Good Intracranial Collaterals Trump Poor ASPECTS (Alberta Stroke Program Early CT Score) for Intravenous Thrombolysis in Anterior Circulation Acute Ischemic Stroke

Abstract Background Numerous studies on acute ischemic stroke (AIS) have been conducted at low-altitude regions, and the related findings have been used to guide clinical management. However, corresponding studies at high altitude are few. This study aimed to analyse the clinical characteristics of AIS patients at high-altitude regions through a hospital-based comparative study between Tibet and Beijing. Methods This study included the diagnoses of AIS patients from People’s Hospital of Tibet Autonomous Region (PHOTAR) and Peking University First Hospital (PUFH) between 1 January 2014 and 31 December 2017, where data including patient demographics, treatment time, onset season, risk factors, infarction location, laboratory data, image examination results, treatments, and AIS subtype were collected and compared. Continuous and categorical variables were analysed with a two-sample t-test or Wilcoxon rank sum test and chi-square test, respectively. Significant risk factors were examined with binary logistic regression analysis. Results In total, 236 and 1021 inpatients from PHOTAR and PUFH were included, respectively. The PHOTAR patients were younger than the PUFH patients (P < 0.001). Young adult stroke, erythrocytosis, and hyperhomocysteinemia were more frequent in PHOTAR patients (all P < 0.001). Other vascular risk factors, including hypertension, diabetes mellitus, hyperlipidaemia, smoking and alcohol consumption history, were less prevalent in PHOTAR patients than in PUFH patients. The rate of intravenous thrombolysis and the rate of within intravenous thrombolysis window time were also lower in PHOTAR patients (both P < 0.001). The PHOTAR group also tended to have anterior circulation infarction. Erythrocytosis and hyperhomocysteinemia were independent risk factors in PHOTAR, and young adults accounted for a larger proportion of stroke cases. Conclusion In Tibet, AIS patients were relatively younger, and anterior circulation infarctions were more common. Erythrocytosis and hyperhomocysteinemia may contribute to these differences. Here, young adult stroke also accounted for a higher proportion, and this may be associated with erythrocytosis. Our findings present the first hospital-based comparative study in Tibet and may contribute to policies for stroke prevention in this region.

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Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results.

10.21203/rs.2.482/v1 ◽

2019 ◽

Author(s):

Massimo Gamba ◽

Nicola Gilberti ◽

Enrico Premi ◽

Angelo Costa ◽

Michele Frigerio ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Safety Profile ◽

Infarct Volume ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage

Abstract Background and Purpose endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients is still unclear. The present study aims to test whether IVT plus ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS by LVO. Methods we performed a single center retrospective observational study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. The patients were divided in 2 groups based on the treatment they received: CoT and, if IVT contraindicated, direct ET. We compared functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up infarct volume (EFIV) (for recanalized patients only) as well as safety profile, defined as symptomatic intracerebral hemorrhage (sICH) and 3-month mortality, between groups. Results 145 subjects were included in the study, 70 in direct ET group and 75 in CoT group. Patients who received CoT presented more frequently a functional independence at 3-months follow-up compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P<0.001. mRS score 0-2: 67.1% vs 37.3%; P<0.001), higher first-pass success rate (62.7% vs 38.6%, P<0.05), higher recanalization rate (84.3% vs 65.3%; P=0.009) and, in recanalized subjects, smaller EFIV (16.4ml vs 62.3ml; P=0.003). The safety profile was similar for the 2 groups. In multivariable regression analysis, low baseline NIHSS score (P<0.05), vessel recanalization (P=0.05) and CoT (P=0.03) were indipendent predictors of 3-month favorable outcome. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

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Characteristics of acute ischemic stroke in hospitalized patients in Tibet: A retrospective comparative study

10.21203/rs.3.rs-24993/v2 ◽

2020 ◽

Author(s):

