Abstract P215: Declining Gastrostomy Tube Utilization in Acute Ischemic Stroke

Objective: To test the hypothesis that placement of percutaneous feeding tubes (PEG) in acute ischemic stroke (AIS) patients has declined following increased usage of intravenous thrombolysis (IV-tPA) and mechanical thrombectomy (MT) over the last decade. Methods: We identified all primary adult AIS admissions contained in the 2005-2017 National Inpatient Sample using International Classification of Diseases (ICD) codes. Age and sex-specific proportions of hospitalizations with coexisting ICD procedural codes for PEG were computed. Joinpoint regression was used to evaluate trends over time. Multivariable adjusted logistic regression was used to compare odds of PEG use between periods and demographic subgroups. Results: From 2005-2017, 4.3% of all AIS hospitalizations had coexisting codes for PEG but usage differed by age, with highest proportion of usage in patients >=80 year old (y.o) (5.2%) and lowest frequency of usage in adults 18-39 y.o (2.7%). On joinpoint regression, there was no significant change in PEG use from 2005-2009, usage declined annually by -3.0% from 2009-2015 (95%CI -4.2% to -1.8%) and then declined sharply by -9.2% (95%CI -13.4 to -4.8%) from 2015 to 2017 (figure 1). The pace of decline was faster in patients >=80y.o compared to other age groups. After multivariable adjustment for clinical and hospital level factors, patients hospitalized in the period 2014-2017 had 25% reduced odds of PEG when compared to admissions in the period 2005-2009 (OR 0.76, 95%CI 0.72-0.79). Female sex and white race were associated with lower odds of PEG compared to males and black patients, respectively. IV-tPA and MT usage increased over time with marked increase in usage after 2015. Conclusion: Overall the rate at which PEG tube have been utilized has decreased significantly over the last decade. This decrease is likely from multifactorial advances in acute stroke (IV-tPA and MT) and post stroke neuro critical care.

Download Full-text

Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study

Stroke ◽

10.1161/str.43.suppl_1.a2779 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Nancy Edwards ◽

Hooman Kamel ◽

S. Andrew Josephson

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Aneurysms ◽

Intravenous Thrombolysis ◽

Aneurysm Rupture ◽

Exact Test ◽

Intravenous Tissue Plasminogen Activator ◽

Unruptured Cerebral Aneurysms ◽

Risk Of Hemorrhage ◽

Iv Tpa

Background and Purpose: Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms. Methods: We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms. Results: We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%). Conclusion: Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.

Download Full-text

Abstract 4: Variation and Temporal Trends in the Characteristics of US Hospitals Treating Acute Ischemic Stroke Patients with IV-tPA: Findings from GWTG-Stroke

Stroke ◽

10.1161/str.44.suppl_1.a4 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Lee H Schwamm ◽

Syed F Ali ◽

Mathew J Reeves ◽

Eric E Smith ◽

Jeffrey L Saver ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Systems Of Care ◽

Team Building ◽

Temporal Trends ◽

High Volume ◽

Wilcoxon Test ◽

Chi Square ◽

Over Time ◽

Iv Tpa

Introduction: Utilization of IV tPA is challenging for many hospitals. Using data from the national Get With The Guidelines-Stroke program, we analyzed changes over time in the characteristics of the hospitals that treated patients with tPA. Methods: We analyzed patient-level data from 2003-2011 at 1600 GWTG hospitals that joined the program at any time during the study period and admitted any acute ischemic stroke (AIS) patients arriving ≤ 2 hr of onset and eligible for tPA. Descriptive trends by time were analyzed by chi-square or Wilcoxon test for continuous data. Results: IV tPA was given within 3 hr at 1394 sites to 50,798/ 75,115 (67.6%) eligible AIS patients arriving ≤ 2 hr; 206 (14.8%) sites had a least one eligible patients but no tPA use. IV tPA treatment rates varied substantially across hospitals (median 61.2%, range 0-100%), with > 200 hospitals providing tPA < 10% of the time (Figure). Over time, more patients and a larger proportion of patients were treated at smaller (median bed size 407 vs. 372, p< 0.001), non-academic, Southern hospitals, and those with lower annualized average ischemic stroke volumes (252.4 vs. 235.2, p< 0.001) (Table). While more than half of all tPA patients were treated at Primary Stroke Centers, this proportion did not change over time. The proportion of patients treated at high volume tPA treatment sites (average > 20/year) increased over time (31.9 vs. 34.5, p< 0.007). Conclusion: Over the past decade, while primary stroke centers still account for more than half of all treatments, tPA has been increasingly delivered in smaller, non-academic hospitals. These data support the continued emphasis on stroke team building and systems of care at US hospitals.

