Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Georgios Tsivgoulis ◽  
Aristeidis H Katsanos ◽  
Jürgen Eggers ◽  
Vincent Larrue ◽  
Lars Thomassen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Safety And Efficacy

Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO. Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented. Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.

Abstract WP110: Intravenous Thrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion and Mild Stroke Severity

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Georgios Tsivgoulis ◽  
Nitin Goyal ◽  
Aristeidis H Katsanos ◽  
Konark Malhotra ◽  
Michael T Frohler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Neurological Deficits ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Safety Outcomes

Introduction: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) and mild neurological deficits defined as National Institutes of Health Stroke Scale scores <6 points (mELVO). Methods: The primary efficacy outcome was three-month functional independence (FI; mRS-scores of 0-2) that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included three-month favorable functional outcome (FFO; mRS-scores of 0-1) and mRS-scores distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. Results: We evaluated 336 AIS patients with mELVO (mean age: 63±15 years, 45% women). Patients treated with IVT (n=162) had higher FI (85.6% vs. 74.8%, p=0.027) with lower mRS scores at hospital discharge (p=0.034) compared to the rest. Three-month mRS-scores tended to be lower in the IVT group (p=0.069). No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality (p>0.1). IVT was associated with higher likelihood of 3-month FI (OR=2.19, 95%CI: 1.09-4.42), 3-month FFO (OR=1.99, 95%CI: 1.10-3.57) and functional improvement at discharge [cOR (per 1-point decrease in mRS-score)=2.94, 95%CI: 1.67-5.26] and at 3 months (cOR=1.72, 95%CI: 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders including mechanical thrombectomy. Conclusion: IVT is independently associated with higher odds of improved discharge and three-month functional outcomes in AIS patients with mELVO. IVT does not increase the risk of systemic or intracranial bleeding.

scholarly journals Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Concomitant Intracranial Hemorrhage

2022 ◽  
Author(s):  
Johannes M. Weller ◽  
Julius N. Meissner ◽  
Sebastian Stösser ◽  
Franziska Dorn ◽  
Gabor C. Petzold ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Good Clinical Outcome ◽  
Vessel Occlusion

Abstract Purpose Intravenous thrombolysis and mechanical thrombectomy (MT) are standard of care in patients with acute ischemic stroke due to large vessel occlusion. Data on MT in patients with intracranial hemorrhage prior to intervention is limited to anecdotal reports, as these patients were excluded from thrombectomy trials. Methods We analyzed patients from an observational multicenter cohort with acute ischemic stroke and endovascular treatment, the German Stroke Registry—Endovascular Treatment trial, with intracranial hemorrhage before MT. Baseline characteristics, procedural parameters and functional outcome at 90 days were analyzed and compared to a propensity score matched cohort. Results Out of 6635 patients, we identified 32 patients (0.5%) with acute ischemic stroke due to large vessel occlusion and preinterventional intracranial hemorrhage who underwent MT. Risk factors of intracranial hemorrhage were head trauma, oral anticoagulation and intravenous thrombolysis. Overall mortality was high (50%) but among patients with a premorbid modified Rankin scale (mRS) of 0–2 (n = 15), good clinical outcome (mRS 0–2) at 90 days was achieved in 40% of patients. Periprocedural and outcome results did not differ between patients with and without preinterventional intracranial hemorrhage. Conclusion Preinterventional intracranial hemorrhage in acute ischemic stroke patients with large vessel occlusion is rare. The use of MT is technically feasible and a substantial number of patients achieve good clinical outcome, indicating that MT should not be withheld in patients with preinterventional intracranial hemorrhage.

scholarly journals Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1616-1619 ◽  
Author(s):  
James Beharry ◽  
Michael J. Waters ◽  
Roy Drew ◽  
John N. Fink ◽  
Duncan Wilson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Scale Score ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

scholarly journals Circulating cytokines and growth factors in acute cerebral large vessel occlusion - association with success of endovascular treatment

