Abstract WP36: Post-ischemic Hyperperfusion After Reperfusion Therapy Predicts Hemorrhagic Transformation

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Shuhei Okazaki ◽  
Takeshi Yoshimoto ◽  
Hiroshi Yamagami ◽  
Katsufumi Kajimoto ◽  
Mikito Hayakawa ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Three Dimensional ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Regional Cerebral Blood ◽  
Stroke Patients ◽  
Mca Occlusion ◽  
Blood Flow Ratio ◽  
The Relationship

Background and Purpose: Post-ischemic hyperperfusion has been considered as a risk factor of hemorrhagic transformation and poor prognosis. To date, however, there is a lack of data about the pathological significance of hyperperfusion after reperfusion therapy. In this study, we evaluated the relationship between hemorrhagic transformation and post-ischemic hyperperfusion after reperfusion therapy by using arterial spin labeled perfusion MRI (ASL) and 123 I IMP-SPECT. Methods: We retrospectively collected data of acute stroke patients with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis and/or endovascular therapy, and underwent pulsed ASL using Q2TIPS-FAIR with 3D-TGSE readout and 123 I IMP-SPECT using dual-table ARG method within 14 days of stroke onset from November 2015 to June 2016. Ipsilateral-contralateral regional cerebral blood flow ratio (IC ratio) was calculated by using three-dimensional stereotactic ROI template (3DSRT) software. Results: Among 47 consecutive acute stroke patients with the MCA occlusion who received reperfusion therapy, 21 underwent only ASL and 10 underwent both ASL and SPECT after reperfusion therapy. The IC ratio of ASL was well correlated with that of SPECT in the MCA territory (r=0.65, p <0.001). Hemorrhagic transformation was observed in 7 patients. IC ratio was higher in patients with hemorrhagic transformation after reperfusion therapy than those without hemorrhagic transformation (2.19±0.35 vs 0.99±0.19, p=0.005). Focal post-ischemic hyperperfusion (IC ratio >1.5) was detected in 7 of 31 patients (23%). The presence of post-ischemic hyperperfusion was significantly associated with hemorrhagic transformation after reperfusion therapy (odds ratio 9.3, 95% confidence interval 1.4 to 64.0, p=0.03). Conclusions: Post-ischemic hyperperfusion detected by ASL predicts hemorrhagic transformation after reperfusion therapy. ASL hyperperfusion may indicate the disruption of blood brain barrier after reperfusion therapy.

scholarly journals Early NT-ProBNP (N-Terminal Probrain Natriuretic Peptide) Elevation Predicts Malignant Edema and Death After Reperfusion Therapy in Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Author(s):  
Xuting Zhang ◽  
Shenqiang Yan ◽  
Wansi Zhong ◽  
Yannan Yu ◽  
Min Lou
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Natriuretic Peptide ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
Median Serum ◽  
The Relationship

Background and Purpose: We aimed to investigate the relationship between early NT-proBNP (N-terminal probrain natriuretic peptide) and all-cause death in patients receiving reperfusion therapy, including intravenous thrombolysis and endovascular thrombectomy (EVT). Methods: This study included 1039 acute ischemic stroke patients with early NT-proBNP data at 2 hours after the beginning of alteplase infusion for those with intravenous thrombolysis only or immediately at the end of EVT for those with EVT. We performed natural log transformation for NT-proBNP (Ln(NT-proBNP)). Malignant brain edema was ascertained by using the SITS-MOST (Safe Implementation of Thrombolysis in Stroke-Monitoring Study) criteria. Results: Median serum NT-proBNP level was 349 pg/mL (interquartile range, 89–1250 pg/mL). One hundred twenty-one (11.6%) patients died. Malignant edema was observed in 78 (7.5%) patients. Ln(NT-proBNP) was independently associated with 3-month mortality in patients with intravenous thrombolysis only (odds ratio, 1.465 [95% CI, 1.169–1.836]; P =0.001) and in those receiving EVT (odds ratio, 1.563 [95% CI, 1.139–2.145]; P =0.006). The elevation of Ln(NT-proBNP) was also independently associated with malignant edema in patients with intravenous thrombolysis only (odds ratio, 1.334 [95% CI, 1.020–1.745]; P =0.036), and in those with EVT (odds ratio, 1.455 [95% CI, 1.057–2.003]; P =0.022). Conclusions: An early increase in NT-proBNP levels was related to malignant edema and stroke mortality after reperfusion therapy.

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.