Yuxuan Lu ◽

Cidan Zhuoga ◽

Haiqiang Jin ◽

Feiqi Zhu ◽

Yuhua Zhao ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Young Adult ◽

Comparative Study ◽

Acute Ischemic Stroke ◽

High Altitude ◽

Intravenous Thrombolysis ◽

Categorical Variables ◽

Anterior Circulation ◽

Tibet Autonomous Region

Abstract Background: Lots of studies of acute ischemic stroke (AIS) had been conducted at low altitude regions, and related findings were used to instruct clinic management while corresponding studies at high altitude were few. This study aimed to analyse AIS clinic characteristics at high altitude regions by conducting a hospital-based comparative study between Tibet and Beijing. Methods: This study included the diagnoses of AIS patients from People’s Hospital of Tibet Autonomous Region (PHOTAR) and Peking University First Hospital (PUFH) between 1st January 2014, and 31st December 2017, where data including patient demographics, treatment time, onset season, risk factors, infarction location, laboratory data, image examination results, treatments, and AIS subtype were collected and compared. Continuous and categorical variables were analysed with a two-sample t-test or Wilcoxon rank sum test and chi-square test, respectively. Significant risk factors were examined with binary logistic regression analysis.Results: In total, 236 and 1021 inpatients from PHOTAR and PUFH were included, respectively. The PHOTAR patients were younger than the PUFH patients (P<0.001). Young adult stroke, erythrocytosis, and hyperhomocysteinemia were more frequent in PHOTAR patients (all P<0.001). Other vascular risk factors, including hypertension, diabetes mellitus, hyperlipidaemia, and smoking and alcohol consumption history, were less prevalent in PHOTAR patients than in PUFH patients. The rate of intravenous thrombolysis and the rate of within intravenous thrombolysis window time were also lower in PHOTAR patients (both P<0.001). PHOTAR groups also tended to have anterior circulation infarction. Erythrocytosis and hyperhomocysteinemia were independent risk factors in PHOTAR, and here young adults accounted for a larger proportion of stroke cases. Conclusion: In Tibet, the average age of AIS patients were less, and anterior circulation infarctions were also more common. Erythrocytosis and hyperhomocysteinemia may contribute to these differences. Here young adult stroke also accounted for a higher proportion, and this may be associated with erythrocytosis. Our findings present the first hospital-based comparative study in Tibet and may contribute to policies for stroke prevention in this region.

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Characteristics of acute ischemic stroke in hospitalized patients in Tibet: A retrospective comparative study

10.21203/rs.3.rs-24993/v3 ◽

2020 ◽

Author(s):

Yuxuan Lu ◽

Cidan Zhuoga ◽

Haiqiang Jin ◽

Feiqi Zhu ◽

Yuhua Zhao ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Young Adult ◽

Comparative Study ◽

Acute Ischemic Stroke ◽

High Altitude ◽

Intravenous Thrombolysis ◽

Categorical Variables ◽

Anterior Circulation ◽

Tibet Autonomous Region

Abstract Background: Numerous studies of acute ischemic stroke (AIS) have been conducted at low altitude regions, and the related findings were used to instruct clinic management while corresponding studies at high altitude are few. This study aimed to analyse AIS clinic characteristics at high altitude regions by conducting a hospital-based comparative study between Tibet and Beijing. Methods: This study included the diagnoses of AIS patients from People’s Hospital of Tibet Autonomous Region (PHOTAR) and Peking University First Hospital (PUFH) between 1st January 2014, and 31st December 2017, where data including patient demographics, treatment time, onset season, risk factors, infarction location, laboratory data, image examination results, treatments, and AIS subtype were collected and compared. Continuous and categorical variables were analysed with a two-sample t-test or Wilcoxon rank sum test and chi-square test, respectively. Significant risk factors were examined with binary logistic regression analysis.Results: In total, 236 and 1021 inpatients from PHOTAR and PUFH were included, respectively. The PHOTAR patients were younger than the PUFH patients (P<0.001). Young adult stroke, erythrocytosis, and hyperhomocysteinemia were more frequent in PHOTAR patients (all P<0.001). Other vascular risk factors, including hypertension, diabetes mellitus, hyperlipidaemia, and smoking and alcohol consumption history, were less prevalent in PHOTAR patients than in PUFH patients. The rate of intravenous thrombolysis and the rate of within intravenous thrombolysis window time were also lower in PHOTAR patients (both P<0.001). PHOTAR groups also tended to have anterior circulation infarction. Erythrocytosis and hyperhomocysteinemia were independent risk factors in PHOTAR, and here young adults accounted for a larger proportion of stroke cases. Conclusion: In Tibet, the average age of AIS patients were less, and anterior circulation infarctions were also more common. Erythrocytosis and hyperhomocysteinemia may contribute to these differences. Here young adult stroke also accounted for a higher proportion, and this may be associated with erythrocytosis. Our findings present the first hospital-based comparative study in Tibet and may contribute to policies for stroke prevention in this region.

