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 Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

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.

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 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.

scholarly journals Early Neurological Change After Ischemic Stroke Is Associated With 90-Day Outcome

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 132-141 ◽  
Author(s):  
Laura Heitsch ◽  
Laura Ibanez ◽  
Caty Carrera ◽  
Michael M. Binkley ◽  
Daniel Strbian ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Scale Score ◽  
Large Scale ◽  
Hemorrhagic Transformation ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Long Term Outcomes ◽  
Vessel Occlusion

Background and Purpose: Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in National Institutes of Health Stroke Scale score (NIHSS) from baseline to 24 hours baseline to 24 hours (NIHSS baseline – NIHSS 24hours = ΔNIHSS 6-24h ), to examine its relevance to AIS mechanisms and long-term outcomes. Methods: Patients with NIHSS prospectively recorded within 6 hours after onset and then 24 hours later were enrolled in the GENISIS study (Genetics of Early Neurological Instability After Ischemic Stroke). Stepwise linear regression determined variables that independently influenced ΔNIHSS 6 –24h . In a subcohort of tPA (alteplase)-treated patients with large vessel occlusion, the influence of early sustained recanalization and hemorrhagic transformation on ΔNIHSS 6–24h was examined. Finally, the association of ΔNIHSS 6 –24h with 90-day favorable outcomes (modified Rankin Scale score 0–2) was assessed. Independent analysis was performed using data from the 2 NINDS-tPA stroke trials (National Institute of Neurological Disorders and Stroke rt-PA). Results: For 2555 patients with AIS, median baseline NIHSS was 9 (interquartile range, 4–16), and median ΔNIHSS 6 –24h was 2 (interquartile range, 0–5). In a multivariable model, baseline NIHSS, tPA-treatment, age, glucose, site, and systolic blood pressure independently predicted ΔNIHSS 6 –24h (R 2 =0.15). In the large vessel occlusion subcohort, early sustained recanalization and hemorrhagic transformation increased the explained variance (R 2 =0.27), but much of the variance remained unexplained. ΔNIHSS 6 –24h had a significant and independent association with 90-day favorable outcome. For the subjects in the 2 NINDS-tPA trials, ΔNIHSS 3 –24h was similarly associated with 90-day outcomes. Conclusions: The dynamic phenotype, ΔNIHSS 6–24h , captures both explained and unexplained mechanisms involved in AIS and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS 6 –24h promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS.

Abstract WP166: The Effectiveness of Statin Therapy After Onset of Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Nobuyuki Sakai ◽  
Hiroshi Yamagami ◽  
Takeshi Morimoto ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Statin Therapy ◽  
Functional Outcome ◽  
Randomized Clinical Trials ◽  
Large Vessel ◽  
Registry Study ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Statin Group

Background: Statin therapy was reported to be associated with lower risk of recurrence of stroke and better functional outcomes in patients with acute ischemic stroke. However, the effect of statin therapy in patients with acute large vessel occlusion (LVO) was not well scrutinized. Thus, we evaluated the effect of statin administration after the onset of stroke on functional outcome based on the large registry study of acute LVO. Methods: RESCUE-Japan Registry-2 was a physician initiated registry study enrolled consecutive patients with acute LVO who were admitted within 24 hours of onset. We compared those with and without statin after onset in terms of modified Rankin Scale (mRS) at 90 days. We estimated the common odds ratio (OR) for a shift towards better mRS adjusting for confounders. Result: Among 2420patients registered, 2399 patients were eligible. Mean age was 75.9 years and men accounted for 55%. Statin were administered in 447 patients(19%) after admission. There are more atherothrombotic cerebral infarction (statin group: 34.2% vs non-statin group: 12.1%, p <0.0001), younger age (73.4 vs 76.5, p <0.0001), and lower NIHSS on admission (14 vs 17, p <0.0001) in the statin group. The adjusted common OR of the statin group was 1.22 (95% confidence interval [CI], 1.04 - 1.37; p =0.02) compared with the non-statin group. The safety profile was similar between groups. The mortality at 90 days was 4.7 % in the statin group lower than 12.5 % in the non-statin group (p <0.0001). The adjusted OR of statin group for mortality was 0.36 (95%CI 0.21 to 0.62, p = 0.022). Conclusions: Statin administration after onset of acute LVO was significantly associated with better functional outcome and mortality within 90 days. Our findings should be attested by randomized clinical trials in patients with acute LVO in future

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