Download Full-text

Abstract 2268: Trends In Reasons For Non-eligibility For tPA

Stroke ◽

10.1161/str.43.suppl_1.a2268 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Xin Tong ◽

Mary G George

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Advanced Age ◽

Stroke Patients ◽

Rapid Improvement ◽

Nihss Score ◽

Mild Stroke ◽

Over Time ◽

Iv Tpa

Background: Use of IV tPA has increased over time, as has the adherence to the NQF endorsed performance measure for receipt of IV tPA within 3 hours. Little is known about trends in the reasons for patient ineligibility for IV tPA. This study examines trends in reasons for not providing IV tPA over time and by race and gender among acute ischemic stroke patients in the Paul Coverdell National Acute Stroke Registry (PCNASR), a quality improvement program for acute stroke implemented by state health departments. Methods: There were 13,164 PCNASR patients enrolled from 2008- 2010 with a clinical diagnosis of acute ischemic stroke with documentation of LKW and who arrived within 2 hours of LKW. Cochran-Armitage tests were used to test for trend on accepted reasons for not providing IV tPA within 3 hours of time last known well (LKW). Chi-square tests were used to test for differences among reasons between men and women and between non-Hispanic whites and minorities. Multiple reasons for not giving tPA could be selected. Results: Among 13,164 acute ischemic patients admitted between 2008 and 2010 with documentation of LKW and who arrived within 2 hours of LKW, 3781 (28.7%) received IV tPA, 7284 (55.3%) had documented reasons for not receiving IV tPA, and 2099 (16.0%) did not receive IV tPA. Contraindications to IV tPA, advanced age, rapid improvement and inability to determine eligibility increased over time. Mild stroke decreased over time. Conditions with warning, advanced age, limited life expectancy and family refusal were more common in women; mild stroke and rapid improvement were more common in men. Contraindications were more common in minorities; advanced age, mild stroke and rapid improvement, and family refusal were more common in non-Hispanic whites. When advanced age was selected, 46.6% of patients were over age 90 and 3.4% were under age 80. When stroke too mild was selected, 44.8% of patients had missing NIHSS scores, 42.1% of scores were 0-4, 8.8% were 5-9, and 4.3% were ≥ 10. The three most common reasons for not providing tPA were rapid improvement (40.9%), mild stroke (33.0%), and contraindications (29.2%) in 2010. Conclusions: More than half of ischemic stroke patients arriving within 2 hours of LKW were ineligible to receive IV tPA. There was little use of advanced age for patients under age 80. Documentation of stroke too mild was not substantiated by an NIHSS score in nearly half of patients. Better documentation of NIHSS score should be provided.

Download Full-text

Abstract WP41: Age-Specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients With Acute Ischemic Stroke: A Community-Wide Perspective

Stroke ◽

10.1161/str.51.suppl_1.wp41 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Saqib A Chaudhry ◽