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Abstract TP54: Topographical Aspects Collateral Score is a Useful Prognostic Factor in Thrombolysed Anterior Circulation Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.47.suppl_1.tp54 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Leonard Yeo ◽

Prakash Paliwal ◽

Teoh Hock Luen ◽

Rahul Rathakrishnan ◽

Derek Soon ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Carotid Artery ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Prognostic Value ◽

Intravenous Thrombolysis ◽

Anterior Circulation ◽

Nihss Score ◽

Multivariable Logistic Regression

Background: the ASPECTS- collateral score on CT-angiograms was shown to be successful in prognosticating functional outcomes and complications during intravenous thrombolysis in acute ischemic stroke (AIS). We studied predetermined topological information to see if any specific region had more prognostic value. Methods: consecutive patients from 2010-2014 with intracranial internal carotid artery, M1 or M2 middle carotid artery occlusions treated with intravenous thrombolysis were included. The primary outcome measure was good clinical outcome (3-month modified Rankin Scale score 0-1). We scored each region as 0= no collaterals, 1= poor compared to contralateral and 2= good collaterals. Prognostic value of the 6 cortical ASPECTS-collateral regions in predicting outcomes was determined by multivariable logistic regression. Results: 310 patients were included (Median age, 66.1±14.5 years; median National Institutes of Health Stroke Scale (NIHSS)- 18 points (range 3-36). Inter-rater reliability for ASPECTS-collaterals was good (κ=0.78). There was no Statistical collinearity among ASPECTS-collateral regions. Using multivariable logistic regression, only the M5 region (odds ratio, 2.72, 95%CI 1.52-4.84, p =0.001), age (OR 0.957 per yr 95%CI 0.936-0.978, p <0.001), Diabetes (OR 0.367, 95%CI 0.193- 0.700, p =0.002) and NIHSSS (OR 0.878 per point, 95%CI 0.836-0.922, p=0.001) were significantly associated with good outcomes. When compared with NIHSS, the receiver operating characteristic curves for NIHSS+M5 (area under the curve, 0.749) correlated well with clinical severity scores. Addition of M5 collateral score showed a statistically significant additive effect to the NIHSS score for predicting good outcomes (Z score: -1.684, p=0.045). Conclusions: Involvement of the parietal region (M5) regions is a reliable predictor of clinical outcome in anterior circulation large artery occlusion. This simple radiological marker can strengthen the clinical NIHSS score and may be considered during prognostication

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Characteristics of acute ischemic stroke in hospitalized patients in Tibet: A retrospective comparative study

10.21203/rs.3.rs-24993/v5 ◽

2020 ◽

Author(s):

Yuxuan Lu ◽

Cidan Zhuoga ◽

Haiqiang Jin ◽

Feiqi Zhu ◽

Yuhua Zhao ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Young Adult ◽

Comparative Study ◽

Acute Ischemic Stroke ◽

High Altitude ◽

Intravenous Thrombolysis ◽

Categorical Variables ◽

Anterior Circulation ◽

Tibet Autonomous Region

Abstract Background: Numerous studies on acute ischemic stroke (AIS) have been conducted at low-altitude regions, and the related findings have been used to guide clinical management. However, corresponding studies at high altitude are few. This study aimed to analyse the clinical characteristics of AIS patients at high-altitude regions through a hospital-based comparative study between Tibet and Beijing.Methods: This study included the diagnoses of AIS patients from People’s Hospital of Tibet Autonomous Region (PHOTAR) and Peking University First Hospital (PUFH) between 1 January 2014 and 31 December 2017, where data including patient demographics, treatment time, onset season, risk factors, infarction location, laboratory data, image examination results, treatments, and AIS subtype were collected and compared. Continuous and categorical variables were analysed with a two-sample t-test or Wilcoxon rank sum test and chi-square test, respectively. Significant risk factors were examined with binary logistic regression analysis.Results: In total, 236 and 1021 inpatients from PHOTAR and PUFH were included, respectively. The PHOTAR patients were younger than the PUFH patients (P<0.001). Young adult stroke, erythrocytosis, and hyperhomocysteinemia were more frequent in PHOTAR patients (all P<0.001). Other vascular risk factors, including hypertension, diabetes mellitus, hyperlipidaemia, and smoking and alcohol consumption history, were less prevalent in PHOTAR patients than in PUFH patients. The rate of intravenous thrombolysis and the rate of within intravenous thrombolysis window time were also lower in PHOTAR patients (both P<0.001). The PHOTAR group also tended to have anterior circulation infarction. Erythrocytosis and hyperhomocysteinemia were independent risk factors in PHOTAR, and young adults accounted for a larger proportion of stroke cases.Conclusion: In Tibet, AIS patients were relatively younger, and anterior circulation infarctions were more common. Erythrocytosis and hyperhomocysteinemia may contribute to these differences. Here, young adult stroke also accounted for a higher proportion, and this may be associated with erythrocytosis. Our findings present the first hospital-based comparative study in Tibet and may contribute to policies for stroke prevention in this region.

