Which Acute Ischemic Stroke Patients Are Fast Progressors?

Background and Purpose: Fast infarct progression in acute ischemic stroke has a severe impact on patient prognosis and benefit of endovascular thrombectomy. In this post hoc analysis of the ESCAPE trial (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke), we identified acute ischemic stroke patients with rapid infarct growth and investigated their baseline clinical and imaging characteristics. Methods: Control arm patients were included if they had follow-up imaging at 2-8 hours without substantial recanalization, and if their baseline Alberta Stroke Program Early CT Score was ≥9. Fast infarct progression was defined as Alberta Stroke Program Early CT Score decay ≥3 points from baseline to 2- to 8-hour follow-up imaging. Clinical and imaging baseline characteristics were compared between fast progressors and other patients, and occlusion site and collateral flow patterns were assessed in detail. Results: Fast infarct progression occurred in 15 of 43 included patients (34.9%). Fast progressors had worse collaterals (poor in 3/15 [20%] versus 0/28 patients, P =0.021) and more carotid-T or -L occlusions (8/15 [53.4%] versus 3/28[10.7%], P =0.021). In 8 out of 15 (53.3%), occlusion site and circle of Willis configuration prevented collateral flow via the anterior or posterior cerebral artery. Conclusions: Most patients with fast infarct progression had terminal carotid occlusions and impaired collateral flow via the anterior or posterior cerebral artery, indicating that occlusion location and intracranial vascular anatomy are relevant for infarct progression.

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Prestroke statin use enhances collateralization in acute ischemic stroke patients

Restorative Neurology and Neuroscience ◽

10.3233/rnn-201012 ◽

2020 ◽

Vol 38 (4) ◽

pp. 311-321

Author(s):

Jiaying Zhu ◽

Mengmeng Ma ◽

Jinghuan Fang ◽

Jiajia Bao ◽

Shuju Dong ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Statin Therapy ◽

Cerebral Artery ◽

Functional Outcomes ◽

Collateral Circulation ◽

Stroke Severity ◽

Stroke Patients ◽

Statin Use

Background: Statin therapy has been shown to be effective in the prevention of ischemic stroke. In addition, recent studies have suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcomes in the event of stroke. It was speculated that prestroke statin use may enhance collateral circulation and result in favorable functional outcomes. Objective: The aim of the study was to investigate the association of prestroke statin use with leptomeningeal collaterals and to determine the association of prestroke statin use with stroke severity and functional outcome in acute ischemic stroke patients. Methods: We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 h in the neurology department of West China Hospital from May 2011 to April 2017. Computed tomographic angiography (CTA) imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; the National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission; the modified Rankin scale (mRS) was used to measure outcome at 90 days; and premorbid medications were recorded. Univariate and multivariate analyses were performed. Results: Overall, 239 patients met the inclusion criteria. Fifty-four patients used statins, and 185 did not use statins before stroke onset. Prestroke statin use was independently associated with good collateral circulation (rLMCS > 10) (odds ratio [OR], 4.786; 95% confidence interval [CI], 1.195–19.171; P = 0.027). Prestroke statin use was not independently associated with lower stroke severity (NIHSS score≤14) (OR, 1.955; 95% CI, 0.657–5.816; p = 0.228), but prestroke statin use was independently associated with favorable outcome (mRS score≤2) (OR, 3.868; 95% CI, 1.325–11.289; P = 0.013). Conclusions: Our findings suggest that prestroke statin use was associated with good leptomeningeal collaterals and clinical outcomes in acute ischemic stroke (AIS) patients presenting with occlusion of the middle cerebral artery. However, clinical studies should be conducted to verify this claim.

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Abstract 176: Long Term Mortality in Acute Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation According to Location and Burden of Cerebral Microbleeds

Stroke ◽

10.1161/str.45.suppl_1.176 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Tae-Jin Song ◽

Jinkwon Kim ◽

Dongbeom Song ◽

Yong-Jae Kim ◽

Hyo Suk Nam ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hemorrhagic Stroke ◽

