Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

Objective: Asymmetrical cortical vein sign (ACVS) shown on susceptibility-weighted imaging (SWI) can reflect regional hypoperfusion. We investigated if ACVS could predict the cerebral collateral circulation (CC) as assessed by digital subtraction angiography (DSA) in acute ischemic stroke patients with ipsilateral severe stenosis/occlusion of the anterior circulation.Methods: Clinical data and imaging data of 62 acute ischemic stroke patients with ipsilateral severe stenosis or occlusion of the anterior circulation confirmed by DSA were collected retrospectively. Participants underwent magnetic resonance imaging, including an SWI sequence. ACVS was defined as more and/or larger venous signals in the cerebral cortex of one side of SWI than that in the contralateral side. ACVS was measured using the Alberta Stroke Program Early Computed Tomography score based on SWI. The grading of the cerebral CC was judged using DSA.Results: Of the 62 patients, 30 patients (48.4%) had moderate-to-severe ACVS. According to DSA assessment, 19 patients (30.6%) had a good CC (grade 3–4), and 43 (69.4%) patients had a poor-to-moderate CC (grade 0–2). Among the 30 patients with moderate-to-severe ACVS, only three (10%) patients had a good CC, and 27 (90%) patients had a poor-to-moderate CC; among the 32 patients with none or mild ACVS, 16 (50%) of them had a good CC, and the other 50% had a moderate-to-severe CC. We constructed two logistic regression models with ACVS grading and none or mild ACVS entered into the models, respectively, together with age and large-artery occlusion. In model 1, no ACVS (compared with severe ACVS; OR = 40.329, 95%CI = 2.817–577.422, P = 0.006), mild ACVS (compared with severe ACVS; OR = 17.186, 1.735–170.224, 0.015) and large-artery occlusion (OR = 45.645, 4.603–452.592, 0.001) correlated with a good CC. In model 2, none or mild ACVS (OR = 36.848, 95%CI = 5.516–246.171, P < 0.001) was significantly associated with a good CC as judged by DSA, adjusted by age and large-artery occlusion.Conclusions: Cortical venous changes in SWI may be a useful indicator for the cerebral CC as confirmed by DSA.

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Prevalence and Clinical Characteristics of Subclavian Steal Phenomenon/Syndrome in Patients with Acute Ischemic Stroke

Journal of Clinical Medicine ◽

10.3390/jcm10225237 ◽

2021 ◽

Vol 10 (22) ◽

pp. 5237

Author(s):

Zoltan Bajko ◽

Anca Motataianu ◽

Adina Stoian ◽

Laura Barcutean ◽

Sebastian Andone ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Group ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Large Artery ◽

Stroke Patients ◽

Steal Phenomenon ◽

Subclavian Steal ◽

Stroke Group

There are no published clinical studies regarding the prevalence of subclavian steal among acute ischemic stroke patients. The aim of this study was to evaluate the prevalence and clinical significance of subclavian steal among a large number of consecutive ischemic stroke patients. Materials and methods: We reviewed the medical records of 2192 consecutive cases of acute ischemic stroke at a tertiary neurology clinic in Targu Mures, Romania, between 2018 and 2020. In total, 47 patients (2.2%) were diagnosed with subclavian steal phenomenon/syndrome. Results: Stroke patients with associated steal phenomenon were significantly younger (64.2 ± 11.1 versus 70.2 ± 12.8, p = 0.005) and predominantly male (68.1%). From among the 47 patients with subclavian steal phenomenon, nine (19.1%) presented stroke symptomatology in the vertebrobasilar territory. Overall, 83.3% of the stroke patients with associated steal phenomenon presented cerebral infarction and 16.7% presented TIA. There was no difference between groups regarding the affected vascular territory (VB versus carotid). Large artery atherosclerosis was more frequent in the stroke group with associated steal phenomenon (81.3% versus 43.5%, p = 0.0033). The NIHSS score at admission was higher in the patient group with associated steal phenomenon, but there was no difference in mRS at discharge. Associated carotid artery occlusion was more frequent in the stroke group with steal phenomenon (p < 0.01). Smoking and peripheral arteriopathy were more frequent in the patient group with associated steal phenomenon. Of the nine symptomatic patients, five underwent revascularization treatment. Conclusions: The prevalence of subclavian steal phenomenon among acute ischemic stroke patients was not higher than in other cohorts with heterogenous peripheral vascular pathologies. Similar to the general population, in acute ischemic stroke patients, the associated subclavian steal behaved like a benign hemodynamical condition, without severe consequences.

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Abstract TP165: Mortality After Large Artery Occlusion Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.tp165 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Rahul R Karamchandani ◽

Jeremy Rhoten ◽

Edwin Strong ◽

Brenda Chang ◽

Sam Singh ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Prediction Models ◽

