHSS), baseline CT perfusion core and hypoperfusion volumes, CT angiogram collateral scores as well as procedural variables. On univariate analysis, smokers had higher rates of good outcomes at 90 days (modified Rankin scale, mRS 0-2: 53.8% vs 42.8%, p=0.01) and similar rates of successful reperfusion (mTICI 2b-3) (92.1% vs 87.7%, p=0.09), parenchymal hematomas (4.2% vs 4%, p=0.84) and mortality at 90 days (20.2% vs 25.7%, p=0.14). Multivariate analysis showed that smoking was not independently associated with good outcomes. Stratifying for (1) stroke etiology and (2) anterior vs. posterior circulation topology yielded similar results. Conclusion: In stroke patients treated with mechanical thrombectomy, smoking does not seem to be associated with outcomes regardless of stroke subtype or location.

Abstract WP129: MRI and Non Contrast CT Clot Imaging for Successful Large Vessel Clot Resolution of Posterior Circulation Ischemic Strokes

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Siddhart Mehta ◽  
Spozhmy Panezai ◽  
Ashish Kulhari ◽  
Audrey Z Arango ◽  
Laura Suhan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Imaging Characteristics ◽  
Ct Angiogram ◽  
Ct Head ◽  
Contrast Ct

Background: Thrombi retrieved from patients with an acute ischemic stroke with Large Vessel Occlusion (LVO) and correlation with hyperdense vessel sign seen on non contrast CT and blooming artifact seen on gradient-echo(GRE) MRI have given relevant insights into the pathophysiology of thrombotic lesions (RBC-dominant vs Fibrin-dominant). This may facilitate the development of safer noninvasive reperfusion treatment approaches. Our goal was to evaluate the benefit of anticoagulation for posterior circulation strokes based on imaging characteristics in patients where endovascular therapy was not justified. Method: Comprehensive prospective evaluation of patients who presented with posterior circulation LVOs at a community based, university affiliated comprehensive stroke center during one year period (January 2015-December 2015) was done. The clot characteristics on thin-sliced reformatted CT, CT Angiogram and GRE MRI were noted. The clot size and characteristics were followed by sequential imaging while the patients were on anticoagulation for presumed embolic thrombus. Results: Total 749 patients presented with acute ischemic stroke during the pre-specified time period. Of those 78 were posterior circulation strokes; of which, 7 had LVO and 4 underwent endovascular treatment. Endovascular therapy was not justified in 3 patients due to clinically stable exam. These patients were thought to have embolic etiology of stroke and therefore were started on anticoagulation. Group A (RBC-dominant thrombus; n=2) mean clot length was 15.5mm, measured on CT, CTA, MRI. GRE MRI showed blooming artifact around the area of thrombus. Thrombus resolved on repeat CTA at 48-72hours. Group B (Fibrin-dominant; n=1) 5.5mm clot was visualized only on CTA (nothing on CT head and MRI) and it persisted on repeat CTA at 48-72hours. Mean initial NIHSS was 2 (SD +/- 1 ). Mean discharge NIHSS was 0.33 (SD +/- 0.577). Mean discharge mRS was 0.67 (SD +/- 0.57). Conclusion: Hyperdense sign on reformatted thin-sliced CT head and blooming artifact on GRE MRI brain in patients with LVO can be used to characterize the composition of thrombus, which could be helpful in deciding medical therapy. A larger prospective randomized trial is needed to corroborate our findings.