Independent Predictor ◽

Stroke Patients ◽

Risk Of Death ◽

Long Term Mortality

Background: Cerebral microbleeds (CMBs) were predictive of mortality in elderly and considered as a putative marker for risk of intracranial hemorrhage. Stroke patients with non valvular atrial fibrillation (NVAF) require anticoagulation, which increases the risk of hemorrhages. We investigated association of CMBs with the long term mortality in acute ischemic stroke patients with NVAF. Methods: During 6 years , consecutive ischemic stroke patients who had NVAF and who had undergone brain MRI with a gradient-recalled echo sequence were enrolled. Long-term mortality and causes of death were identified using data from Korean National Statistical Office. Survival analysis was performed whether the presence, number and location of CMBs were related with all causes, cardiovascular, and cerebrovascular mortality during follow-up. Results: Total 506 patients were enrolled during the study period and were followed up for median 2.5 years. CMBs were found in 30.8% of patients (156/506). Oral anticoagulation with warfarin was prescribed at discharge in 477 (82.7%) patients. During follow up, 177 (35%) patients died and cerebrovascular death was noted in 93 patients (81 ischemic stroke and 12 hemorrhagic stroke). After adjusting age, sex and significant variables in univariate analysis (p<0.1), multiple CMBs (≥5) were the independent predictor for all-cause, cardiovascular and ischemic stroke mortalities. The strictly lobar CMBs were associated with hemorrhagic stroke mortality in multivariate Cox regression analysis (HR 4.776, p=0.032) (Figure 1). Conclusions: Multiple CMBs were the independent predictor for the long term mortality in stroke patients with NVAF. Among them, patients with strictly lobar CMBs had a high risk of death due to hemorrhagic stroke. Our findings suggest that detection of CMBs in stroke patients with NVAF are of clinical relevance for predicting long term outcome and that particular concern is necessary in those with strictly lobar CMBs for their increased risk of death due to hemorrhagic stroke. Figure 1.

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Abstract MP86: Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Acute Ischemic Stroke Patients by History of Hypertension and Use of Antihypertensive Medications

Circulation ◽

10.1161/circ.131.suppl_1.mp86 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Tan Xu ◽

Yonghong Zhang ◽

Yingxian Sun ◽

Chung-Shiuan Chen ◽

Jing Chen ◽

...

Keyword(s):

Ischemic Stroke ◽

Treatment Group ◽

Acute Ischemic Stroke ◽

Hospital Discharge ◽

Odds Ratio ◽

Recurrent Stroke ◽

Stroke Patients ◽

Antihypertensive Medications ◽

History Of

Introduction: The effects of blood pressure (BP) reduction on clinical outcomes among acute stroke patient remain uncertain. Hypothesis: We tested the effects of immediate BP reduction on death and major disability at 14 days or hospital discharge and 3-month follow-up in acute ischemic stroke patients with and without a previous history of hypertension or use of antihypertensive medications. Methods: The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomly assigned patients with ischemic stroke within 48 hours of onset and elevated systolic BP (SBP) to receive antihypertensive treatment (N=2,038) or to discontinue all antihypertensive medications (N=2,033) during hospitalization. Randomization was stratified by participating hospitals and use of antihypertensive medications. Study outcomes were assessed at 14 days or hospital discharge and 3-month post-treatment follow-up. The primary outcome was death and major disability (modified Rankin Scale score≥3), and secondary outcomes included recurrent stroke and vascular events. Results: Mean SBP was reduced 12.7% in the treatment group and 7.2% in the control group within 24 hours after randomization (P<0.001). Mean SBP was 137.3 mmHg in the treatment group and 146.5 in the control group at day 7 after randomization (P<0.001). At 14 days or hospital discharge, the primary and secondary outcomes were not significantly different between the treatment and control groups by subgroups. At the 3-month follow-up, recurrent stroke was significantly reduced in the antihypertensive treatment group among patients with a history of hypertension (odds ratio 0.43, 95% CI 0.24-0.75, P=0.003) and among patients with a history of use of antihypertensive medications (odds ratio 0.41, 95% CI 0.20-0.84, P=0.01). All-cause mortality (odds ratio 2.84, 95% CI 1.11-7.27, P=0.03) was increased among patients without a history of hypertension. Conclusion: Immediate BP reduction lowers recurrent stroke among acute ischemic stroke patients with a previous history of hypertension or use of antihypertensive medications at 3 months. On the other hand, BP reduction increases all-cause mortality among patients without a history of hypertension.

