Is Endovascular Treatment Still Good for Ischemic Stroke in Real World?

Background and Purpose: Although endovascular treatment (EVT) for acute ischemic stroke is classified as I evidence, outcomes after EVT in real-world practice appear to be less superior than those in randomized clinical trials (RCTs). Additionally, the effect of EVT is unclear compared with medical treatment (MT) for patients with mild symptoms defined by National Institutes of Health Stroke Scale score <6 or with severe symptoms defined by Alberta Stroke Program Early CT Score <6. Methods: Literatures were searched in big databases and major meetings from December 6, 2009, to December 6, 2019, including RCTs and observational studies comparing EVT against MT for patients with acute ischemic stroke. Observational studies were precategorized into 3 groups based on imaging data on admission: mild stroke group with National Institutes of Health Stroke Scale score <6, severe stroke group with Alberta Stroke Program Early CT Score <6 or ischemic core ≥50 mL, and normal stroke group for all others. Outcome was measured as modified Rankin Scale score of 0 to 2, mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) at 24 hours. Results: Fifteen RCTs (n=3694) and 37 observational studies (n=9090) were included. EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality in RCTs and normal stroke group, whereas EVT was associated with higher sICH rate in normal stroke group, and no difference of sICH rate appeared between EVT and MT in RCTs. In severe stroke group, EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality, whereas no difference of sICH rate was found. In mild stroke group, there was no difference in modified Rankin Scale 0 to 2 rate between EVT and MT, whereas EVT was associated with higher mortality and sICH rate. Conclusions: Evidence from RCTs and observational studies supports the use of EVT as the first-line choice for eligible patients corresponding to the latest guideline. For patients with Alberta Stroke Program Early CT Score <6, EVT showed superiority over MT, also in line with the guidelines. On the contrary to the guideline, our data do not support EVT for patients with National Institutes of Health Stroke Scale score <6.

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Safety and feasibility of intraarterial eptifibatide as a revascularization tool in acute ischemic stroke

Journal of Neurosurgery ◽

10.3171/2010.8.jns10318 ◽

2011 ◽

Vol 114 (4) ◽

pp. 1008-1013 ◽

Cited By ~ 16

Author(s):

Muhammad Zeeshan Memon ◽

Sabareesh K. Natarajan ◽

Jitendra Sharma ◽

Marlon S. Mathews ◽

Kenneth V. Snyder ◽

...

Keyword(s):

Myocardial Infarction ◽

Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Scale Score ◽

Intracranial Hemorrhage ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Tissue Plasminogen ◽

Symptomatic Intracranial Hemorrhage

Object Experience with the use of platelet glycoprotein (GP) IIb–IIIa inhibitor eptifibatide in patients with ischemic stroke is limited. The authors report the off-label use of intraarterial eptifibatide during endovascular ischemic stroke revascularization procedures for reocclusion after documented recanalization or formed fresh thrombi in distal vessels that were inaccessible to endovascular devices. Methods Patients who received intraarterial eptifibatide were identified from a prospectively collected database of patients in whom endovascular revascularization for acute ischemic stroke was attempted between 2005 and 2008. Data were analyzed retrospectively. The intraarterial eptifibatide dose was a single-bolus dose of 180 μg/kg body weight. Primary outcome measures were angiographic recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3), symptomatic intracranial hemorrhage rate, overall mortality rate, and favorable 3-month modified Rankin Scale score (≤ 2). Results The study included 35 patients (mean age 62 years, range 18–85 years). The median presenting National Institutes of Health Stroke Scale score was 13. Two patients received intravenous tissue plasminogen activator before endovascular therapy. The median time from symptom onset to therapy initiation was 230 minutes (range 90–1370 minutes). Twelve patients (34%) received intraarterial tissue plasminogen activator without mechanical measures. Mechanical revascularization measures used were Merci retriever in 19 (54%), Penumbra device in 1 (3%), balloon angioplasty in 15 (43%), and stent placement in 22 (63%) patients. The mean dose of intraarterial eptifibatide was 11.6 mg (range 5–16.6 mg). Partial-to-complete recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3) was achieved in 27 patients (77%). Postprocedure intracranial hemorrhage occurred in 13 patients (37%), causing symptoms in 5 (14%). In the 5 symptomatic intracranial hemorrhage cases, all patients but one presented more than 8 hours after symptom onset and all received intraarterial recombinant tissue plasminogen activator. The median discharge National Institutes of Health Stroke Scale score was 7 (range 0–17). At 3 months postprocedure, 21 patients (60%) had a modified Rankin Scale score ≤ 2, and 8 patients (23%) had died. Conclusions Adjunctive intraarterial eptifibatide is a feasible option for salvage of reocclusion and thrombolysis of distal inaccessible thrombi during endovascular stroke revascularization. Its safety and efficacy need to be studied further in larger, multicenter, controlled studies.