Univariate Analysis ◽

Female Gender ◽

Artery Occlusion ◽

Large Artery ◽

Multivariable Logistic Regression Model ◽

Factors Associated ◽

Social Security Death Index

Introduction: Despite randomized trials demonstrating the benefit of endovascular therapy (EVT), large artery occlusion (LAO) acute ischemic stroke (AIS) remains associated with high mortality. Identifying factors associated with mortality for patients presenting with LAO AIS can assist in therapeutic decision-making and prognostication. Hypothesis: Among patients with LAO AIS, factors associated with 90-day mortality include older age, higher presenting NIHSS score, and lower final Thrombolysis in Cerebral Infarction (TICI) score. Methods: From November 2016 to April 2019, we conducted a retrospective analysis from a large healthcare system’s stroke network registry of patients presenting with ICA and/or MCA occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Results: Among 796 patients with 800 encounters, mean age was 68 years, 52% were women, mean presenting NIHSS was 14, and 97% presented within 24 hours of last known well time. Fifty-one percent were treated with EVT. Mortality rate for the entire cohort was 25%. In a univariate analysis, there were significant differences in age, gender, race, blood glucose, presenting NIHSS, hypertension, atrial fibrillation, CTP core volume, CTP delayed perfusion volume, EVT treatment, number of passes for EVT, final TICI score, and discharge mRS, between patients with and without 90-day mortality. In the multivariable model, increasing age (per 10 years, OR 1.54, 95% CI 1.20, 1.97) and higher discharge mRS (per 1 point, OR 4.47, 95% CI 3.05, 6.55) were associated with 90-day mortality. Female gender (OR 0.57, 95% CI 0.27, 1.18) and final TICI score of 2B or better (OR 0.42, 95% CI 0.18, 1.01) were protective against 90-day mortality. Conclusions: Increasing age and worse discharge functional outcome are associated with 90-day mortality after LAO AIS. Female gender and better revascularization after EVT are associated with lower mortality. Additional studies are required to refine mortality outcome prediction models for patients presenting with LAO AIS.

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Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

Case Reports in Neurology ◽

10.1159/000507185 ◽

2020 ◽

Vol 12 (Suppl. 1) ◽

pp. 49-55

Author(s):

Huong Bich Thi Nguyen ◽

Thang Huy Nguyen

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Time Window ◽

Recurrent Stroke ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Large Artery ◽

Limited Information ◽

Anterior Circulation ◽

Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

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Impact of the COVID-19 pandemic on the process and outcome of thrombectomy for acute ischemic stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016177 ◽

2020 ◽

Vol 12 (7) ◽

pp. 664-668 ◽

Cited By ~ 11

Author(s):

Bin Yang ◽

Tao Wang ◽

Jian Chen ◽

Yanfei Chen ◽

Yabing Wang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Artery Occlusion ◽

Large Artery ◽

Medical Work ◽

Protection Measures ◽

Hospital Arrival ◽

Comprehensive Stroke Center ◽

Novel Coronavirus ◽

The Impact

BackgroundThe novel coronavirus disease 2019 (COVID-19) pandemic is still spreading across the world. Although the pandemic has an all-round impact on medical work, the degree of its impact on endovascular thrombectomy (EVT) for patients with acute ischemic stroke (AIS) is unclear.MethodsWe continuously included AIS patients with large artery occlusion who underwent EVT in a comprehensive stroke center before and during the Wuhan shutdown. The protected code stroke (PCS) for screening and treating AIS patients was established during the pandemic. The efficacy and safety outcomes including the rate of successful reperfusion (defined as modified Thrombolysis In Cerebral Infarction (mTICI) graded 2b or 3) and time intervals for reperfusion were compared between two groups: pre-pandemic and pandemic.ResultsA total of 55 AIS patients who received EVT were included. The baseline characteristics were comparable between the two groups. The time from hospital arrival to puncture (174 vs 125.5 min; p=0.002) and time from hospital arrival to reperfusion (213 vs 172 min; p=0.047) were significantly prolonged in the pandemic group compared with the pre-pandemic group. The rate of successful reperfusion was not significantly different between the two groups (85.7% (n=18) vs 88.2% (n=30); OR 0.971, 95% CI 0.785 to 1.203; p=1.000).ConclusionThe results of this study suggest a proper PCS algorithm which combines the COVID-19 screening and protection measures could decrease the impact of the disease on the clinical outcomes of EVT for AIS patients to the lowest extent possible during the pandemic.

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Primary acute stroke thrombectomy within 3 h for large artery occlusion (PAST3-LAO): a pilot study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012172 ◽

2016 ◽

Vol 9 (4) ◽

pp. 352-356 ◽

Cited By ~ 1

Author(s):

Yahia Lodi ◽

Varun Reddy ◽

Gorge Petro ◽

Ashok Devasenapathy ◽

Anas Hourani ◽

...

Keyword(s):

Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Artery Occlusion ◽

Large Artery ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Nihss Score ◽

Tissue Plasminogen ◽

Poor Outcomes

Background and purposeIn recent trials, acute ischemic stroke (AIS) from large artery occlusion (LAO) was resistant to intravenous thrombolysis and adjunctive stent retriever thrombectomy (SRT) was associated with better perfusion and outcomes. Despite benefit, 39–68% of patients had poor outcomes. Thrombectomy in AIS with LAO within 3 h is performed secondary to intravenous thrombolysis, which may be associated with delay. The purpose of our study is to evaluate the safety, feasibility, recanalization rate, and outcome of primary SRT within 3 h without intravenous thrombolysis in AIS from LAO.MethodsBased on an institutionally approved protocol, stroke patients with LAO within 3 h were offered primary SRT as an alternative to intravenous recombinant tissue plasminogen activator. Consecutive patients who underwent primary SRT for LAO within 3 h from 2012 to 2014 were enrolled. Outcomes were measured using the modified Rankin Scale (mRS).Results18 patients with LAO of mean age 62.83±15.32 years and median NIH Stroke Scale (NIHSS) score 16 (10–23) chose primary SRT after giving informed consent. Near complete (TICI 2b in 1 patient) or complete (TICI 3 in 17 patients) recanalization was observed in all patients. Time to recanalization from symptom onset and groin puncture was 188.5±82.7 and 64.61±40.14 min, respectively. NIHSS scores immediately after thrombectomy, at 24 h and 30 days were 4 (0–12), 1 (0–12), and 0 (0–4), respectively. Asymptomatic perfusion-related hemorrhage developed in four patients (22%). 90-day outcomes were mRS 0 in 50%, mRS 1 in 44.4%, and mRS 2 in 5.6%.ConclusionsOur study demonstrates that primary SRT in AIS from LAO is safe and feasible and is associated with complete recanalization and good outcome. Further study is required.

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