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Capillary Index Score Derived from Computed Tomography Angiography as An Indicator of Collateral Flow after Acute Ischemic Stroke

10.21203/rs.2.10603/v1 ◽

2019 ◽

Author(s):

Shang Kai ◽

Xiaoxing Zhang ◽

Yuehua Li

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Treatment Strategies ◽

Artery Occlusion ◽

Index Score ◽

Collateral Flow ◽

Imaging Data ◽

Flow Group ◽

Cerebral Artery Occlusion

Abstract Background The capillary index score (CIS) determined from DSA is used to evaluate cerebral collateral flow in acute ischemic stroke (AIS) caused by cerebral artery occlusion. Our aim was to determine the reliability of CIS calculated from MIP-CTA images as an alternative to DSA-based CIS, as CTA is less invasive and less expensive. Methods Clinical and imaging data of 40 patients with AIS caused by cerebral artery occlusion within 6 h from symptom onset were collected. CIS was calculated from CTA and DSA images. Patients were classified into the favorable collateral flow group if CIS was ≥2 (fCIS), and into the poor collateral flow group if CIS was <2 (pCIS). Agreement between the methods was evaluated using the Kappa test. Logistic regression was performed to explore the relationship between CTA-based CIS and clinical outcomes. Results The two methods had high consistency (Kappa = 0.72), and the diagnostic accuracy of CTA for CIS classification was 87.5%. The decrease in the NIHSS score at discharge was not significantly different between the fCIS and pCIS groups according to CTA (p = 0.156), while the 90-day mRS was higher in the pCIS group (p = 0.04). High CTA-based CIS and low blood glucose at admission were significantly correlated with good outcome. Conclusion CIS calculated using CTA is as reliable as DSA-based CIS for assessing collateral flow in AIS, and is also a good predictor of clinical outcome. This index could be useful for guiding patient selection and treatment strategies for AIS.

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Hypoperfusion in lenticulostriate arteries territory related to unexplained early neurological deterioration after intravenous thrombolysis

International Journal of Stroke ◽

10.1177/1747493019830595 ◽

2019 ◽

Vol 14 (3) ◽

pp. 306-309 ◽

Cited By ~ 2

Author(s):

Ying Zhou ◽

Wansi Zhong ◽

Anli Wang ◽

Wanyun Huang ◽

Shenqiang Yan ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Intravenous Thrombolysis ◽

Neurological Deterioration ◽

Terminal Branch ◽

Stroke Patients ◽

Lenticulostriate Arteries ◽

Early Neurological Deterioration

Background Early neurological deterioration occurs in approximately 10% acute ischemic stroke patients after thrombolysis. Over half of the early neurological deterioration occurred without known causes and is called unexplained early neurological deterioration. Aims We aimed to explore the development of early neurological deterioration at 24 h after thrombolysis, and whether it could be predicted by the presence of baseline hypoperfusion in lenticulostriate arteries territory in acute ischemic stroke patients. Methods We retrospectively reviewed our prospectively collected database of acute ischemic stroke patients in the unilateral middle cerebral artery territory who had baseline perfusion image and received thrombolysis. Unexplained early neurological deterioration was defined as ≥ 2 points increase of National Institutes of Health Stroke Scale (NIHSS) from baseline to 24 h, without known causes. Hypoperfusion lesions in different territories were identified on perfusion maps. Results A total of 306 patients were included in analysis. Patients with pure lenticulostriate arteries hypoperfusion (defined as the presence of hypoperfusion in lenticulostriate artery territory, but not in middle cerebral artery terminal branch territory) were more likely to have unexplained early neurological deterioration than others (27.6% vs. 6.1%; OR, 5.974; p = 0.001), after adjusting for age, baseline NIHSS and onset to treatment time. Conclusions Patients presenting hypoperfusion in pure lenticulostriate arteries territory were easier to experience unexplained early neurological deterioration.

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Unusual acute ischemic stroke of the ipsilateral middle and posterior cerebral artery territory

Acta Neurologica Belgica ◽

10.1007/s13760-016-0652-z ◽

2016 ◽

Vol 117 (1) ◽

pp. 305-307 ◽

Cited By ~ 1

Author(s):

Laurens Hermie ◽

Jeroen De Groote ◽

Bert Geerts ◽

Peter Vanlangenhove

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Posterior Cerebral Artery

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The Utility of Middle Cerebral Artery Clot Density and Burden Assessment by Noncontrast Computed Tomography in Acute Ischemic Stroke Patients Treated with Thrombolysis

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2013.08.026 ◽

2014 ◽

Vol 23 (2) ◽

pp. e85-e91 ◽

Cited By ~ 22

Author(s):

Mehmet A. Topcuoglu ◽

E. Murat Arsava ◽

Oguzhan Kursun ◽

Erhan Akpinar ◽

Bulent Erbil

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Stroke Patients ◽

Noncontrast Computed Tomography

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Prevention of the collapse of pial collaterals by remote ischemic perconditioning during acute ischemic stroke

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x16680636 ◽

2016 ◽

Vol 37 (8) ◽

pp. 3001-3014 ◽

Cited By ~ 14

Author(s):

Junqiang Ma ◽

Yonglie Ma ◽

Bin Dong ◽

Mischa V Bandet ◽

Ashfaq Shuaib ◽

...