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Adiposity and Outcome After Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.027900 ◽

2021 ◽

Vol 52 (1) ◽

pp. 144-151

Author(s):

Zuolu Liu ◽

Nerses Sanossian ◽

Sidney Starkman ◽

Gilda Avila-Rinek ◽

Marc Eckstein ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Odds Ratio ◽

Functional Outcomes ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Related Quality ◽

Severely Obese

Background and Purpose: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. Methods: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2–6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. Results: Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival ( P =0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6–4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5–1.4]), obese (0.5, [CI, 0.3–1.0]), and severely obese (0.4 [CI, 0.2–0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2–6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. Conclusions: Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients’ adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

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Abstract T P203: Tissue Plasminogen Activator is Safe Via Telemedicine for Treatment of Mild Acute Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.tp203 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Kasey Gildersleeve ◽

Amanda L Jagolino ◽

Hari Kishan Indupuru ◽

Chunyan Cai ◽

Mohammad H Rahbar ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Severe Stroke ◽

Significant Difference ◽

Tissue Plasminogen ◽

Stroke Group ◽

Baseline Characteristics ◽

Mild Stroke ◽

Iv Tpa

Objective: Telemedicine (TM) has increased the use of intravenous (IV) tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Administration of tPA via TM has been shown to be safe when given in the setting of established treatment guidelines. Debate exists regarding the use of tPA in patients deemed to have “mild” stroke. We report our study demonstrating the safety of tPA via TM for mild stroke. Methods: In this retrospective chart review from 4/12 to 4/13, we identified 137 patients who were given IV-tPA via TM in our 14 spoke network. Baseline characteristics and clinical variables were abstracted. We defined mild stroke by NIHSS of ≤4. Poor outcomes were defined as symptomatic intracranial hemorrhage (sICH), neurological worsening (an increase in NIHSS of ≥2 points regardless of cause of decline), angioedema, and death. Logistic regression analysis was performed between groups with NIHSS≤4 and NIHSS>4. Results: Table 1 depicts baseline characteristics. Of 137 patients, 27 presented with an NIHSS≤4 (20%) and 110 with an NIHSS>4 (80%). Although rates of sICH were higher in patients with NIHSS>4 compared to those with NIHSS≤4, there was no significant difference (1.8% vs 0%) (Table 2). There was no significant difference in the rates of neurologic worsening between mild (3.7%) and severe strokes (7.3%) (p<0.69). While rates of angioedema were higher in patients with severe stroke, this increment was not significant (0.9% vs 0%) (Table 2). Four deaths occurred in the severe stroke group compared to none in the mild stroke group, with no significant difference (Table 2). Conclusion: Our results suggest that IV tPA given via TM did not increase the risk of complications in patients with mild stroke. However, our sample size was small and we cannot rule out that some of the mild stroke patients had stroke mimics. Our results support using TM to enroll patients at community hospitals in the upcoming PRISM trial testing the efficacy of tPA in patients with mild stroke.