Iqra N Akhtar ◽

Ameer E Hassan ◽

Mohammad Rauf A Chaudhry ◽

Mohsain Gill ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

International Classification Of Diseases ◽

The United States ◽

Primary Diagnosis ◽

Limited Information ◽

Hospital Outcomes ◽

The Impact ◽

Over Time

Background: Relatively limited information is available about trends over time in the use of endovascular treatment in patients of different ages hospitalized with acute ischemic stroke and the association between use of thrombectomy treatment and hospital outcomes in age strata. We performed this analysis to evaluate trends in the utilization of endovascular treatment in acute ischemic stroke by age strata in real-world practice. Methods: We conducted this study by identifying patients admitted with a primary diagnosis of ischemic stroke in the United States from 2007 to 2016 using the Nationwide Inpatient Sample. International Classification of Diseases, ninth revision, and tenth, Clinical Modification (ICD-9-CM, ICD-10-CM) codes were used to identify patients admitted for ischemic stroke and undergoing endovascular treatment. Results: Of the 4,590,533 patients admitted with ischemic stroke, 269,922 (5.88%) received intravenous thrombolytic treatment, and 51,375 (1.12%) underwent endovascular treatment. There is almost 12-fold significant increase in the use of endovascular treatment patients admitted with acute ischemic stroke between 2007 to 2016. Patients who were 75 years and older experienced a marked increase in the receipt of endovascular treatment over time (0.12% 2007; 1.91% 2016; trend p<0.0001). We observed statistically significant improvement in outcomes including minimal disability (6.3% to 18.8%; trend p<0.0001) and in hospital mortality (25.0% to 16.5%; trend p<0.0001) in patients 75 years and older treated with endovascular treatment in study period. We observed similar trend of outcomes in each of the other age-specific groups under study (<55, 55-64 and 65-74 years). Conclusions: Our findings indicate a recent increase in the use of endovascular in middle-aged and elderly patients with acute ischemic strokes. The impact of endovascular treatment on hospital outcomes was observed in each of our age strata understudy though the magnitude of absolute and relative benefit varied according to age.

Download Full-text

Abstract WMP94: Temporal Trends in Racial, Age, and Sex-Specific Utilization of Decompressive Hemicraniectomy Among Acute Ischemic Stroke Patients in the United States

Stroke ◽

10.1161/str.51.suppl_1.wmp94 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sai P Polineni ◽

Fadar O Otite ◽

Seemant Chaturvedi

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Temporal Trends ◽

Age Groups ◽

The United States ◽

Decompressive Hemicraniectomy ◽

Study Results ◽

Over Time ◽

Age And Sex

Background: The aim of this study is to evaluate current trends in racial, age, and sex-specific utilization of decompressive hemicraniectomy (HC) in acute ischemic stroke (AIS) patients in the United States over the last decade. Methods: All adult patients with a diagnosis of AIS were identified from the 2004-2015 Nationwide Inpatient Sample (weighted N=4,792,428) using International Classification of Diseases Ninth revision (ICD-9) codes. Proportion of patients undergoing HC in various age, race, and sex groups were ascertained using ICD-9 procedural codes. Temporal trends were mapped by year in order to track changes in utilization over time. Analysis of utilization disparities and trends within age, sex, and race subgroups was conducted via multivariate logistic regression. Results: Of all eligible AIS patients from 2004-2015, 0.25% underwent HC (.08 in 2004 to .46 in 2015). Increased utilization over time was seen in both men (.13 to .57) and women (.08 to .54), with women showing comparable odds of utilization to men [OR: 0.95 (95% CI: .87-1.04, p=0.27)]. Similarly, increased utilization trends were seen in all age groups (Figure 1) with the highest rates in the 18-39 subgroup (1.41%). Compared to trends in this younger subgroup (.43 to 2.12), patients aged 60-79 experienced a similar overall increase but at lower utilization rates (.06 to .37). Compared to white patients in multivariate models, blacks did not show significant differences in odds of HC [1.09 (.96-1.24, p=0.20)], while patients from Hispanic [1.25 (1.03-1.51, p=0.02)] and other [1.26 (1.04-1.52, p=0.02)] race-ethnic groups showed increased odds. Conclusions: From 2004-2015, hemicraniectomy rates have seen substantial increases in all age, sex, and race groups. The increasing rates of hemicraniectomies among those over age 60 suggest that there has been at least partial acceptance of DESTINY 2 study results.

Download Full-text

Abstract 2545: Does Participation in a Stroke Registry Improve tPA Administration Rates?