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Laser Speckle ◽

Laser Scanning Microscopy ◽

Collateral Flow ◽

Contrast Imaging ◽

Peripheral Ischemia ◽

Remote Ischemic Perconditioning

Collateral circulation is a key variable determining prognosis and response to recanalization therapy during acute ischemic stroke. Remote ischemic perconditioning (RIPerC) involves inducing peripheral ischemia (typically in the limbs) during stroke and may reduce perfusion deficits and brain damage due to cerebral ischemia. In this study, we directly investigated pial collateral flow augmentation due to RIPerC during distal middle cerebral artery occlusion (MCAo) in rats. Blood flow through pial collaterals between the anterior cerebral artery (ACA) and the MCA was assessed in male Sprague Dawley rats using in vivo laser speckle contrast imaging (LSCI) and two photon laser scanning microscopy (TPLSM) during distal MCAo. LSCI and TPLSM revealed that RIPerC augmented collateral flow into distal MCA segments. Notably, while control rats exhibited an initial dilation followed by a progressive narrowing of pial arterioles 60 to 150-min post-MCAo (constricting to 80–90% of post-MCAo peak diameter), this constriction was prevented or reversed by RIPerC (such that vessel diameters increased to 105–110% of post-MCAo, pre-RIPerC diameter). RIPerC significantly reduced early ischemic damage measured 6 h after stroke onset. Thus, prevention of collateral collapse via RIPerC is neuroprotective and may facilitate other protective or recanalization therapies by improving blood flow in penumbral tissue.

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DWI Lesion Patterns Predict Outcome in Stroke Patients with Thrombolysis

Cerebrovascular Diseases ◽

10.1159/000441153 ◽

2015 ◽

Vol 40 (5-6) ◽

pp. 279-285 ◽

Cited By ~ 9

Author(s):

Dezhi Liu ◽

Fabien Scalzo ◽

Sidney Starkman ◽

Neal M. Rao ◽

Jason D. Hinman ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Infarct Volume ◽

Multivariable Analysis ◽

Intravenous Thrombolysis ◽

Favorable Outcome ◽

Border Zone ◽

Stroke Patients ◽

Mri Scan

Background: Lesion patterns may predict prognosis after acute ischemic stroke within the middle cerebral artery (MCA) territory; yet it remains unclear whether such imaging prognostic factors are related to patient outcome after intravenous thrombolysis. Aims: The aim of this study is to investigate the clinical outcome after intravenous thrombolysis in acute MCA ischemic strokes with respect to diffusion-weighted imaging (DWI) lesion patterns. Methods: Consecutive acute ischemic stroke cases of the MCA territory treated over a 7-year period were retrospectively analyzed. All acute MCA stroke patients underwent a MRI scan before intravenous thrombolytic therapy was included. DWI lesions were divided into 6 patterns (territorial, other cortical, small superficial, internal border zone, small deep, and other deep infarcts). Lesion volumes were measured by dedicated imaging processing software. Favorable outcome was defined as modified Rankin scale (mRS) of 0-2 at 90 days. Results: Among the 172 patients included in our study, 75 (43.6%) were observed to have territorial infarct patterns or other deep infarct patterns. These patients also had higher baseline NIHSS score (p < 0.001), a higher proportion of large cerebral artery occlusions (p < 0.001) and larger infarct volume (p < 0.001). Favorable outcome (mRS 0-2) was achieved in 89 patients (51.7%). After multivariable analysis, groups with specific lesion patterns, including territorial infarct and other deep infarct pattern, were independently associated with favorable outcome (OR 0.40; 95% CI 0.16-0.99; p = 0.047). Conclusions: Specific lesion patterns predict differential outcome after intravenous thrombolysis therapy in acute MCA stroke patients.

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