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Mechanical Thrombectomy with or without Intravenous Thrombolysis in Acute Ischemic Stroke: A Meta-Analysis for Randomized Controlled Trials

European Neurology ◽

10.1159/000520085 ◽

2021 ◽

pp. 1-10

Author(s):

Hang Li ◽

Siyuan Yang ◽

Yi Zhong ◽

Jiahe Wang ◽

Xiang Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Randomized Controlled Trials ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Controlled Trials ◽

Efficacy And Safety ◽

Anterior Circulation ◽

Randomized Controlled

Introduction: The combination of mechanical thrombectomy (MT) and intravenous thrombolysis (IVT) is more effective than IVT alone in patients with large vessel occlusion, which has been proven in recent studies. However, there are still debates over whether IVT benefits patients treated with only direct mechanical thrombectomy (dMT). Methods: PubMed, Embase, and Cochrane Library were searched on June 15, 2021, for randomized controlled trials (RCTs). Seven RCTs with 2,143 patients were enrolled in our study. Results: MT combined with IVT had comparable efficacy and safety outcome compared with dMT in proximal anterior circulation occlusion at 90 days. For the primary outcome, pooled data showed no significant difference in the modified Rankin Scale (mRS) 0–2 at 90 days between the dMT and MT+IVT groups (pooled odds ratio 0.96, 95% confidence interval, 0.79, 1.17, p = 0.39). As for the mRS score 0–1 at 90 days, the degree of benefit conferred by dMT was substantial: for every 100 patients treated, the number of patients which had an excellent outcome in the dMT group was 10 higher than that of the MT+IVT group. Conclusion: In this meta-analysis including 7 RCTs, MT had comparable consequences to bridging treatment in efficacy and safety outcomes for patients with ischemic stroke caused by the occlusion of proximal anterior circulation, irrespective of geographical location. These findings support the adoption of dMT in acute ischemic stroke treatments and have higher cost-effectiveness in global applications.

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ENDOVASCULARAPPROACHES TOACUTE ISCHEMIC STROKE- INDIAN PERSPECTIVE

PERSPECTIVES IN MEDICAL RESEARCH - 2 ◽

10.47799/pimr.0703.02 ◽

2020 ◽

Vol 7 (3) ◽

pp. 7-14

Author(s):

Pramod Dhonde ◽

N. Kadam

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Review Literature ◽

Large Artery ◽

Stroke Event ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Indian Perspective

Aim: To review literature about endovascular approaches to acute ischemic stroke and provide Indian perspective about managing these cases. Brief Summary: In acute ischemic stroke cases, intravenous thrombolysis (IVT) with altepase within 4.5 hours has been the standard of care. Due to certain limitations of IVT, in pooled patientlevel data from 5 trials (HERMES [Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials], which included the 5 trials MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA), mechanical thrombectomy (MT) is indicated for patients with acute ischemic stroke due to a large artery occlusion (LVO) in the anterior circulation who can be treated within 24 hours of the time last known to be well (ie, at neurologic baseline), regardless of whether they received intravenous alteplase for the same ischemic stroke event. The maximum benefit can be achieved within 6 hours of onset of symptoms. There are studies suggesting the benefit of MT in posterior circulation stroke as well as in distal arteries. We are going to review the methodology of endovascular techniques in brief alongwith Indian perspective on feasibility of this treatment approach in AIS. Conclusion: Mechnicalthrombectomy is certainly an effective modality of treatment in large vessel occlusion in anterior circulation within 24 hours. More awareness regarding the approach in India, can reduce the stroke morbidity and mortality in many of the cases in future

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Predictors of Postthrombolysis Outcome and Symptomatic Postthrombolysis Hemorrhage following Intravenous Thrombolysis with Alteplase for Acute Ischemic Stroke

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0040-1709946 ◽

2020 ◽

Vol 11 (02) ◽

pp. 315-324

Author(s):

Suman Das ◽

Gourango Prosad Mondal ◽

Ramesh Bhattacharya ◽

Kartick Chandra Ghosh ◽

Sarbajit Das ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Unfavorable Outcome ◽