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Exploration of factors affecting prognosis of stroke preceded by transient ischemic attack

Asian Journal of Medical Sciences ◽

10.3126/ajms.v7i4.14704 ◽

2016 ◽

Vol 7 (4) ◽

pp. 68-74

Author(s):

Nermien Adly ◽

Safaa Hussein Ali

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Medical Sciences ◽

Severe Stroke ◽

Factors Affecting ◽

Brain Computed Tomography ◽

Regional Brain ◽

Ischemic Attack

Background: Age is the most important risk factor for stroke. The regional brain affection was not considered in a comparison between different brain locations as a predictor for outcome in those with and without prior TIA.Aims and Objectives: Can transient Ischemic attack predict stroke prognosis?Materials and Methods: Fifty nine patients, aged ≥ 55 years old, with recent ischemic stroke were studied, with (cases, 40.68%) and without (controls) antecedent TIA. National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (MRS), and California risk score (CRS) were assessed. A brain computed tomography was done.Results: Older age was a predictor of more severe stroke (P<0.001). Different latencies for TIA were studied. With reference to our controls, better prognosis was found only in cases with TIA ≤ seven days as a predictor for better NIHSS and MRS. In cases, CRS was a significant predictor of shorter latency. Infratentorial ischemic stroke, not supratentorial ischemic stroke, with prior TIA, was a significant predictor of lower NIHSS.Conclusion: TIA ≤ seven days is a predictor for better NIHSS and MRS.Asian Journal of Medical Sciences Vol.7(4) 2016 68-74

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Predictors of Unexplained Early Neurological Deterioration After Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.120.029494 ◽

2020 ◽

Vol 51 (10) ◽

pp. 2943-2950 ◽

Cited By ~ 2

Author(s):

Jean-Baptiste Girot ◽

Sébastien Richard ◽

Florent Gariel ◽

Igor Sibon ◽

Julien Labreuche ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Scale Score ◽

National Institutes Of Health ◽

Neurological Deterioration ◽

Anterior Circulation ◽

Early Neurological Deterioration ◽

Direct Admission ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Purpose: Although the efficacy of endovascular treatment (EVT) in patients with anterior circulation ischemic stroke (AIS) is well documented, early neurological deterioration after EVT remains a serious issue associated with poor outcome. Besides obvious causes, such as lack of reperfusion, procedural complications, or parenchymal hemorrhage, early neurological deterioration may remain unexplained (UnEND). Our aim was to investigate predictors of UnEND after EVT in patients with AIS. Methods: Patients who underwent EVT for AIS, with an initial National Institutes of Health Stroke Scale score >5, Alberta Stroke Program Early CT Score ≥6, and included in a multicenter prospective observational registry were analyzed. Predictors of UnEND, defined as ≥4-point increase in the National Institutes of Health Stroke Scale score between baseline and day 1 after EVT, were determined via center-adjusted analyses. Results: Among the 1925 included in the analysis, 128 UnEND (6.6%) were recorded. In multivariate analysis, predictors of UnEND were diabetes mellitus (odds ratio [OR], 2.17 [95% CI, 1.32–3.56]), prestroke modified Rankin Scale score ≥2 (OR, 2.22 [95% CI, 1.09–4.55]), general anesthesia (OR, 2.55 [95% CI, 1.51–4.30]), admission systolic blood pressure (OR, 1.10 [95% CI, 1.01–1.20]), age (OR, 1.38 [95% CI, 1.14–1.67]), number of passes (OR, 1.16 [95% CI, 1.04–1.28]), direct admission or not to a comprehensive stroke center (OR, 0.49 [95% CI, 0.30–0.81]), and initial National Institutes of Health Stroke Scale score (OR, 0.65 [95% CI, 0.52–0.81]). Conclusions: Severely impaired AIS patients with nonmodifiable factors are more likely to develop UnEND. Some modifiable predictors of UnEND such as the number of EVT passes could be the object of improvement in AIS management.