Stroke ◽

10.1161/str.43.suppl_1.a2545 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Moges Ido ◽

Lydia Clarkson ◽

Deborah Camp ◽

Kerrie Krompf ◽

Michael Frankel

Keyword(s):

Quality Improvement ◽

Ischemic Stroke ◽

Length Of Stay ◽

Patient Care ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

Hospital Size ◽

Stroke Registry ◽

Over Time ◽

Iv Tpa

Background: The purpose of the Georgia Coverdell Acute Stroke Registry (GCASR) is to improve the quality of patient care. GCASR conducts regular quality improvement activities to educate hospital staff and improve systems and processes. Administration of intravenous tissue plasminogen activator (IV tPA) is standard treatment for eligible acute ischemic stroke patients and can dramatically improve outcomes. Purpose: To determine whether GCASR hospitals were more likely to administer tPA to acute ischemic stroke patients than non-GCASR hospitals. Methods: Hospitalization data from acute care hospitals in Georgia was provided by the Georgia Hospital Association for November 2005 through December 2009. Acute ischemic stroke patients receiving tPA were identified using ICD-9 codes (433 and 434), procedure codes (9910), and healthcare common procedure system codes (J2997). A hospital was defined as a GCASR facility if it was actively participating in the registry at the time of patient hospitalization. A generalized estimating equation with robust variance estimation was applied using the SAS GLIMMIX procedure. “Hospital” was treated as a random variable. Relative risks for receiving tPA were estimated and adjusted for demographics, co-morbidities, hospital size, urbanicity, and length of stay. Results: A total of 55,403 patients were admitted with a principal diagnosis of acute ischemic stroke during the study period, and two percent (1,231) received tPA. Three percent of patients (871) seen at registry facilities received tPA, compared to 1.4% (360) of those seen at non-GCASR facilities. Age, gender, race, length of stay, hospital size, and participation in the registry all predicted tPA administration, either at or near significant levels (p-values from <0.0001 to 0.0646). Although IV tPA administration has increased over time in both hospital groups, patients treated at GCASR facilities were more likely to receive tPA after controlling for confounders (OR=1.64; 95% CI: 0.97-2.78), which approached significance (p=0.0646). Approximately 340 fewer people would have received tPA had all study patients been treated at non-GCASR facilities. Conclusions: Although all Georgia hospitals have improved their rate of tPA administration over time, GCASR hospitals maintained a higher rate than non-GCASR hospitals. This may be due in part to the quality improvement activities that registry facilities participate in and the assistance they receive. These results support the stroke registry model as a method of improving stroke patient care and outcomes.

Download Full-text

Abstract 16: IV TPA in the 0-3 Hour Window: Quantitative Fragility-Robustness Assessment of the Strength of the RCT Evidence

Stroke ◽

10.1161/str.52.suppl_1.16 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Katherine T Mun ◽