Abstract 3268: Ct Perfusion As A Tool To Predict The Risk Of Hemorrhagic Transformation In Ischemic Stroke Treated With Tissue Plasminogen Activator: A Single Center Experience.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tareq Kass-Hout ◽  
Maxim Mokin ◽  
Omar Kass-Hout ◽  
Emad Nourollahzadeh ◽  
David Wack ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Brain Tissue ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Stroke Therapy ◽  
Two Phase ◽  
The Mean

Objective: To use the Computed Tomography Perfusion (CTP) parameters at the time of hospital admission, including Cerebral Blood Volume (CBV) and Permeability Surface area product (PS), to identify patients with higher risk to develop hemorrhagic transformation in the setting of acute stroke therapy with intravenous thrombolysis. Methods: Retrospective study that compared admission CTP variables between patients with Hemorrhagic Transformation (HT) acute stroke and those with no hemorrhagic transformation. Both groups received standard of care intravenous thrombolysis with tPA. Twenty patients presented to our stroke center between the years 2007 - 2011 within 3 hours after stroke symptoms onset. All patients underwent two-phase 320 slice CTP which creates CBV and PS measurements. Patients were divided into two groups according to whether or not they had HT on a follow up CT head without contrast, done within 36 hours of the thrombolysis therapy. Clinical, demographic and CTP variables were compared between the HT and non-HT groups using logistic regression analyses. Results: HT developed in 8 (40%) patients. Patients with HT had lower ASPECT score ( P =.03), higher NIHSS on admission ( P= .01) and worse outcome ( P= .04) compared to patients who did not develop HT. Baseline blood flow defects were comparable between the two groups. The mean PS for the HT group was 0.53 mL/min/100g brain tissue, which was significantly higher than that for the non-HT group of 0.04 mL/min/100g brain tissue ( P <.0001). The mean area under the curve was 0.92 (95% CI). The PS threshold of 0.26 mL/min/100g brain tissue had a sensitivity of 80% and a specificity of 92% for detecting patients with high risk of hemorrhagic transformation after intravenous thrombolysis. Conclusions: Admission CTP measurements might be useful to predict patients who are at higher risk to develop hemorrhagic transformation after acute ischemic stroke therapy.

Abstract P327: Utilizing Iodine Contrast Extravasation Post Reperfusion and Dual Energy Ct Imaging to Predict Risk of Hemorrhagic Conversion in Acute Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Tri Huynh* ◽  
Niran Vijayaraghavan* ◽  
Hannah Branstetter ◽  
Natalie Buchwald ◽  
Justin De Prey ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Infarct Volume ◽  
Reperfusion Therapy ◽  
Dual Energy ◽  
Ct Imaging ◽  
Dual Energy Ct ◽  
Stroke Patients ◽  
Post Intervention ◽  
Contrast Extravasation ◽  
Post Contrast

Introduction: Hyperintense acute reperfusion marker (HARM) has been identified on post-contrast magnetic resonance imaging (MRI) to be a marker of hemorrhagic conversion (HC) post reperfusion therapy in acute stroke patients. We have previously described a case where MRI HARM was mimicked on post contrast computed topography (CT) imaging in an acute stroke patient post reperfusion. Dual-Energy (DECT) allows for differentiation between acute blood and iodine contrast extravasation (ICE), and thus can have utility when ICE is present. Here we sought to validate whether post-intervention ICE/CT hyperdensity reperfusion maker (CT HARM), and contrast subtracted on DECT is associated with HC in acute stroke patients. Method: Data was obtained from our Institutional Review Board approved stroke admission database from January 2017 to November 2019, including ischemic stroke patients that received thrombolysis or thrombectomy, had evaluable images within 24 hours of admission, and received a DECT. Ischemic volumes of the stroke was measured on diffusion-weighted image (DWI). ICE was measured on CT head and DECT using the freehand 3D region of interest tool on the Visage Imaging PACS System. Susceptibility weighted MRI sequences were used to grade HC. Data analysis was conducted with regression modeling. Results: A total of 82 patients were included, 49% women, median age 73 (interquartile range (IQR), 61- 77), admission NIHSS 12 (IQR, 7 - 21), 24 hour change in NIHSS 4 (IQR, 0 -13), glucose 125 (IQR, 106 -158), creatinine 1.0 (IQR, 0.8 - 1.2), infarct volume 50.6 ± 7.1 mL, 48% treated with thrombectomy, 7% with PH-1 or PH-2 identified on MRI, and 56% with MCA infarcts. ICE volume was 2.6 ± 1.0 mL and DECT volume was 2.2 ± 1.1mL. ICE increased the likelihood of MRI confirmed PH-1 or PH-2 hemorrhagic conversion (odds ratio (OR) 14.34, 95% confidence interval (CI) 5.74 - 22.94) and decreased likelihood of increase in NIHSS at 24 hours (OR 0.20, 95% CI 0.01 to 0.40). There were no other significant associations with ICE or DECT volumes. Conclusion: Our results are supportive of our proposed association between CT HARM and risk of HC. More studies are needed to study whether quantitative of DECT can be predictive of stroke outcomes post reperfusion therapy.

Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eva Mistry ◽  
Adam H De Havenon ◽  
Christopher Leon Guerrero ◽  
Amre Nouh ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
The United States ◽  
Hemorrhagic Transformation ◽  
Stroke Patients ◽  
Increased Risk ◽  
Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

Abstract T P299: Ambulatory Status: A Protective Mechanism against Venous Thromboembolism in Acute Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jason-Flor Sisante ◽  
Michael Abraham ◽  
Sandra Billinger ◽  
Manoj Mittal
Keyword(s):  
Venous Thromboembolism ◽  
Subarachnoid Hemorrhage ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Early Mobilization ◽  
Protective Mechanism ◽  
Stroke Patients ◽  
Ambulatory Status ◽  
Stroke Type ◽  
The Relationship

Introduction: Deep vein thrombosis (DVT) is reported in 23% to 50% of hemiplegic stroke survivors and the highest rate of incidence occurs within one week of stroke onset. Pulmonary embolism (PE) is reported in up to 5% of stroke patients. There is limited data about the relationship of ambulatory status and the rate of venous thromboembolism (VTE) following a stroke. Hypothesis: The goal of our retrospective cohort study was to understand the relationship between VTE and a patient’s ambulatory status, adjusting for age, gender, and stroke type (ischemic, intracerebral hemorrhage, or subarachnoid hemorrhage). We assessed the hypothesis that the stroke patients who are able to ambulate during hospitalization would have lower rates of DVT and PE. Methods: We retrospectively analyzed 1670 acute stroke patients who were admitted to an academic comprehensive stroke center between Feb 2006 and May 2014. “Get with the guideline data” was used to identify stroke patients and their ambulatory status (yes/no). VTE was identified using discharge diagnosis. Chi square test and logistic regression methods were used for statistical analysis. Results: Mean age was 64.9 ± 14.6 years with 51% men. 1138 (68%) patients were classified as having ischemic stroke; 291 (17.5%) patients had intracerebral hemorrhage; and 241 (14.5%) patients had subarachnoid hemorrhage. During hospitalization, 444 (27%) were ambulatory. Patients able to ambulate during hospitalization had less rate of DVT (6.3% vs 15.3%; p<0.0001) and PE (2.9% vs 5.3%; p=0.04), when compared to non-ambulating patients. After adjusting for age, gender, and stroke type; patients who were able to ambulate still had lower rates of DVT (OR: 0.42, 95% CI 0.27-0.63) and PE (OR: 0.49, 95% CI 0.25-0.88). Conclusion: In conclusion, our findings suggest that the patient’s ambulatory status during hospitalization is an independent predictor of VTE. Further research is needed to understand if early mobilization in non-ambulatory stroke patients would have similar protective effect against VTE or not.

Abstract WMP16: Improved Prediction of Hemorrhagic Transformation in Acute Stroke Patients Using Lowered Cerebral Blood Volume on MRI and Clinical Severity by NIHSS

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Sundeep Saini ◽  
Steven Warach ◽  
Marie Luby ◽  
Keyword(s):  
Image Registration ◽  
Acute Stroke ◽  
Blood Volume ◽  
Cerebral Blood Volume ◽  
Lesion Size ◽  
Hemorrhagic Transformation ◽  
Multinomial Regression ◽  
Stroke Patients ◽  
Pre Treatment ◽  
Iv Tpa