2021 ◽  
Author(s):  
Gerrit M Grosse ◽  
Christopher Werlein ◽  
Nicole Blume ◽  
Omar Abu-Fares ◽  
Friedrich Goetz ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Growth Factors ◽  
Growth Factor ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Efficient Treatment ◽  
Circulating Cytokines

Mechanical thrombectomy (MT) is a highly efficient treatment in patients with acute ischemic stroke due to large vessel occlusion (LVO). However, in a relevant proportion of LVO, no sufficient recanalization can be achieved. The composition of cerebral thrombi is highly heterogeneous and may constitute a relevant factor for insufficient reperfusion. We hypothesized that circulating cytokines and growth factors involved in thrombo-inflammation and platelet activation may be associated with reperfusion status and thrombus composition in patients undergoing MT. An according biomarker panel was measured in plasma specimens taken prior to MT and at a seven-day follow-up. Reperfusion status was categorized into sufficient or insufficient. Composition of retrieved thrombi was histologically analyzed. Differences of baseline biomarker-concentrations between insufficient and sufficient reperfusion were highest for interferon (IFN)-γ, epidermal growth factor (EGF), platelet derived growth factor (PDGF)-AB/BB, and interferon-γ induced protein 10 (IP-10/CXCL10). After applying correction for multiple comparisons and logistic regression analysis adjusting for stroke etiology, intravenous thrombolysis and vascular risk factors, PDGF-AB/BB was identified as an independent predictor of reperfusion status (odds ratio: 0.403 (95%-CI: 0.199–0.819). Histological analysis revealed that the majority of thrombi had a mixed composition. In conclusion, this study provides first evidence that cytokines and growth factors are potential effectors in patients undergoing MT for the treatment of acute ischemic stroke.

scholarly journals Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (4) ◽  
pp. 1192-1202
Author(s):  
Vanessa H.E. Chen ◽  
Grace K.H. Lee ◽  
Choon-Han Tan ◽  
Aloysius S.T. Leow ◽  
Ying-Kiat Tan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Risk Ratio ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Tissue Type ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: In patients with acute ischemic stroke with large vessel occlusion, the role of intra-arterial adjunctive medications (IAMs), such as urokinase, tPA (tissue-type plasminogen activator), or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We aim to evaluate the efficacy and safety of concomitant or rescue IAM for acute ischemic stroke with large vessel occlusion patients undergoing MT. Methods: We searched Medline, Embase, and Cochrane Stroke Group Trials Register databases from inception until March 13, 2020. We analyzed all studies with patients diagnosed with acute ischemic stroke with large vessel occlusion in the anterior or posterior circulation that provided data for the two treatment arms, (1) MT+IAM and (2) MT only, and also reported on at least one of the following efficacy outcomes, recanalization and 90-day modified Rankin Scale, or safety outcomes, symptomatic intracranial hemorrhage and 90-day mortality. Data were collated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Sixteen nonrandomized observational studies with a total of 4581 patients were analyzed. MT only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT and IAM. As compared with patients treated with MT alone, patients treated with combination therapy (MT+IAM) had a higher likelihood of achieving good functional outcome (risk ratio, 1.13 [95% CI, 1.03–1.24]) and a lower risk of 90-day mortality (risk ratio, 0.82 [95% CI, 0.72–0.94]). There was no significant difference in successful recanalization (risk ratio, 1.02 [95% CI, 0.99–1.06]) and symptomatic intracranial hemorrhage between the two groups (risk ratio, 1.13 [95% CI, 0.87–1.46]). Conclusions: In acute ischemic stroke with large vessel occlusion, the use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to establish the safety and efficacy of IAM as adjunctive treatment to MT.

scholarly journals Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19

Stroke ◽  
2020 ◽  
Vol 51 (8) ◽  
pp. 2540-2543 ◽  
Author(s):  
Simon Escalard ◽  
Benjamin Maïer ◽  
Hocine Redjem ◽  
François Delvoye ◽  
Solène Hébert ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Stroke Onset ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Neurological Improvement ◽  
Poor Outcomes