Jordan B Bonomo ◽

David S Liebeskind ◽

Jeffrey L Saver

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Individual Patient Data ◽

Endovascular Thrombectomy ◽

Strength Of Evidence ◽

Evidence Strength ◽

Meta Analyses ◽

Robustness Assessment ◽

Over Time ◽

Iv Tpa

Background: After 3 decades, the era of RCTs of IV tPA as a standalone therapy in acute ischemic stroke has now likely closed, with the completion of TESPI, PRISMS, and late, imaging-selection RCTs, and the advent of endovascular thrombectomy. Some non-expert contrarians questioned the accumulating evidence regarding tPA; the recently formulated fragility-robustness index (FRI) enables quantification of the actual rigor of evidence throughout the era of IV tPA investigation. Methods: The FRI summarizing the strength of the statistical evidence for clinical trial findings is the minimum nonevent to event changes needed to turn a statistically significant to non-significant result. The FRI was applied to disability-free (mRS 0-1) and independence (mRS 0-2) outcomes; cumulative meta-analyses delineated evidence strength after each successive RCT. FRI scores were classified: Not Robust (FRI 0-4), Somewhat Robust (5-12), Robust (13-33), and Highly Robust (>33). Results: Systematic search identified 8 RCTs (1960 patients) of IV tPA in the 0-3h window from 1995 - 2018. Study-level meta-analyses showed FRIs of 42 for mRS 0-1 and 40 for mRS 0-2; individual patient data meta-analyses showed FRIs of 40 for both mRS 0-1 and mRS 0-2, placing IV tPA in the highest quintile of FRIs among meta-analyses for all conditions. Evolution of RCT evidence over time is shown in Table 1. Strength of evidence for IV tPA superiority was already robust with publication of the initial 2 NINDS-tPA in 1995, remained robust through 2011 after 4 additional RCTs, increased to highly robust with the IST-3 mega-trial in 2012, and remains highly robust today after 1 additional trial. Conclusions: Intravenous tPA for acute ischemic stroke in 0-3h patients is one of the most robustly proven therapies in medicine. This therapy was already robustly supported with publication of the initial trials 25 years ago and advanced 9 years ago after additional trials to highly robust/non-fragile.

Download Full-text

Abstract 3994: Obese Patients Receiving Intravenous Thrombolysis in Acute Ischemic Stroke Have lower Rates of Intracerebral hemorrhage and Mortality

Stroke ◽

10.1161/str.43.suppl_1.a3994 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Ameer Hassan ◽

Mikayel Grigoryan ◽

Saqib Chaudhry ◽

Adnan Qureshi

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Multivariate Logistic Regression Analysis ◽

Intravenous Thrombolysis ◽

International Classification Of Diseases ◽

The United States ◽

Obese Patients ◽

Stroke Patients ◽

Intravenous Tissue Plasminogen Activator ◽

Classification Of Diseases

Background: The current recommended dose of intravenous tissue plasminogen activator (IV rt-PA) for ischemic stroke patients weighing >100 kg is fixed at 90 mg and thus obese patients receive less than the recommend 0.9mg/kg dosage. We hypothesized that obese patients receive a lower dose of thrombolytics and they will have a lower rates of intracerebral hemorrhages (ICH), but lower rates of clinical benefit from IV rt-PA. Objective: To determine the relationship between obesity and clinical outcomes among acute ischemic stroke patients receiving IV rt-PA. Methods: Data were obtained from all states within the United States that contributed to the Nationwide Inpatient Sample. All patients admitted to US hospitals between 2002 and 2009 with a primary discharge diagnosis of stroke treated with IV thrombolysis (identified by the International Classification of Diseases, Ninth Revision procedure codes) were included. We analyzed whether the presence of obesity was associated with clinical outcome and ICH with multivariate logistic regression analysis after adjusting for potential confounders. Results: Of the 84,727 patients with ischemic stroke treated with IV rt-PA, 5,437 (6.4%) had concurrent obesity. The ICH rates between obese and non-obese patients was 4.3% versus 6.1% (p=0.005). After adjusting for age, sex, hypertension, diabetes mellitus, renal failure, hospital teaching status, and ICH, the presence of obesity was not associated with increased rates of self-care (odds ratio [OR] 0.929, 95% confidence interval [CI] 0.815-1.063, p=0.27), but was associated with decreased rates of mortality (OR 0.78, 95% CI 0.61 - 0.94, p=0.045) at discharge. Conclusion: Obese patients undergoing IV t-PA treatment for acute ischemic stroke appear to have lower rates of ICHs and mortality presumably due to lower weight adjusted thrombolytic dose.

Download Full-text

Abstract WP122: Refusal of Intravenous Thrombolysis for Acute Ischemic Stroke in San Diego

Stroke ◽

10.1161/str.51.suppl_1.wp122 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Tara von Kleist ◽

Dawn Meyer ◽

Karen Rapp ◽

Brett Meyer ◽

Royya Modir

Keyword(s):