Endovascular therapy for ischemic stroke

Neurology ◽  
2017 ◽  
Vol 88 (22) ◽  
pp. 2123-2127 ◽  
Author(s):  
Atte Meretoja ◽  
Mahsa Keshtkaran ◽  
Turgut Tatlisumak ◽  
Geoffrey A. Donnan ◽  
Leonid Churilov
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Treatment Time ◽  
Prediction Interval ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Treatment Delays ◽  
Mr Clean

Objective:To quantify the patient lifetime benefits gained from reduced delays in endovascular therapy for acute ischemic stroke.Methods:We used observational prospective data of consecutive stroke patients treated with IV thrombolysis in Helsinki (1998–2014; n = 2,474) to describe distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale (mRS) in routine clinical practice. We used treatment effects by time of endovascular therapy in large vessel occlusion over and above thrombolysis as reported by the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) study to model the shift in 3-month mRS distributions with reducing treatment delays. From the 3-month outcomes we derived patient-expected lifetimes and cumulative long-term disability with incremental treatment delay reductions.Results:Each minute saved in onset-to-treatment time granted on average 4.2 days of extra healthy life, with a 95% prediction interval 2.3–5.4. Women gained slightly more than men due to their longer life expectancies. Patients younger than 55 years with severe strokes of NIH Stroke Scale score above 10 gained more than a week per each minute saved. In the whole cohort, every 20 minutes decrease in treatment delays led to a gain of average equivalent of 3 months of disability-free life.Conclusions:Small reductions in endovascular delays lead to marked health benefits over patients' lifetimes. Services need to be optimized to reduce delays to endovascular therapy.

Association of admission leukocyte count with clinical outcomes in acute ischemic stroke patients undergoing intravenous thrombolysis with recombinant tissue plasminogen activator

2020 ◽  
Vol 17 ◽  
Author(s):  
Jie Chen ◽  
Fu-Liang Zhang ◽  
Shan Lv ◽  
Hang Jin ◽  
Yun Luo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Leukocyte Count ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Functional Independence ◽  
Tissue Plasminogen ◽  
Poor Outcomes

Objective:: Increased leukocyte count are positively associated with poor outcomes and all-cause mortality in coronary heart disease, cancer, and ischemic stroke. The role of leukocyte count in acute ischemic stroke (AIS) remains important. We aimed to investigate the association between admission leukocyte count before thrombolysis with recombinant tissue plasminogen activator (rt-PA) and 3-month outcomes in AIS patients. Methods:: This retrospective study included consecutive AIS patients who received intravenous (IV) rt-PA within 4.5 h of symptom onset between January 2016 and December 2018. We assessed outcomes including short-term hemorrhagic transformation (HT), 3-month mortality, and functional independence (modified Rankin Scale [mRS] score of 0–2 or 0–1). Results:: Among 579 patients who received IV rt-PA, 77 (13.3%) exhibited HT at 24 h, 43 (7.4%) died within 3 months, and 211 (36.4%) exhibited functional independence (mRS score: 0–2). Multivariable logistic regression revealed admission leukocyte count as an independent predictor of good and excellent outcomes at 3 months. Each 1-point increase in admission leukocyte count increased the odds of poor outcomes at 3 months by 7.6% (mRS score: 3–6, odds ratio (OR): 1.076, 95% confidence interval (CI): 1.003–1.154, p=0.041) and 7.8% (mRS score: 2–6, OR: 1.078, 95% CI: 1.006–1.154, p=0.033). Multivariable regression analysis revealed no association between HT and 3-month mortality. Admission neutrophil and lymphocyte count were not associated with 3-month functional outcomes or 3-month mortality. Conclusion:: Lower admission leukocyte count independently predicts good and excellent outcomes at 3 months in AIS patients undergoing rt-PA treatment.

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

2021 ◽  
pp. 1-12
Author(s):  
Jang Hun Kim ◽  
Wonki Yoon ◽  
Chi Kyung Kim ◽  
Haewon Roh ◽  
Hee Jin Bae ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Pooled Analysis ◽  
Published Data ◽  
Efficacy And Safety ◽  
Nihss Score

<b><i>Background:</i></b> Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. <b><i>Aims:</i></b> We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. <b><i>Methods:</i></b> Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. <b><i>Results:</i></b> In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. <b><i>Conclusions:</i></b> Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

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