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National Institutes of Health Stroke Scale Zero Strokes

Stroke ◽

10.1161/strokeaha.118.022517 ◽

2018 ◽

Vol 49 (12) ◽

pp. 3057-3059

Author(s):

Elissavet Eskioglou ◽

Mitra Huchmandzadeh Millotte ◽

Michael Amiguet ◽

Patrik Michel

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Significant Proportion ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Recurrence Rates ◽

Long Term Outcome

Background and Purpose— We aimed to characterize acute ischemic stroke patients who have an immeasurable deficit on the admission National Institutes of Health Stroke Scale (NIHSS), and to evaluate their long-term outcome. Methods— We retrospectively compared all acute ischemic stroke patients with an admission NIHSS of 0 in the Acute Stroke Registry and Analysis of Lausanne from 2003 to 2013 with all other acute ischemic stroke patients. We compared demographics, clinical, radiological, and laboratory findings. Outcome was considered favorable at 3 months if the modified Rankin Scale score corrected for prestroke disability was ≤1. Stroke recurrences >12 months were also assessed. Results— Comparing 108 NIHSS zero (NIHSS=0) patients with the 2889 other strokes by multivariate analysis, NIHSS=0 had lower prestroke disability, longer onset-to-hospital delays and more lacunar and infratentorial strokes. NIHSS=0 patients were less likely to have early ischemic changes on acute computed tomography, had less arterial pathology and lower creatinine levels. They were more likely to have favorable modified Rankin Scale score after correction for prestroke modified Rankin Scale score (zero versus others: 83.2% versus 44.6%) and less likely to die (3.9% versus 13.3%) at 12 months. Stroke and transient ischemic attack recurrence rates were similar (11% versus 11.4%), however. Conclusions— Patients with NIHSS=0 strokes are characterized by lacunar and infrantentorial strokes, normal acute computed tomography, and less arterial pathology. However, a significant proportion face recurrent ischemic events and persistent handicap at 12 months. Therefore, NIHSS=0 stroke patients require aggressive secondary prevention and adequate follow-up.

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Tenecteplase Versus Alteplase Between 3 and 4.5 Hours in Low National Institutes of Health Stroke Scale

Stroke ◽

10.1161/strokeaha.118.024223 ◽

2019 ◽

Vol 50 (2) ◽

pp. 498-500 ◽

Cited By ~ 4

Author(s):

Ole Morten Rønning ◽

Nicola Logallo ◽

Bente Thommessen ◽

Håkon Tobro ◽

Vojtech Novotny ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Odds Ratio ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Unique Identifier ◽

Clinical Trial Registration ◽

Intention To Treat ◽

Good Functional Outcome

Background and Purpose— Thrombolysis with alteplase has beneficial effect on outcome and is safe within 4.5 hours. The present study compares the efficacy and safety of tenecteplase and alteplase in patients treated 3 to 4.5 hours after ischemic stroke. Methods— The data are from a prespecified substudy of patients included in The NOR-TEST (Norwegian Tenecteplase Stroke Trial), a randomized control trial comparing tenecteplase with alteplase. Results— The median admission National Institutes of Health Stroke Scale for this study population was 3 (interquartile range, 2–6). In the intention-to-treat analysis, 57% of patients that received tenecteplase and 53% of patients that received alteplase reached good functional outcome (modified Rankin Scale score of 0–1) at 3 months (odds ratio, 1.19; 95% CI, 0.68–2.10). The rates of intracranial hemorrhage in the first 48 hours were 5.7% in the tenecteplase group and 6.7% in the alteplase group (odds ratio, 0.84; 95% CI, 0.26–2.70). At 3 months, mortality was 5.7% and 4.5%, respectively. After excluding stroke mimics and patients with modified Rankin Scale score of >1 before stroke, the proportion of patients with good functional outcome was 61% in the tenecteplase group and 57% in the alteplase group (odds ratio, 1.24; 95% CI, 0.65–2.37). Conclusions— Tenecteplase is at least as effective as alteplase to achieve a good clinical outcome in patients with mild stroke treated between 3 and 4.5 hours after ischemic stroke. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01949948.