Anterior Circulation ◽

Chads2 Score ◽

National Medical ◽

Arterial Blood ◽

Increased Risk

Abstract Background Thrombolysis improves the outcome in acute ischemic stroke (AIS), albeit with an increased risk of symptomatic intracranial hemorrhage (sICH). Biomarkers to find patients at risk of sICH, and guide treatment and prognosis would be valuable. Methods Consecutive patients of AIS thrombolysed between February 2017 and September 2019 at Calcutta National Medical College were studied prospectively for sICH and outcome at 6-month follow-up. We identified the independent risk factors for unfavorable outcomes, mortality, and sICH using multivariate analysis. Prethrombolysis and 24-hour postthrombolysis fibrinogen levels were estimated to evaluate its biomarker role. Results Out of 180 AIS patients admitted during the study period, 60 patients were thrombolysed. Door to needle time was <3 hours among 24 patients and 3 to 4.5 hours among 36 patients. Favorable outcomes occurred among 76.67% and sICH occurred among 13.33% patients. Upper tertile of National Institute of Health Stroke Scale (NIHSS) had the highest adjusted odds for sICH (17.5 [95% confidence intervals=1.7–178.44]). Total anterior circulation stroke had the highest adjusted odds for unfavorable outcome (19.11 [3.9–92.6]). Following thrombolysis, the mean (standard deviation) fibrinogen level of 449.27 (32.87) decreased 7% to postthrombolysis level of 420 (20.5; p< 0.0001). Higher tertiles of fibrinogen levels had progressively increasing odds for morbidity and sICH. Conclusion Congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke (double weight), i.e., CHADS2 score >2, low ejection fraction, the occurrence of total anterior circulation stroke and higher mean arterial blood pressure, blood glucose level, NIHSS score, and fibrinogen at admission were the common risk factors significantly predicting postthrombolysis sICH and morbidity. Antiplatelet and anticoagulant therapy, lower ASPECT (Alberta Stroke Program Early CT Score), and higher SEDAN scores also predicted sICH . Fibrinogen levels were significantly higher among those developing sICH and having unfavorable outcome. The performance of thrombolysis within 3 hours or between 3 and 4.5 hours after symptom onset did not affect morbidity, mortality, or the occurrence of sICH.

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Characteristics of Acute Ischemic Stroke in Hospitalized Patients in Tibet: A Retrospective Comparative Study

10.21203/rs.3.rs-24993/v1 ◽

2020 ◽

Author(s):

Yuxuan Lu ◽

Cidan Zhuoga ◽

Haiqiang Jin ◽

Feiqi Zhu ◽

Yuhua Zhao ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Young Adult ◽

Comparative Study ◽

Acute Ischemic Stroke ◽

High Altitude ◽

Intravenous Thrombolysis ◽

Categorical Variables ◽

Anterior Circulation ◽

Tibet Autonomous Region

Abstract BackgroundLots of studies of acute ischemic stroke (AIS) had been conducted at low altitude regions, and related findings were used to instruct clinic management while corresponding studies at high altitude were few. This study aimed to analyse AIS clinic characteristics at high altitude regions by conducting a hospital-based comparative study between Tibet and Beijing.MethodsThis study included diagnoses of AIS patients from People’s Hospital of Tibet Autonomous Region (PHOTAR) and Peking University First Hospital (PUFH) between 1st January 2014, and 31st December 2017, where data including patient demographics, treatment time, onset season, risk factors, infarction location, laboratory data, image examination results, treatments, and AIS subtype were collected and compared. Continuous and categorical variables were analysed with a two-sample t-test or Wilcoxon rank sum test and chi-square test, respectively. Significant risk factors were examined with binary logistic regression analysis.ResultsIn total, 236 and 1021 inpatients from PHOTAR and PUFH were included, respectively. The PHOTAR patients were younger than the PUFH patients (P < 0.001). Young adult stroke, erythrocytosis, and hyperhomocysteinemia were more frequent in PHOTAR patients (all P < 0.001). Other vascular risk factors, including hypertension, diabetes mellitus, hyperlipidaemia, and smoking and alcohol consumption history, were less prevalent in PHOTAR patients than in PUFH patients. The rate of intravenous thrombolysis and intravenous thrombolysis window time were also lower in PHOTAR patients (both P < 0.001). PHOTAR groups also tended to have anterior circulation infarction. Erythrocytosis and hyperhomocysteinemia were independent risk factors in PHOTAR, and here young adults accounted for a larger proportion of stroke cases.ConclusionIn Tibet, the average age of AIS patients were less, and anterior circulation infarctions were also more common. Erythrocytosis and hyperhomocysteinemia may contribute to these differences. Here young adult stroke also accounted for a higher proportion, and this may be associated with erythrocytosis. Our findings present the first hospital-based comparative study in Tibet and may contribute to policies for stroke prevention in this region.

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