Background and Purpose: Higher rates of strokes have been observed in patients with coronavirus disease 2019 (COVID-19), but data regarding the outcomes of COVID-19 patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) are lacking. We report our initial experience in the treatment of acute ischemic stroke with LVO in patients with COVID-19. Methods: All consecutive patients with COVID-19 with acute ischemic stroke due to LVO treated in our institution during the 6 first weeks of the COVID-19 outbreak were included. Baseline clinical and radiological findings, treatment, and short-term outcomes are reported. Results: We identified 10 patients with confirmed COVID-19 treated for an acute ischemic stroke due to LVO. Eight were men, with a median age of 59.5 years. Seven had none or mild symptoms of COVID-19 at stroke onset. Median time from COVID-19 symptoms to stroke onset was 6 days. All patients had brain imaging within 3 hours from symptoms onset. Five patients had multi-territory LVO. Five received intravenous alteplase. All patients had mechanical thrombectomy. Nine patients achieved successful recanalization (mTICI2B-3), none experienced early neurological improvement, 4 had early cerebral reocclusion, and a total of 6 patients (60%) died in the hospital. Conclusions: Best medical care including early intravenous thrombolysis, and successful and prompt recanalization achieved with mechanical thrombectomy, resulted in poor outcomes in patients with COVID-19. Although our results require further confirmation, a different pharmacological approach (antiplatelet or other) should be investigated to take in account inflammatory and coagulation disorders associated with COVID-19.

Endovascular versus medical therapy for large-vessel anterior occlusive stroke presenting with mild symptoms

2019 ◽  
Vol 15 (3) ◽  
pp. 324-331 ◽  
Author(s):  
Dylan N Wolman ◽  
David G Marcellus ◽  
Maarten G Lansberg ◽  
Gregory Albers ◽  
Adrien Guenego ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Medical Management ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage

Background Acute ischemic stroke patients with a large-vessel occlusion but mild symptoms (NIHSS ≤ 6) pose a treatment dilemma between medical management and endovascular thrombectomy. Aims To evaluate the differences in clinical outcomes of endovascular thrombectomy-eligible patients with target-mismatch perfusion profiles who undergo either medical management or endovascular thrombectomy. Methods Forty-seven patients with acute ischemic stroke due to large-vessel occlusion, NIHSS ≤ 6, and a target-mismatch perfusion imaging profile were included. Patients underwent medical management or endovascular thrombectomy following treating neurointerventionalist and neurologist consensus. The primary outcome measure was NIHSS shift. Secondary outcome measures were symptomatic intracranial hemorrhage, in-hospital mortality, and 90-day mRS scores. The primary intention-to-treat and as-treated analyses were compared to determine the impact of crossover patient allocation on study outcome measures. Results Forty-seven patients were included. Thirty underwent medical management (64%) and 17 underwent endovascular thrombectomy (36%). Three medical management patients underwent endovascular thrombectomy due to early clinical deterioration. Presentation NIHSS ( P = 0.82), NIHSS shift ( P = 0.62), and 90-day functional independence (mRS 0–2; P = 0.25) were similar between groups. Endovascular thrombectomy patients demonstrated an increased overall rate of intracranial hemorrhage (35.3% vs. 10.0%; P = 0.04), but symptomatic intracranial hemorrhage was similar between groups ( P = 0.25). In-hospital mortality was similar between groups ( P = 0.46), though all two deaths in the medical management group occurred among crossover patients. Endovascular thrombectomy patients demonstrated a longer length of stay (7.6 ± 7.2 vs. 4.3 ± 3.9 days; P = 0.04) and a higher frequency of unfavorable discharge to a skilled-nursing facility ( P = 0.03) rather than home ( P = 0.05). Conclusions Endovascular thrombectomy may pose an unfavorable risk-benefit profile over medical management for endovascular thrombectomy-eligible acute ischemic stroke patients with mild symptoms, which warrants a randomized trial in this subpopulation.

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