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Anesthetic management during endovascular treatment of acute ischemic stroke in the MR CLEAN Registry

Neurology ◽

10.1212/wnl.0000000000008674 ◽

2019 ◽

Vol 94 (1) ◽

pp. e97-e106 ◽

Cited By ~ 9

Author(s):

Robert-Jan B. Goldhoorn ◽

Marie Louise E. Bernsen ◽

Jeannette Hofmeijer ◽

Jasper M. Martens ◽

Hester F. Lingsma ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Anesthetic Management ◽

Anesthetic Technique ◽

Modified Rankin Scale ◽

Class Iii ◽

Mr Clean

ObjectiveTo compare outcomes after endovascular treatment (EVT) for acute ischemic stroke with 3 different types of anesthetic management in clinical practice, as anesthetic management may influence functional outcome.MethodsData of patients with an anterior circulation occlusion, included in the Dutch nationwide, prospective Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry between March 2014 and June 2016, were analyzed. Patients were divided into 3 groups defined by anesthetic technique performed during EVT: local anesthesia only (LA), general anesthesia (GA), or conscious sedation (CS). Primary outcome was the modified Rankin Scale score at 90 days. To compare functional outcome between groups, we estimated a common odds ratio (OR) with ordinal logistic regression, adjusted for age, sex, prestroke modified Rankin Scale score, baseline NIH Stroke Scale score, collaterals, and time from onset to arrival at intervention center.ResultsA total of 1,376 patients were included. Performed anesthetic technique was LA in 821 (60%), GA in 381 (28%), and CS in 174 (13%) patients. Compared to LA, both GA and CS were associated with worse functional outcome on the modified Rankin Scale score at 90 days (GA cORadj 0.75; 95% confidence interval [CI] 0.58–0.97; CS cORadj 0.45; 95% CI 0.33–0.62). CS was associated with worse functional outcome than GA (cORadj 0.60; 95% CI 0.42–0.87).ConclusionsLA is associated with better functional outcome than systemic sedation in patients undergoing EVT for acute ischemic stroke. Whereas LA had a clear advantage over CS, this was less prominent compared to GA.Classification of evidenceThis study provides Class III evidence that for patients with acute ischemic stroke undergoing EVT, LA improves functional outcome compared to GA or CS.

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Treatment with Clopidogrel Prior to Acute Non-Cardioembolic Ischemic Stroke Attenuates Stroke Severity

Cerebrovascular Diseases ◽

10.1159/000443745 ◽

2016 ◽

Vol 41 (5-6) ◽

pp. 226-232 ◽

Cited By ~ 2

Author(s):

Konstantinos Tziomalos ◽

Vasilios Giampatzis ◽

Stella D. Bouziana ◽

Marianna Spanou ◽

Stavroula Kostaki ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Independent Predictor ◽