Objectives: Hemorrhagic transformation of the ischemic lesion is a common thrombolytic complication when treating acute stroke patients with standard IV-tPA. In a retrospective study we demonstrated that patients that have HT post-thrombolysis have a significantly lowered cerebral blood volume (CBV) on their pre-thrombolysis MRI compared to non HT patients. The objective of this study was to determine prospectively whether reduced CBV in combination with stroke severity can predict the occurrence of HT in patients post-thrombolysis. Methods: Patients were selected from the NINDS Stroke Registry if they: had an acute ischemic stroke located in the MCA territory, were treated with standard IV-tPA, had a pre-treatment MRI with evaluable DWI and PWI, and had post-treatment MRI evaluation for HT. A rater calculated CBV maps in PMA™ (ASIST-Japan) and performed image registration and region of interest analyses in MIPAV™ (NIH). The rater repeated the CBV analysis without image registration using DICOM software available on the scanner. Multinomial regression with covariates of baseline NIHSS, DWI lesion size, and CBV ratio was performed. All MRI scans were reviewed by expert readers blinded to the CBV analyses to determine the presence of HT using the ECASS-II criteria. Results: Seventy-six patients met the study criteria with a mean (SD) age of 68.1 (±14.1) years, median baseline NIHSS of 12 (IQR25-75: 5-18) and median onset to first MRI of 109 minutes (IQR25-75: 82-157). Thirty-six percent of patients (27/76) were positive for HT post-thrombolysis. The mean CBV ratio was 0.25 (STD ± 0.23) in the positive HT patients compared to 0.55 (STD ±0.24) in the negative HT patients. Multinomial regression demonstrated that the CBV ratio < 0.5 (p<0.006) and baseline NIHSS > 15 (p<0.034) significantly predicted the occurrence of any HT. The CBV ratio < 0.5 was the only independent predictor of severe HT, PH1 or PH2 (p<0.008). DWI lesion size using > 100 ml involvement of the MCA territory was not significant in predicting any or severe HT. Conclusions: Pre-treatment CBV ratio used in combination with baseline NIHSS are promising predictors of HT after standard IV-tPA. The ability to calculate CBV ratios directly on the scanner supports usage in acute intervention decision making.

Abstract T P158: Albuminuria Is Associated With Neurological Deterioration and Poor Outcome in Acute Stroke Patients With Non-valvular Atrial Fibrillation: The SAMURAI-NVAF Study

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Takayuki Matsuki ◽  
Masatoshi Koga ◽  
Shoji Arihiro ◽  
Kenichi Todo ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Reperfusion Therapy ◽  
Neurological Deterioration ◽  
Stroke Patients ◽  
Multicenter Observational Study ◽  
Spot Urine ◽  
Poor Outcome ◽  
The Impact

Background and purpose: The impact of albuminuria on clinical outcomes in acute cardioembolic stroke is not fully investigated. We assessed whether high spot urine albumin/creatinine ratio (ACR) was associated with clinical outcomes in acute stroke with non-valvular atrial fibrillation (NVAF). Methods: From 2011 to 2014, we enrolled acute ischemic stroke/TIA patients with NVAF in the SAMURAI-NVAF study, which is a multicenter, observational study. Patients with complete ACR values were included in the analysis. They were divided into the N (normal, ACR < 30mg/g) and the H (high, ACR ≥ 30mg/g) groups. Clinical outcomes were neurological deterioration (an increase of NIHSS ≥1 point during the initial 7 days) and poor outcome (mRS of 4-6 at 3 months). Results: Of 558 patients (328 men, 77±10 y) who were included, 271 and 287 were assigned to the H group and the N group, respectively. As compared with patients in the N group, those in the H group were more frequently female (52 vs 31%, p < 0.001) and older (80±10 vs 75±10 y, p < 0.001). On admission, patients in the H group more frequently had diabetes (28 vs 17%, p = 0.003), less frequently had paroxysmal AF (68 vs 57%, p = 0.009), had higher levels of SBP (157±28 vs 151±24 mmHg, p = 0.003), NIHSS score (11 vs 5, p < 0.001), CHA2DS2-VASc score (6 vs 5, p < 0.001), plasma glucose (141±62 vs 132±41 mg/dL, p = 0.04), and brain natriuretic peptide (348±331 vs 259±309 pg/mL, p = 0.002), and had lower levels of hemoglobin (13±2 vs 14±2 g/dL, p = 0.02), and estimated glomerular filtration ratio (eGFR) (60±24 vs 66±20 mL/min/1.73m2 p = 0.002). On imaging studies, patients in the H group more frequently had large infarct (29 vs 20 %, p = 0.02) and culprit artery occlusion (64 vs 48%, p < 0.001). Neurological deterioration (14 vs 4%, p < 0.001) and poor outcome (49 vs 24%, p < 0.001) were more frequently observed in the H group. On multivariate regression analysis adjusted for significant confounders and reperfusion therapy, the H group was associated with neurological deterioration (OR 2.43; 95% CI 1.14-5.5; p = 0.02) and poor outcome (OR 2.75; 95% CI 1.45-5.2; p = 0.002), although eGFR was not significantly related to either. Conclusion: High ACR, a marker of albuminuria, was independently associated with unfavorable outcomes in acute stroke patients with NVAF.

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