Ischemic Stroke ◽

Informed Consent ◽

Acute Ischemic Stroke ◽

San Diego ◽

Intravenous Thrombolysis ◽

Treatment Decision ◽

Decision Time ◽

Stroke Registry ◽

Institutional Review ◽

Iv Tpa

Purpose: To assess the demographic and clinical characteristics of patients who refuse intravenous thrombolysis (IV tPA) for acute ischemic stroke from the Stroke Registry population collected by the University of California San Diego (UCSD) Stroke Team and to compare outcomes between those who were treated with IV tPA and those who refused. Methods: We evaluated patients between July 2004 and July 2019 from the prospective Institutional Review Board (IRB) approved Stroke Registry project. Patients who either received IV tPA or refused IV tPA were included. Baseline demographics, NIHSS, treatment times and 90 day mRS were collected. Results: A total of 1056 patients were included in the analysis. Forty-seven patients (4.5%) refused IV tPA. There were no differences in demographics between patients who were treated with IV tPA and those who refused. Patients who refused IV tPA had a significantly lower baseline NIHSS (4 vs 9, p=<0.0001) and higher baseline mRS (1.3 vs 0.6, p=0.00043) compared to patients who received IV tPA. The time from arrival to treatment decision was significantly longer in patients who refused IV tPA (group mean 57.9 min vs 48.8 min, p=0.03). There was no difference in 90 day mRS between groups. Conclusions: There is a low rate of IV tPA refusal in our registry population which is similar to what previous studies have shown 1,2 . We found that patients who refuse IV tPA have milder deficits and worse pre-morbid disability. We suspect that the longer “arrival to treatment decision” time in the refuse IV tPA group is due to longer informed consent discussions. This study demonstrates the utility of informed consent in clinical practice and highlights the importance of respecting patient autonomy.

Download Full-text

Abstract W P227: Cerebral Hyperperfusion Syndrome after Intravenous Thrombolysis for Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.wp227 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Leonard Yeo ◽

Rahul Rathakrishnan ◽

Hock Luen Teoh ◽

Prakash Paliwal ◽

Kay W Ng ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Neuropsychiatric Symptoms ◽

Intravenous Thrombolysis ◽

Fluid Restriction ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion ◽

Hmpao Spect ◽

Iv Tpa

Background: Cerebral hyperperfusion syndrome (CHS) is a recognized complication after surgical revascularization of a chronically atherosclerotic artery. However, this phenomenon is unexpected when an acutely occluded artery is recanalized by IV-TPA for acute ischemic stroke (AIS).In patients with discrepant neuroimaging and clinical findings, our multimodal evaluations revealed CHS in a series of 7 patientsmafter IV- TPA therapy. Methods: Patients in whom the occluded ICA or MCA in pre-TPA CT-angiogram (CTA) showed recanalization in the day-2 CTA, were observed for any new unexpected neuropsychiatric symptoms/signs. If these were present they underwent multimodal evaluation including serial transcranial Doppler (TCD), quantitative electroencephalography (QEEG) and HMPAO-SPECT. Patients with considerable mismatch between clinical and neuroimaging findings were also included. CHS was deemed to have occurred if the unexpected neuropsychiatric signs corresponded with TCD flow velocity >100% of the contralateral vessel, EEG showed abnormal activity and HMPAO-SPECT scan showed markedly increased cerebral perfusion compared to the contralateral side. Results: Out of 155 patients treated with IV-TPA, 7 (4.5%) patients fulfilled our definition of CHS. All 7 patients developed the symptoms 2-3 days after IV-TPA. Abnormalities on TCD, QEEG and HMPAO-SPECT were observed in all patients. The unexpected symptoms included generalized headache (4 cases), unexplained persistent drowsiness (3 cases), visual neglect (2 cases), aphasia (2 cases) and severe suicidal thoughts despite complete neurological recovery (1 case). All cases had hypertension prior to the index stroke. Upright posture, fluid restriction and aggressive blood pressure control resulted in rapid resolution of abnormal features in all cases within a week. All patients achieved modified Rankin score 0-1 with no intracranial hemorrhage. Conclusion: CHS after intravenous thrombolysis in acute ischemic stroke should be suspected in patients that achieve arterial recanalization with unexplained new neuropsychiatric manifestations. Early diagnosis and appropriate management might prevent hemorrhage and achieve good functional outcomes.

Download Full-text