Male Gender ◽

National Institutes Of Health ◽

Heart Valve Disease ◽

Stroke Severity ◽

Modified Rankin Scale ◽

Antiplatelet Treatment ◽

Severe Stroke

Background: Clopidogrel reduces the risk of non-cardioembolic ischemic stroke, but it is unclear whether it affects the severity and outcome of stroke. We aimed at evaluating the effect of prior treatment with clopidogrel on acute non-cardioembolic ischemic stroke severity and in-hospital outcome. Methods: We prospectively studied 608 consecutive patients (39.5% males, age 79.1 ± 6.6 years) who were admitted with acute ischemic stroke. The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS ≥21. The outcome was assessed using the dependency rates that prevailed at the time of discharge (i.e. modified Rankin scale between 2 and 5) and with in-hospital mortality. Results: At admission, 397 patients did not have atrial fibrillation or heart valve disease. Among these 397 patients, 69 were receiving monotherapy with clopidogrel prior to stroke, 69 were receiving monotherapy with aspirin and 236 patients were not on any antiplatelet treatment. The prevalence of severe stroke was lower in patients who were receiving clopidogrel than in patients who were receiving aspirin and patients who were not on antiplatelets (1.4, 13.0 and 11.0%, respectively; p < 0.05). Independent predictors of severe stroke at admission were male gender (relative risk (RR) 0.31, 95% CI 0.12-0.78, p < 0.05) and treatment with clopidogrel prior to stroke compared with no antiplatelet treatment (RR 0.13, 95% CI 0.02-0.97, p < 0.05). Treatment with aspirin prior to stroke did not predict severe stroke compared with no antiplatelet treatment (RR 1.24, 95% CI 0.51-2.98, p = NS). The rate of dependency at discharge did not differ between patients who were receiving clopidogrel, patients who were receiving aspirin and those who were not on antiplatelets (57.9, 47.8 and 59.7%, respectively; p = NS). Independent predictors of dependency at discharge were age (RR 1.12, 95% CI 1.05-1.19, p < 0.001) and NIHSS at admission (RR 1.67, 95% CI 1.46-1.92, p < 0.001). In-hospital mortality rate also did not differ between patients who were receiving clopidogrel, patients who were receiving aspirin and those who were not on antiplatelets (4.3, 4.3 and 5.0%, respectively; p = NS). The only independent predictor of in-hospital mortality was NIHSS at admission (RR 1.22, 95% CI 1.14-1.30, p < 0.001). Conclusions: Treatment with clopidogrel prior to acute non-cardioembolic ischemic stroke attenuates the severity of stroke at admission but does not appear to affect the functional outcome at discharge or the in-hospital mortality of these patients.

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Endovascular Thrombectomy for Acute Ischemic Stroke Beyond 6 Hours From Onset

Stroke ◽

10.1161/strokeaha.119.027974 ◽

2020 ◽

Vol 51 (7) ◽

pp. 2051-2057 ◽

Cited By ~ 4

Author(s):

Ilaria Casetta ◽

Enrico Fainardi ◽

Valentina Saia ◽

Giovanni Pracucci ◽

Marina Padroni ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Scale Score ◽

Intracranial Hemorrhage ◽

Ct Perfusion ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: To evaluate outcome and safety of endovascular treatment beyond 6 hours of onset of ischemic stroke due to large vessel occlusion in the anterior circulation, in routine clinical practice. Methods: From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke of known onset beyond 6 hours. Additional inclusion criteria were prestroke modified Rankin Scale score ≤2 and ASPECTS score ≥6. Patients were selected on individual basis by a combination of CT perfusion mismatch (difference between total hypoperfusion and infarct core sizes) and CT collateral score. The primary outcome measure was the score on modified Rankin Scale at 90 days. Safety outcomes were 90-day mortality and the occurrence of symptomatic intracranial hemorrhage. Data were compared with those from patients treated within 6 hours. Results: Out of 3057 patients, 327 were treated beyond 6 hours. Their mean age was 66.8±14.9 years, the median baseline National Institutes of Health Stroke Scale 16, and the median onset to groin puncture time 430 minutes. The most frequent site of occlusion was middle cerebral artery (45.1%). Functional independence (90-day modified Rankin Scale score, 0–2) was achieved by 41.3% of cases. Symptomatic intracranial hemorrhage occurred in 6.7% of patients, and 3-month case fatality rate was 17.1%. The probability of surviving with modified Rankin Scale score, 0–2 (odds ratio, 0.58 [95% CI, 0.43–0.77]) was significantly lower in patients treated beyond 6 hours as compared with patients treated earlier No differences were found regarding recanalization rates and safety outcomes between patients treated within and beyond 6 hours. There were no differences in outcome between people treated 6-12 hours from onset (278 patients) and those treated 12 to 24 hours from onset (49 patients). Conclusions: This real-world study suggests that in patients with large vessel occlusion selected on the basis of CT perfusion and collateral circulation assessment, endovascular treatment beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

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